respiratory assessment

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respiratory assessment
2014-04-25 19:07:14

nursing fundamentals
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  1. Functions:
    - Supply O2 to the body for energy

    - Removes CO2 as waste product

    - Maintain homeostasis (acid based balanced)
  2. Structures of Respiratory systems
    Upper Airway
    - nasal cavaties and mouth (nasal cavities warms and moistens the air)

    - pharynx (throat)

    - larynx (voice box)

    • - Epiglottis- flap that closes trachea so food
    • doesn’t go inside (sometimes this function is lost during stroke- the way to
    • test is tickle the back of the throat)

    - If food get into the trachea u could aspirate.
  3. Lower Airway
    - Trachea- transports air

    - bronchi- mainstem, segmental, terminal

    • - alveoli- functional unit of respiratory
    • system-where gas exchanges (air sacs) like 300 million
  4. Thorax/chest
    Pleural cavity
    - parietal membrane- the chest walls

    • - visceral membrane- lines the lungs (this
    • membrane is continuous)

    • - pleural spaces- are spaces between to the chest wall and the lungs. There is fluid in there so that the chest wall and lungs
    • don’t rub together. (when this becomes inflamed it can cause a friction rub
    • which is sometime described as sharp pain)
  5. Respiration/gas exchange
    - Controlled by: CNS (pons/medulla)- involuntary, Peripheral control- chemo receptors stimulates person to breath- when you increase in CO2 and u breath faster to in more O2.

    - Lung cycle- inspiration to breath in. Expiration to breath out.

    • - COPD- hypoxic drive- O2 levels low, CO2 levels high chronically overtime. PC no longer works for them. This is why u see them
    • short of breath. Do not administer more than 2-3L of O2 because you could knock
    • out the drive to breath
  6. Inhalation
    - diaphragm flattens

    - Intercostal muscles co- Lung expands

    - Volume of lung thoracic cavity increases

    - Air flows down pressure gradient into the lungs
  7. Exhalation
    - muscle of inhalation relaxes

    - thoracic cavity recoils

    - lung volume decreases

    • - air flows down pressure gradient and out of
    • lungs
  8. Landmarks for respiratory system
    -  apices above the clavicles

    • - 2nd- rib angle of louie where
    • bifurcation where the trachea splits

    - base of 6th rib MCL
  9. Posterior
    - T3-T4- bifurcation of trachea

    - T1-T10- lung tissue

    - T12 with deep breath ‘
  10. Lateral
    - 8th rib MAL
  11. Review of lungs 
    - Right side- 3 lobes, shorter because of liver

    - Left side- 2 lobes and narrower because of heart

    - Anterior- upper lobes better to hear

    - Posterior- lower lobes better to hear

    - Lateral- upper and lower lobes
  12. Factors affecting respiration:
    1.Development/age- infants 30-60 breaths vs adult 12-20. Children are abdominal breathers and adults thoracic. With age the A/P gets larger over time.

    2. Level of health- COPD effects O2. Anemia, m/s chronic illness

    • 3. Lifestyle- smoking, work environment
    • 4. Medication- like opiods/morphine effect the medulla which slows down a persons respiratory system (breathing)

    5. environment- like work, air pollution

    6. Psychological health- ie stress respiration rate increases. 
  13. Acute Assessment Nursing intervention for acute SOB
    - Immediate assessment- RR, P, BP, and O2 stat. Auscultate lungs

    - Immediate interventions- Administered O2, raise head of the bed (DO THIS FIRST), stay with patient to maintain calm.
  14. Health Hx
    • - Present Hx/problem: dyspnea, SOB, chronic cough, chest pain- how would u rate this normally? What does it feel like today? Does this
    • affect your daily activities

    - Past Hx- any respiratory issue, use of inhalers. Surgeries

    - Family Hx- Asthma

    - Risk factor- smoking, work environment.

    -  IF pt had two inhalers: dilator or steroid- use dilator first to open up lungs so that steroid.
  15. Inspection
    General Appearance/position

    • Effort (for breathing), color (not cyanosis), comfort,
    • expression, movements, LOC (first sign to go when someone is hypoxic)
  16. Skin/nails
    • Cap refill, color of nail, edema, clubbing (>180),
    • cyanosis,
  17. HEENT
    • Trachea is midline
    • Mucous membrane are moist and pink
    • Abnormal founding- pursed lips, nasal flaring,
    • cyanosis
  18. Inspection of chest:Sit on edge of bed. Modified/high fowlers position- adequate
    1. color – even consistent with culture

    2. shape- symmetrical, even shape diameter- A/P to transverse (lateral) 1:2 A/P front to back lateral side to side

    • 3. breathing patterns- Eupnea- quiet smooth even breathing effortless, equal depth chest expansion is even. Thoracic chest
    • movements no retractions or use of accessory muscles  (shallow breathing with people in pain).
  19. Abnormal findings from inspection of chest:
    1. barrel chest- A/P to lateral 2:2 usually seen in chronic lung disease

    • 2.Pectus Excavetum- funnel chest, decrease A/P diameter, sunken sternum, seen at the xiphoid process during inspiration cause
    • is unknown

    3. Pectus Carinatum- pigeon chest

    4. Change in structure- scoliosis
  20. Altered Respiratory Patterns
    - tachypnea

    - bradypnea

    - hyperpnea- (hyperventilation)

    - apnea

    - Cheyne Stokes respiration- could mean the end of life. Rapid respiratory rate and then apnea

    - Sighing- a good thing. I think it helps to open airway

    - Labored using muscle u should not, dyspnea, DOE dyspnea of excursion, orthopnea
  21. Signs and Symptoms of Hypoxia
    - change in mental status (confusion)

    - restlessness

    - 2nd stage- tachycardia, tachypnea

    - elevated BP

    - SOB, DOE, retractions

    - Pallor, diaphoretic

    • - 3rd stage- cyanosis (central and
    • peripheral)

    - clubbing of nails

    - difficulty speaking and swallowing

    - sudden absence of lung sounds
  22. Palpations
    Used to detect areas for:
    - sensitivity

    - chest expansion

    - vibration

    - position of trachea
  23. Palpation of the Chest
    - Palpate Ant/Lat/Pos

    - Assess each side and compare

    - Temperature, moisture, muscle development tenderness/pain, masses

    • Normal:
    • - areas should be bilaterally symmetrical

    - no areas of pain, tenderness, masses

    - should be firm and smooth

    • Abnormal
    • - crepitus- air in subcutaneos issue

    - pain or tenderness

    - masses
  24. Chest Expansion/Excursion 
    - Respiratory expansion

    - Assess for symmetrical chest expansion

    - Posterior- hands at the level of the 9th-10th rib, thumbs close to vertebrae

    - Palms should have contact with the skin

    - Ask patient to take several breaths

    - Normal- equal chest expansion
  25. Tactile vocal Fremitus
    - Fremitus is a vibration felt on the outer chest as pt speaks

    - Aids in evaluating air flow in tissues

    • - Do this for pneumonia (not necessarily needed
    • all the time)

    Best Assessed:

    - large diameters of the airways

    - 2nd rib ICS

    - level of bifurcation of the bronchi

    • Normal Adult:
    • - not felt below 3rd – 4th ICS anterior

    - not felt below T6-T8 ICS posterior

    - ask pt to say “1 2 3” or “99”

    - Palpate the pts chest with palmers surfaces of fingers or ulnar surface of fist

    - Palpate both side simultaneously

    - Normal= equal bilaterally, variation are wide ranging

    - Increases fremitus- consolidation (becoming solid), mass, fluid (pneumonia)

    - Decreased fremitus- air trapping, obstruction, excess air in lungs (COPD)
  26. Percussion
    - used to determine- lung position, size, density, presence of air, masses, solid material within the lungs

    - it is symmetrical in an organized manner

    - Anterior/lateral- raise arms above head

    - Posterior- cross arms at chest

    - Normal: resonance over lung tissue
  27. Absent lung sounds
    - caused by masses, plugged mucous, chronic lung disease

    - can be a critical finding

    - could affect the ability to exchange gases
  28. Diminished lungs sounds:
    - difficult to hear, are present (not as loud as usual)

    - assess atelectasis

    - happens when pt is hospitalized

    • - intervention have pt cough and do deep breaths. Change position,  and incentive
    • spirometer 
  29. Crackles/rales
    - sticky- passage of air through small airways that adherent due to mucous, moisture or fluid.

    - Best heard over the periphery (bases lungs)

    - Heard at the end of inspiration

    - Sounds like crackles, hair rubbing together or velco

    - Often associated with pneumonia, pulmonary edema, chf,

    - May be cleared with a cough

    (air going thru small places and fluid in the bases)
  30. Rhonchi (coarse wheezes or gurgles)
    - passage of air thru the larger airways occulded by mucous fluid (trachea and bronchus)

    - best heard over the larger airways

    - heard during exhalation

    - sounds like gurgles or snoring

    - often associated with pneumonia or bronchitis

    - intervention- maybe cleared with the a cough

    - also make sure the pt has hydrated air if they can tolerate it. 
  31. Wheezes
    - passage of airway thru narrow airways

    - often louder with inspiration

    - with increase severity can be heard with both inspiration and expiration

    - sounds like a whistle or squeak

    - continuous high pitch sound

    - often associated with asthma or bronchitis

    - may clear with cough 
  32. Pleural friction rub
    - caused by rubbing of the pleural surfaces

    - best heard of over the lower anterior surfaces

    • - can be heard with both inspiration and
    • expiration

    - loud, low pitched rubbing/grating sound

    - often associated with pneumonia, lung cancer or infection

    - not affected with cough

    - need to know the difference between this and cardiac friction rub. – do this by simple asking pt to hold breath. 
  33. Stridor
    • - caused by obstruction of the upper airway,
    • spasms

    - loud harsh high pitched sounds, honking

    - louder in upper airways

    - acute respiratory distress

    - retraction- disperately trying to get air in
  34. Vocal Resonance (not usually assess by RN)
    - helpful in assess for fluid, consolidation (things becoming more solid)

    - auscultate while the pt is speaking a few words or numbers

    - normal- sounds should be muffled

    - if heard clearly then pt has bronchophony
  35. Assess for Egophony
    • - have pt say E and if it sounds like “ay” there
    • is consolidation
  36. Whisper Pectoriloquy
    • - ask pt to whisper a few words and if heard
    • clearly then there is consolidation
  37. O2 Stat
    - pulse oximetry

    - amount of O2 in the vascular tissue

    - can not give information regarding ventilation

    - normal values 95-100

    - inaccurate values less than 70- abn hgb, anemia, low perfusion rates, thick artificial nails, CO poisoning
  38. Nursing Dx
    • Ineffective airway clearance
    • - abn breath sounds, changes in rate/depth of respiration, cough, sputum

    - dyspnea, cyanosis

    • Ineffective breathing patterns
    • - dyspnea, DOE, tachypnea, increased

    • - A-P diameter increased, use of accessory muscles
    • - Cough, nasal flaring

    • Impaired gas exchanged
    • - Abn ABG (aterial blood gases), restlessness, DOE, hypoxia, somnolence, changes in mental status

    • Activity Intolerance
    • - weakness, dizziness, reports fatigue, DOE,
    • increase respiration and pulse rate- if u don’t have enough oxygen going around
    • ur body these things will increase
  39. Nursing Interventions:
    1. Teaching

    • a. proper breathing techniques like breathing in thru your nose and out your mouth
    • b. relaxation techniques for pts with anxiety
    • c. incentive spirometer- alveoli expansion
    • d. smoking cessation
    • e. preventing infection- handwashing
    • f.  proper use of inhalers
    • g. healthy habits

    • 2. encourage coughing and deep breathing- to clear secretion esp after abd/thoracic surgery. Have pt do this every 2 hours while
    • awake

    • 3.  assess and monitor hydration status- not
    • CHF/renal failure pt but others make sure pt has an adequate supply of fluids.

    Avoid milk products because it could make secretions tenacious (hard)

    4. assess monitor mobility- even if pt can not walk let them sit in the chair. Movement is important

    5. assess nutrition- small frequent meals. Don’t give pt empty calories. Avoid foods causing a lot of gas

    6. Chest PT (resp. therapy)

    • 7. Medication- morphine, opiods slow respiration rate.
    • - glucocorticoids 9(steroids)
    • - pain meds- be careful
    • - decongestants- helps clear secretions
    • - anti anxiety meds- calm pt down
    • - bronchodilators
    • - cough suppressants

    8. Oxygen Therapy- needs MD order, medication careful assessment- different types of ways to administer oxygen
  40. Diagnostic tests
    • - chest xray- most frequently used.
    • - CT/MRI with/without contrast
    • - Check for any allergies to dye or shellfish
    • - Check for claustrophobia- anxiety meds
    • - Post- if dye is used tell pt to drink plenty fluid to flush it out. 
  41. Bronchoscopy
    Visualize larynx, trachea, bronchi, bispsy, aspirate fluid

    Pre- NPO, consent form, meds

    • Post- check gag because u want to make sure epiglossitis is
    • working, VS, S/S bleeding. Resp status- sore throat
  42. Lung Biopsy
    • Needle or open
    • Ofen done with bronchoscopy
    • Identify tissue, staging (cancer
    • Informed conset
    • NPO
    • Pre- op meds
  43. Thoracentensis
    • aspirate fluids from the pleural cavity
    • Diagnostic or treatment
    • Can be done at the bedside
    • Informed consrnt
    • Post- assess VS, RR, O2 stat, bleeding, chest xray (checking for pneumonia)