Assessment of Oxygenation

Subjective Data Past History Upper resp infections Lower resp problems (asthma, TB, pneumonia, COPD) Related illness that affect resp system – AIDS, CHF Immunizations, TB skin tests, CXRs Allergies Medications

Subjective Data Family History Personal and social history Focus on resp illnesses Personal and social history Occupational history Factory, chemical plants, coal mines, farming, heavy traffic are all high risk for respiratory system Smoking history How long? How much? (pk yrs = # pks/day X # years) Substance abuse ETOH – risk for aspiration pneumonia IV drugs and AIDS risk for pnuemonia Activity Tolerance SOB or fatigue with daily activities? How far/fast can you walk?

Subjective Data Specific Symptoms Cough How long? Onset (gradual, sudden); When (a.m., all day?) How often? Productive? How much? Color (yellow/green – bacteria; frothy pink – pulmonary edema) Odor? Blood?

Subjective Data Specific Symptoms Shortness of breath (SOB) Chest pain Precipitating factors, severity, duration Effect of position (lying down? Upright?) Association with other symptoms (chest pain, cough) What makes it better/worse (rest, oxygen, inhalers, meds) Effect on activities? Chest pain PQRST (does breathing affect the pain?)

Objective Data Mouth, nose, pharynx, neck, heart Lungs and thorax

Objective Data: Inspection Note position (upright, leaning on table?) Evidence of respiratory distress/quality of respirations Nasal flaring, accessory muscles, intercostal retraction or bulging Shape and symmetry of chest Normal AP:transverse ratio is 1:2 – 5:7 Barrel chest: increased AP diameter in relation to transverse

Objective Data: Inspection Respiratory rate (N = 12 – 20) Respiratory pattern Tachypnea – rapid, shallow, > 24/min Bradypnea – slow (< 10/min) Hyperventilation – increased rate and depth Hypoventilation – shallow Cheyne-Stokes

Objective Data: Inspection Skin color Cyanosis (indicative of deoxygenated blood) Nails Clubbing (increased angle between base of nail and fingernail to 180 degrees or more Usually accompanied by increased depth, bulk and sponginess of end of fingers

Objective Data: Palpation Symmetric expansion Tactile fremitus Palpable vibration generated by vocal cords “99” Using palmar base of fingers, palpate from side to side Increased when lung is fluid-filled/more dense Decreased when lung is farther from hand or if hyper-inflated Absent over areas of collapse (pneumothorax, atelectasis)

Objective Data: Percussion To assess density or aeration Dull over areas of consolidation (e.g. pneumonia) Hyper-resonance over areas of hyper-inflation (e.g. asthma, COPD)

Objective Data: Auscultation Normal breath sounds Vesicular Soft, low pitch, gentle rustling Heard over peripheral lungs Bronchial Loudest, high pitch, like air through hollow pipe Over trachea and larynx Bronchovesicular Medium pitch and louness Mix of above qualities Anteriorly – over bronchi, either side of sternum Posteriorly – between scapula

Objective Data: Auscultation Abnormal/adventitious breath sounds Discontinuous sounds Crackles (fine) Crackles (coarse) Pleural friction rub Continuous sounds Rhonchi Wheeze Stridor

Objective Data: Auscultation Discontinuous sounds Crackles (fine) Short, crackling, popping sound at end-inspiration When collapsed alveoli or bronchioles snap open Associated with pneumonia, early pulmonary edema, atelectasis Crackles (coarse) Short, low-pitched bubbling sounds, mostly during inspiration Caused by air passing through airway that is intermittently occluded with secretions in larger airways Associated with pnuemonia, pulmonary edema Pleural friction rub Creaking, grating sound (like leather being rubbed together) During inspiration and/or expiration Due to inflamed pleural surfaces rubbing together Associated with pleurisy, pneumonia

Objective Data: Auscultation Continuous sounds Rhonchi Low pitch, snoring, moaning sound mostly on expiration Air passing through large airways with secretions COPD, pneumonia Wheeze High pitched squeaking sound, mostly on expiration Sometimes audible without stethescope Caused by air passing through narrowed airways (d/t spasm, swelling, tumors, secretions) Stridor High pitch crowing sound; often audible without stethescope Caused by partial obstruction of larynx or trachea Associated with croup, epiglottitis, laryngeal edema or spasm (post extubation)

Diagnostic Tests Sputum studies Bronchoscopy C & S Gram stain (classifies as gram + ve or – ve) AFB (acid fast bacilli) – for TB Cytology – examination for abnormal cells Bronchoscopy Bronchi visualized with fiberoptic tube inserted through nose into airways Can take biopsy, remove foreign bodies, mucus plugs NPO and sedation pre-test Post procedure: NPO until gag returns; assess for laryngeal edema,, hemorrhage (if bx taken), recovery from sedation

Diagnostic Tests Pulmonary Function tests Arterial blood gases (ABGs) Measures lung volumes and airflow Arterial blood gases (ABGs)