Respiratory Assessment
Hypoxia
Inadequate tissue oxygenation at the cellular level
Decreased Fremitus
Occurs with *obstruction* of vibrations Ex: Atelectasis, Pneumothorax
Auscultation - Anterior Chest Wall
Use diaphragm of stethoscope and listen to one full respiration in each location. Compare side to side in symmetrical locations.
Auscultation - Posterior Chest Wall
Using the same points as percussion, palpation, etc. Instruct client to sit, leaning forward slightly. Can ask patient to cross arms. Instruct client to breath more deeply than normal through the mouth. Use diaphragm of stethoscope and listen to one full respiration in each location. Compare side to side in symmetrical locations.
Pulmonary Function/Spirometry
Usually done in the pulmonologist's office Looks at every portion of respiration (multiple different readings)
Respiratory Physiology
Ventilation Perfusion Oxygen Transport Inspiration/Expiration Diffusion Carbon Dioxide Transport
Hyperventilation
Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism
Environment - Developmental Influences
air quality stress (suppresses immune system and increases risk of infection) Altitude (higher altitude = lower oxygen levels)
The term "Kussmaul" refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx. a) True b) False
b) False -Stridor is the correct answer
Which diagnostic test/exam would best measure a client's level of hypoxemia? a) Chest x-ray b) Pulse oximeter reading c) ABG d) Peak expiratory flow rate
c) ABG (arterial blood gas) hypoxemia is low arterial blood oxygen levels
Bronchovesicular
heard over major bronchi between scapulae and upper sternum 1st and second ICS (inspiration = expiration)
Vesicular
heard over periphery of lung (longer inspiration/short expiration)
Bronchial
heard over trachea & larynx (short inspiration/ longer expiration) (shouldn't hear over lower part of the lung = might mean fluid which transmits sound differently)
Cheyne-Stokes
increasing irregular pattern and then decreasing and periods of apnea
Biot
irregular pattern with apnea
Increased Fremitus
Occurs with *consolidation* of the lung tissue
An elderly patient with pneumonia may appear with which symptoms first? 1) Altered mental status and dehydration 2) Fever and chills 3) Hemoptysis and dyspnea 4) Pleuritic chest pain and cough
1) Altered mental status and dehydration -older adults are atypical and don't have the same response as others -this is a normal response for older adults with illnesses
Which respiratory disorder is most common in the first 24-48 hours after surgery? 1) Atelectasis 2) Bronchitis 3) Pneumonia 4) Pneumothorax
1) Atelectasis don't take deep breaths which causes mucus buildup and blocked airways --> leads to alveolar collapse common post-op complication
A-P Diameter Normal
1:2 A-P Diameter No Transverse Diameter
Which additional assessment data should immediately be gathered to determine the status of a patient with a respiratory rate of 4 bpm? 1) Arterial blood gas and breath sounds 2) Level of consciousness and pulse oximetry value 3) Breath sounds and pulses 4) Pulse oximetry and heart sounds
2) level of consciousness and pulse oximetry value - patients can control their respiratory rate, more awake may increase rate
A pulse oximeter gives what type of information about a patient? 1) Amount of carbon dioxide in the blood 2) The respiratory rate 3) The amount of oxygen in the blood 4) The percentage of hemoglobin carrying oxygen
4) The percentage of hemoglobin carrying oxygen
Pulmonary System
Airways and lungs Ventilation Movement of air into/out of the lungs Respiration Exchange of oxygen/carbon dioxide Alveolar capillary/capillary cell membrane
Hypoventilation
Alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide
Inspiration/Expiration
An active process stimulated by chemical receptors in the aorta and a passive process for expiration
Physical Examination - Palpation
Anterior Posterior Palpate for pain/discomfort
Atelectasis Definition
Anything that reduces ventilation or causes the alveoli to collapse (secretions, foreign body, tumor)
Assessment Steps
Assessing for Risk factors - demographics - age - gender - cardiovascular/pulmonary issues - environment - lifestyle Physical Exam Assess Breathing Patterns: (*Shallow or deep) Eupnea: NI; 12-20 bpm Tachypnea > 24 Bradypnea < 10 Kussmaul Biot's Cheyne-Stokes Apnea *Risk for atelectasis* - surgery - any blockage of airway
Chest Expansion
Asymmetry with an airway obstruction, pleural effusion, or pneumothorax Normal = symmetry As they take a deep breath your thumb and fingers should move apart
A-P Diameter Abnormal
Barrel Chest = 1:1 A-P Diameter
Cyanosis
Blue discoloration of the skin and mucous membranes Desaturation of hemoglobin Late stage hypoxia
Auscultate Normal Breath Sounds
Bronchial Bronchovesicular Vesicular
Voice Sounds
Bronchophony Egophony Whispered Pectoriloquy
Apnea
Cessation of breathing
History
Cough (yes - then PQRSTU) Shortness of Breath (yes - then PQRSTU) Chest Pain with Breathing Past History of Respiratory Infections Past History of Respiratory Diseases Past History of Allergies Cigarette Smoking Environmental Exposure
Assessment of Cough and Sputum
Cough - Recurring or productive or chronic - Type - Other SX - normal protection mechanism for the body - coughs become persistent, recurring, or very productive, last longer then 3 weeks - can be dry, hacking, productive (bringing up mucus) - ask about other symptoms (fever, chest congestion, sneezing, sore throat, etc.) (can lead you to various disease possibilities) Sputum Appearance - COLOR - clear/white = allergies green/yellow = allergies or infection black = soot or smoke inhalation rust = pneumonia or TB = presence of blood pink and frothy = pulmonary edema Odor = Infection Amount Timing
Changes in the Older Adult
Decline in respiratory muscle strength results in decreased ability to cough Loss of elasticity causes more rigid lung Decreased alveoli causes less gas exchange Decreased ventilation causes dyspnea with exertion Increased respiratory rate, more shallow Greater risk for developing kyphosis Greater risk for falls and rib fractures
Physiological Factors
Decreased oxygen-carrying capacity (ex: anemia) Decreased inspired oxygen (ex: asthma, high altitude, obstruction) Hypovolemia (not enough fluid/plasma in blood) (ex: dehydration, shock) (not enough volume = decreased perfusion to tissues) Increased metabolic rate (pregnancy, hyperthyroidism, etc.)
Kussmaul
Deep, labored breathing
Inspiration
Diaphragm and intercostals contract Thoracic cavity size increases Lung volume increases Intrapulmonary pressure decreases Air rushes into lungs to equalize pressure *Surfactant*
Expiration
Diaphragm and intercostals relax Intrapulmonary pressure rises Air is expelled
Carbon Dioxide Transport
Diffuses into red blood cells and is hydrated into carbonic acid
Pulse Oximetry
Estimates arterial blood oxygen saturation (Sao2) Sao2: reflects % of Hgb molecules carrying oxygen Healthy Patients: 95-100% Interferes: Movement. Nail polish/nails, Cold environment
Anterior Palpation
Evaluate *symmetric chest expansion* by placing hands on anterolateral chest wall along the costal margins. Evaluate symmetric chest expansion by placing hands on posterolateral chest wall with thumbs at T8 to T10.
Posterior Palpation
Evaluate *symmetric chest expansion* by placing hands on posterolateral chest wall with thumbs at T8 to T10. Evaluate symmetric chest expansion by placing hands on posterolateral chest wall with thumbs at T8 to T10.
Diffusion
Exchange of respiratory gases in the alveoli and capillaries
Tachypnea
Fast breathing > 24 bpm
Precuts Excavatum
Funnel Chest
Physical Examination - Inspection
General Inspection Anterior Inspection Posterior Inspection
Nursing Role
History Assessment Diagnostic Tests: CBC (red blood cells, anemic or not) ABG (carbon dioxide in blood) TB skin test (TB exposure) Pulmonary Function/Spirometry (information of ventilation and respiration) Bronchoscopy (able to look and/or take specimens at bronchial tree) Lung Scan (look at lungs for blood clots, pulmonary emboli, etc.) Pulse Oximetry Thoracentesis (removes fluid from pleural space) Chest X-ray (show density of the lung) Sputum cultures - (see what is growing) For C&S For AFB For Cytology
Alterations in Respiratory Functioning
Hyperventilation Hypoventilation Hypoxia Cyanosis
Lifespan - Development Influences
Infants/premature babies Earlier then 34 weeks don't have surfactant = alveoli can collapse and they can go into respiratory distress Immature Immune system and brain also - controls breathing - infants and premature babies can have irregular breathing - higher risk of infection Much more narrow airways (easier for airway collapse) Children and Toddlers are at high risk for upper respiratory infections
What Happens When We Breathe?
Inspiration Expiration
Anterior View - Lobes of the Lungs
Left Side has 2 lobes Right Side has 3 lobes
General Inspection
Level of consciousness Position assumed by patient to breathe Effort, quality, rate, rhythm Skin color and condition (cyanosis, pallor) Anteroposterior diameter/ Transverse diameter (barrel chested?)
Factors That Influence Pulmonary Function
Life span and development (e.g., respiratory distress syndrome, upper respiratory infections [URIs], adolescent smoking, cardiac insufficiency) Environment (e.g., stress, allergies) Lifestyle (e.g., nutrition, exercise, substance abuse) Medications Smoking Pathophysiological Conditions
Oxygen Transport
Lungs and cardiovascular system
Assessment of Respiratory Effort
Nasal Flaring: Helps reduce resistance to airflow in nose (done when a person has difficulty breathing) (How hard is the person working to breath?) Retractions: - Use of Accessory Muscles (movement of subclavian muscles) (retraction of ribs when breathing - Grunting (noises difficult breathing, forcing air out on a closed epiglottis) - Body position (many people who are in respiratory distress use tripod position, sitting up with hands braced in front of them) - Paroxysmal nocturnal (patient wakes up suddenly in the middle of the night and can't breath) (Ask how many pillows a person sleeps with) - Dyspnea (PND) - Stridor (high pitched crowing sound on inspiration due to a partially obstructed airway) (croup, foreign body) - Wheeze (musical sounds, partially obstructed small airways, usually obstructed by mucus)
Eupnea
Normal Breathing 10 - 20 bpm
Lifestyle - Developmental Influences
Obesity will restrict ventilation - more likely to get an infection - higher risk for sleep apnea Exercise - respiratory rate increased while exercising Smoking - causes cancer - causes chronic inflammation - increases secretions Pregnancy - increases the oxygen demand - breath faster in late term pregnancy Work Environments - coal mine - construction (dust) - casino/bar (second hand smoke) - firefighter - nail salon - kitchen workers (grease, smoke, steam)
Physical Examination
Palpation using **Tactile Fremitus**: Fremitus - palpable vibrations transmitted through the bronchopulmonary tree to the chest wall when the patient speaks Palpate anterior and posterior Use palmar base or ulnar edge of hand. Compare symmetrical areas for tactile fremitus as patient says "99". Normal - most prominent over major bronchi, decreases as you progress downward
Peak Flow Monitoring
Peak expiratory flow rate (PEFR): Measures air exhaled with forcible effort Monitors, NOT diagnosis of asthma Small hand-held apparatus - person should stand and take a deep breath - then exhale forcefully into machine (for as hard and long as possible) - will pick up subtle changes in air flow - measured in meters per minute - should take 3 readings and then take the highest of the three readings - can determine person's personal best over time
Percussion (1)
Percuss in between the rib space Both sides (back and forth Start right above the shoulder Want to hear resonance Hyper-resonance is lower-pitched booming sound (excess air in the lung = pneumothorax, emphysema, overinflation) Dull sound if there is fluid over the space (pneumonia, effusion (fluid in lining), or tumor) May be dullness as you move further down due to organs (liver and kidney) Must be skin on skin
Assessing Oxygenation Status
Physical examination: Using *inspection, palpation, percussion, and auscultation* Breathing pattern: - Eupnea, bradypnea, tachypnea - Apnea, Kussmaul, Biot, Cheyne-Stokes Respiratory effort (the amount of work it takes a person to breath) Pulse oximetry
Factors Affecting Oxygenation
Physiological Factors Conditions Affecting Chest Wall Movement
Precuts Carinatum
Pigeon Breast
Conditions Affecting Chest Wall Movement
Pregnancy (infant pushes up and lungs can't expand) Obesity (much more difficult, abdominal organs pushing up on lungs) Musculoskeletal Abnormalities (Kyphosis, Scoliosis) Trauma Neuromuscular disease CNS alterations
Pathophysiological Conditions
Pulmonary System Abnormalities: - structural Abnormalities - airway Inflammation (allergies or asthma) - obstruction (foreign body - children/infants/older adults) - atelectasis - CNS Abnormalities (head injury, stroke, etc.) - neuromuscular - abnormalities Respiratory Infections: URI: Influenza (very young and very old) LRI: Pneumonia
Assessment
Pulse Oximetry Peak Flow Monitoring
Bronchophony
Repeat 99 Normal = muffled Abnormal (ex: fluid in lungs) = Hear 99
Anterior Inspection
Shape and configuration of the chest wall Costal angle (angle between the ribs) Symmetry of the thoracic cage Retraction or bulging of interspaces Use of abdominal muscles
Posterior Inspection
Shape and configuration of the chest wall Kyphosis/Scoliosis Symmetry of the thoracic cage Position of the spinous processes
Bradypnea
Slow breathing < 10 bpm
Percussion
Start at apices and work down, going side to side Resonance: low-pitched, clear, hollow sound that predominates healthy lung tissue in the adult Hyperresonance: lower-pitch, booming (emphysema or pneumothorax) Dull" soft, muffled thud (abnormal density like in pneumonia, pleural effusion, atelectasis, or tumor)
Perfusion
The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs
Ventilation
The process of moving gases into and out of the lungs
Normal Breath Sounds - Posterior Chest
Three T
Percussion (2)
Typically percuss more on the back Go around and down Flatness over scapula Resonance over ribs Lower into bases you may have more dullness due to organs (liver, pancreas, and kidneys)
The Airway
Upper: Above larynx Nasal passages, mouth, and pharynx Lower: Below Larynx Trachea, bronchi, bronchioles Considered sterile