Physical Assessment of the Respiratory System Day 2A
History Physical problems Function problems Life style Smoking Family Hx Occupation hx Allergens / environment Recreational exposure Anxiety S&S
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy? A.Low birth weight B.Large for gestational age C.Preterm birth, but appropriate size for gestation D.Growth retardation in weight and length
Inspection Normal chest – Slight retraction of intercostal spaces – 2x as wide as deep – Anterior/posterior diameter 1:2
Inspection Barrel chest – D/t over inflation of lungs – anterior-posterior diameter 2:2
Inspection Funnel chest – Depression of the lower portion of the sternum – Complications Heart damage Cardiac output – Nrs management Murmurs
Inspection Pigeon chest – Sternum protrudes outward – anterior-posterior diameter
Inspection Scoliosis – Lateral curvature of thoracic spine – Assessment Shoulders elevated? – Complications Lung & heart damage Back problems Body image
Quiz? How many hours a day should a child wear a brace for treating scoliosis? A.8 hr B.12 hr C.23 hr D.24 hr
Inspection Kyphosis – AKA Hunchback – Abnormal curvature of the thoracic spine
Inspection Lordosis – AKA Sway-back – Abnormal curvature of the lumbar spine
Inspection Uniform expansion of the chest – Pneumonia – Pleural effusion – Pneumothorax Bulging intercostal spaces – Obstruction – Emphysema
Inspection Marked retraction of intercostal spaces – Blockage Shoulder rise Accessory muscles Posture
Inspection: Breathing patterns Rate Eupnea – Normal – / min Tachypnea – rate – Pnuemonia, pulm edema, acidosis, septicemia, pain Bradypnea – rate – ICP, drug OD
Inspection: Breathing patterns Depth Hyperpnea – depth Hyperventilation – depth & rate Hypoventilation – depth & rate
Inspection: Breathing patterns Depth Kussmaul's – rate & depth – Assoc. with sever acidosis Apneustic – Prolonged gasping I following by short
Inspection: Breathing patterns Rhythm Apnea – Not breathing Cheyne-stokes – Varying depth f/b apnea – Death rattles – Death rales
Inspection: Breathing patterns Rhythm Biot ’ s – rate & depth w/ abrupt pauses – Assoc w/ ICP
Inspection: Trachea – ? Deviation Pleural effusion Tension pneumothorax Atelectasis Color LOC Emotional state
Palpation TML – Tenderness (T) – Masses (M) – Lesions (L) Sinuses – Palpate below eyebrow & Cheekbone Crepitus – Subcutaneous emphysema – Air leaks into the sub-q tissue
Percussion Rational To determine if underlying tissue is filled with air or solid material Procedure Pt sitting Tap starting at shoulder compare rt to lf
Percussion: results Resonance – drum like – Normal Hyper-resonance – Too much air – Emphysema Flatness / dull – Fluid or solid – Pleural effusion – Pneumonia – Tumor
Auscultation Purpose Asses air flow through bronchial tree Procedure Diaphragm of stethoscope Superior inferior Compare rt to lf
Auscultation: Results Normal Vesicular – Lung field – Soft and low Bronchial – Trachea & bronchi – Hollow Bronchovesicular – Mixed – Between scapulae – Side of sternum – 1 st & 2 nd intercostal space
Auscultation: Results Adventitious Crackles – Rales – air bronchi with secretions Fine crackles – Air suddenly reinflated Course Crackles – Moist
Auscultation: Results Wheezes – Sonorous wheezes Deep low pitched Snoring > E Caused by air narrowed passages D/t secretions – Sibilant Wheezes High pitched Whistle-like I & E Caused by air narrowed passages D/t constriction – Asthma
Auscultation: Results Pleural friction rub – D/t inflammation of pleural membranes – Grating, creaking – I & E – Best heard Anterior, Lower, lateral area
Auscultation: Results Stridor – Crowing – Partial obstruction of the larynx or trachea
Quiz? A child with difficulty breathing and a “ barking ” cough id displaying signs associated with which condition? A.Asthma B.Croup C.Cystic fibrosis D.Epiglottitis
Quiz? When assessing the lung sounds of a child with asthma, which sound are you most likely to hear? A.Murmurs B.Sonorous Wheezing C.Sibilant Wheezing D.Crackles E.Pleural friction rub
Early & late signs of hypoxia Anxiety Bradycardia Cyanosis Depressed respirations Diaphoresis Disorientation Dyspnea Restlessness Headache Agitation Poor judgment Retraction Tachycardia Tachypnea
The nurse recognizes which of the following as an early sign of hypoxia? A.Restlessness, yawning & tachycardia B.Dyspnea, confusion & bradycardia C.Bradycardia, hypotension dyspnea D.Dyspnea, restlessness, hypotension
Dyspnea Definition – SOB – SOB, flat affect, BS x 4
Dyspnea Significance – Common with cardiac & resp. disease – Sudden onset – healthy person Pneumothorax – Sudden onset ill, post-op or injury Pulmonary emboli
Dyspnea Orthopnea – Sit up to breath COPD CHF
Dyspnea Right ventricle – If chronic airway resistance – pressure – Rt ventricle work – Rt. Vent damage
Dyspnea Nrs Management – Find cause – Give O 2 – HOB – Communication KISS
Cough Definition – To expel air from the lungs suddenly – Irritation of mucous membrane
Cough Significance – Infection – Irritants – Protective mechanism – Dry, irritating URT – Cough + chest pain Pleural or musculoskeletal
Cough Nrs management – Assess – Describe – Directed – Pain control Splinting – Infection control – Suppressants / Anti-tussives
Sputum Production Definition Matter discharged from resp. track that contains mucus and pus, blood, fibrin, or bacteria
Sputum Production Significance Purulent – Thick, yellow/green – Bacteria Rusty – Strep or staph Thin, mucous – Viral
Sputum Production Pink-tinged – Lung CA – TB Pink tinged, profuse, frothy – Pulmonary edema Malodorous – Lung abscess
Sputum Production Nrs Management Thick – Hydrate water Nebulizer Humidifier TCDB No smoking Oral care Appetite
Do You Know????? What breath sound would you expect to hear on a patient with increased sputum production? A.Vesicular B.Crackles C.Sonorous wheezes D.Sibilant wheezes
Obtaining a sputum specimen Explain – From lungs Sterile cup Deep breath x 3 Cough deeply Expectorate Best time for specimen collection? – AM
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A.Ask client to cough sputum into container B.Have the client take several deep breaths C.Provide a appropriate specimen container D.Assist with oral hygiene
Chest pain Definition Cardiac or pulmonary
Chest pain Significance CA (late stage) Pneumonia Pulmonary embolism Pleurisy
Chest pain Pleurisy – Inflammation of pleura – Sharp with breath – breath sounds
What????? What breath sound would you expect to hear on a patient suffering from pleurisy? A.Crackles B.Sonorous wheezes C.Sibilant wheezes D.Pleural Friction Rub
Chest pain Nrs Management Assess Analgesics OK, but … Position for pain – Affected side – Splint
Clubbed fingers Definition Sponginess of the nail bed Loss of the nail bed angle Finger tip is round and bulbous
Clubbed Finger Significance chronic hypoxia Nrs Management Marker
Mr. Caveman: Mr. Caveman enters the ER unconscious following an Automobile accident. The paramedics report that his O2 sats are 86%. You note that Mr. Caveman has clubbed fingers. What does this tell you?
Hemoptysis Definition Expectoration of blood from the respiratory tract
Hemoptysis Significance Pulm or cardiac Common causes – Pulm infection – CA of lungs – Pulm. Emboli – Pulm. Infarction – TB
Hemoptysis – Definition? Coughed up blood – From? Pulm hemorrhage – Description Pink, red, mixed with sputum – Blood pH Alkaline blood Hematemesis – Definition? Vomited blood – From? Stomach / GI – Description “ Coffee ground ” – Blood ph Acidic blood
Hemoptysis Nrs Management Determine source Serious
Cyanosis Definition Bluish coloring of skin
Cyanosis Significance Very late indicator of hypoxia Appears when O2 sats < 85% NOT a reliable sign of hypoxia – Esp. with anemia
Cyanosis O2 sat definition – % of hemoglobin carrying oxygen compared to total # of hemoglobin
Cyanosis Normal Breath 100 O2 molecules 98 cross into blood Blood: 100 Hgb O2 SATS – 98% – No cyanosis
Cyanosis Hypoxia Breath 100 O2 molecules 75 cross into blood Blood: 100 Hgb O2 SATS – 75% – Cyanosis
Cyanosis Anemic and hypoxic Breath 100 O2 molecules 75 cross into blood Blood: 75 Hgb O2 SATS – 100% – No Cyanosis
Cyanosis Nrs. Management Know color of Pt. skin Assess color of tongue & lips Fingernail polish African-American Vasoconstriction (cold weather) peripheral cyanosis