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What is the purpose of the upper respiratory tract?
Warms and filters air
What is the purpose of the lower respiratory tract?
What information should be obtained to identify risk factors during a respiratory system assessment?
- Hx of trauma to the ribs or lung Sx
- Number of pillows used when sleeping
- Associated chest pain
- Sputum production
- Hx of allergies
- Environmental exposures
- Hx of smoking
- Family Hx of lung disease
- Chronic or frequent respiratory infections
- Signs and symptoms (why are they being seen or at the hospital?)
What are sign and symptoms which could represent a problem with the respiratory system?
- Dyspnea or Orthopnea
- Sputum production
- Chest pain
- Clubbing of fingers - sign of chronic hypoxia
- Hemoptysis - bloody sputum
When conducting a respiratory assessment, what should be inspected?
- Skin moisture & color - pale, cool, diaphoretic, cyanotic
- Mentation - Confusion or agitation, alteration in LOC
- Posture - upright, tripod
- Respiratory pattern - rate, depth & degree of distress
- Edema - location, pitting vs non-pitting
- Accessory Muscle Usage - Intercostal retractions, abd. muscle usage
- Shape/contour of chest - Anterior/Posterior diameter, barrel chest (COPD)
- Symmetry of chest rise and fall - should be equal
What should be assessed when auscultating lung sounds?
- Abnormal Sounds
What methods should be used when auscultating the lungs?
- Snake-like pattern from top to bottom of thorax
- Listen for full resp. cycle
- Use both bell and diaphragm of stethoscope
- Ask pt. to breathe slowly and deeply
Locations for Respiratory Auscultation
- Vesicular - All lung fields except over sternum & scapula
- Broncho vesicular - 1st & 2nd ICS
- Bronchial - Manubrium (broad, upper part of the sternum)
- Tracheal - Trachea
What are stertorous respirations?
Abnormal breath sound characterized by strenuous breathing
What is stridor?
Abnormal breath sound characterized by harsh, high pitched sounds on inspiration as a result of narrowing of the upper airways. Croup
What are crackles?
- Abnormal breath sound characterized by fine to course crackling which is made as air moves through wet secretions.
- Course sounds may also be called rhonchi
What are wheezes?
Abnormal breath sounds characterized by high-pitched musical sounds on inspiration and/or expiration which is made as air passes through small passages narrowed by edema, secretions or tumors.
What should be palpated when assessing the respiratory system?
- Chest Expansion - symmetry and degree of expansion
- Tactile Fremitus - vibration felt on the patient's chest during low frequency vocalization
What age related (pediatric) variations should be expected when conducting a respiratory system assessment?
- Louder breath sounds on auscultation
- More rapid rate (until approx. age 8-10)
- Abdominal muscle usage
- Rounded chest wall in infants & children up to age 6 - AP vs. transverse diameter are equal
What age related (geriatric) variations should be expected when conducting a respiratory system assessment?
- Increased AP diameter
- Kyphosis (dorsal spine curvature)
- Decreased thoracic expansion
- Accessory muscles used to exhale
What are common diagnostic tests used when assessing the respiratory system?
- CXR - identifies fluids, masses, shifting, etc..
- PFT - Pulmonary Function Test - evaluation of pulmonary status & identify abnormalities using spirometry & peak flow
- Pulse Oximetry - measure of SaO2 (95% and above is normal)
- ABGs - exact amount of O2 in the blood
What is a bronchoscopy?
- Direct visualization of the resp. tract structures.
- Can obtain biopsies, remove foreign substances or drain abscesses
What is a Lung Scan?
- Dye is injected and circulated through the lungs
- Images are taken of the radioactive waves emitted
What is VQ?
- Ventilation (V) Perfusion (Q) Scan
- detects ventilation abnormalities and measures integrity of pulmonary blood vessels and blood flow.
What is the purpose of sputum cytology?
Detects malignant cells & identifies organisms causing infection and/or blood/pus in sputum
Respiratory Nursing Diagnoses
- Ineffective airway clearance r/t increase mucous production
- Impaired gas exchange r/t bronchoconstriction
- Ineffective breathing pattern r/t pain or ALOC
- Activity intolerance r/t fatigue and weakness
- Pain r/t fever and pleuritic irritation
- Anxiety r/t difficulty breathing
What might percussion be used to assess during a respiratory assessment?
- Lung position and size
- Detect the presence of air, liquids or solids in the lungs