1. Assessing For Alteration In Respiratory Function

2. Respiratory Alterations Risk Factors
Age
Sex
Ethnic origin
Family History
Smoking History
Medications Use
Allergies
Diet

3. History of Present Illness
In relation to cough, sputum production, chest pain, and SOB at rest and exertion.
Onset
Duration
Location
Frequency
Progression and radiation
Aggravating and relieving factors
Associated signs and symptoms
Treatment

4. Assessment Techniques
Inspection
Palpation
Percussion
Auscultation

5. Assessment of Upper Respiratory Tract
Nose and sinuses
Inspect: symmetry, nasal flaring, deformities, swelling, redness, or drainage?
Palpate: tenderness or swelling over sinuses?
Pharynx, Trachea, and Larynx
Inspect: symmetry, discharge, inflammation of mouth or pharynx? Masses, swelling, or palpable lymph nodes? Vocal changes?
Palpate: deviations, tenderness, or masses of trachea?

6. Assessment of Lungs and Thorax- Inspection
Compare one side with the other (symmetry)
Any discoloration, scars (wounds or surgical), lesions, masses?
Any spinal deformities: kyphosis, scoliosis, lordosis?
Observe rate, rhythm, depth of respirations, symmetry
Inspiratory phase greater that expiratory phase (I>E)
Prolonged (E) r/t airflow obstruction
Type of breathing used: pursed-lip, diaphragmatic, accessory muscles
Inspect shape and diameter of chest
Any retractions of intercostal spaces?

7. Assessment of Lungs and Thorax- Palpation
Symmetry of respiratory movement
Areas of tenderness, masses, lesions, swelling
Thoracic expansion
Crepitus

8. Assessment of Lungs and Thorax- Percussion
Pulmonary resonance: lungs are 99% air
Percussion notes
Resonance: low, hollow, lasts long
Hyperresonance: higher, booming, lasts long
Flatness or Dullness: soft, short
Tympany: high, drumlike,
Boundaries of organs: dull or flat
Diaphragmatic excursion:

10. Assessment of Lungs and Thorax- Auscultation
Normal breath sounds
The larger the airway, the louder and higher pitched the sound( no extra sounds, just air passing in and out of the airways)
Auscultation of lungs with a stethoscope assesses airflow, obstruction and general condition of the lungs and pleural space
The diaphragm of the stethoscope is used in listening for one full breath in the sequence demonstrated on the screen

11. Bronchial Sounds Heard over the bronchial areas Loud and high pitched
Heard over the hilar region when breathing hard (i.e. after exercise). 
Heard over the bronchial areas
Loud and high pitched
Expiratory time is greater than inspiratory time
If heard in the lung periphery bronchial sounds are abnormal
Pneumonia
Pulmonary Edema
Pulmonary Hemorrhage

12. Bronchial Sounds
Suggestive of lung consolidation and pulmonary disease. 
Pulmonary consolidation results in improved transmission of breath sounds originating in the trachea and primary bronchi that are then heard at increased intensity over the thorax.

13. Bronchovesicular Sounds
Normally heard in the areas around the mainstem bronchi below the clavicles and between the scapulae
The pitch and intensity of these sounds are moderate Inspiratory - expiratory time ratio is 1:1
These sounds are abnormal if audible in the periphery of the lung field

14. Vesicular Breath Sounds
Heard in peripheral lung tissue away from large airways
Soft
Low-pitched, blowing
Inspiratory – expiratory time ratio is 5:2
Can be normally diminished to the bases

15. Adventitious Breath Sounds
Adventitious breath sounds are superimposed over normal breath sounds
When crackles, wheezes or rubs are heard note loudness, duration, pitch location and whether they are audible with every breath
If possible have patient cough to see if it produces any changes in breath sounds

16. Assessment of Lungs and Thorax- Auscultation
Adventitious breath sounds
Crackle (Rales): high pitched (rubbing your hair between your finger)
Wheeze: high pitched, squeaky and musical
Rhonchi: snoring or gurgling (a sound that is not a crackle or a wheeze is probably a rhonchi)
Pleural friction rub: grating, rubbing sound (two pieces of sandpaper rubbing together)

17. Adventitious Breath Sounds: Crackles
Crackles are caused by fluid in the alveoli or by sudden re-opening of the alveoli
Usually first heard at the base of the lung but may progress to all portions of the lung field
Heard in patients with heart failure, prolonged bedrest and atelectesis

18. Adventitious Breath Sounds: Wheezes
Caused by rapid air movement through constricted airways
Continuous, often musical sounds
Heard most often on expiration but can be heard during both inspiration and expiration
Usually associated with underlying respiratory disorders such as asthma and obstructive lung disease but can also be caused by interstitial pulmonary edema that compresses small airways
Wheezes that are ‘fixed’ is characteristic of a bronchial mass or tumor

19. Adventitious Breath Sounds: Pleural Rub
Caused by pleura that is inflamed rubbing against each other
The rubbing sound is course, grating sound
Heard on inspiration and expiration

20. Voice Transmission Tests
Tactile Fremitus: While patient repeats the phrase “99” PALPATE the chest with the palmer surface of your hands
Normal findings: vibration from the sound transmission is felt
Abnormal findings:
increased tactile fremitus suggests consolidation
Decreased tactile fremitus noted in pneumothorax

21. Voice Transmission Tests
Egophony: While patient repeats the phrase “EE” AUSCULTATE the lungs
Normal findings: “EE” heard
Abnormal findings: “AY” heard

22. Voice Transmission Tests
Bronchophony: While the patient repeats the phrase “99” AUSCULTATE the lungs
Normal findings: sounds are muffled and distinct
Abnormal findings: sounds are louder and phrase is clear
Whispered Pectoriloquy: While the patient whispers the phrase “1,2,3” AUSCULTATE the lungs
Normal findings: faint or no sound
Abnormal findings: phrase is clearly heard or loud

23. Other Indicators of Respiratory Adequacy
Skin and mucous membranes: pallor, cyanosis
Clubbing of fingers
Muscle development: weight loss, muscle mass loss
Physical endurance: SOB, DOE

24. Interpreting ABG’s Normal Ranges pH: 7.35-7.45 PaO2: 80-100 mm Hg
PaCO2: mm Hg
HCO3: mEq/L

25. ABG Analysis 1) Look at pH first 2) Look at PaCO2 3) Look at HCO3
Draw an arrow if it is low or high
Low means acidosis
High means alkalosis
2) Look at PaCO2
If arrows are opposite: problem is respiratory
3) Look at HCO3
Draw an arrow if its low or high
If pH and HCO3 arrows are in the same direction: problem is metabolic

26. ABG Analysis Additional Analysis
Compensation: If the arrows of PaCO2 and HCO3 are opposite
Partial Compensation: If the arrows of PaCO2 and HCO3 are in the same direction

27. Diagnostic Studies Blood Studies Oximetry Hemoglobin Hematocrit
Arterial Blood Gas
Oximetry
Noninvasive monitor SpO2 and SvO2

28. Diagnostic Studies Sputum Studies Culture and Sensitivity
Identifies infecting organism
Confirms diagnosis
Observe for color, blood, volume, viscosity

29. Diagnostic Studies Skin Tests Allergic reactions
Exposure to tuberculosis
Antigen
Positive- has been exposed
induration

30. Diagnostic Studies Chest X-rays CT Scan MRI
Radiographic Studies
Chest X-rays
CT Scan
MRI
Ventilation-Perfusion Scan (V/P)
Pulmonary vasculature is outlined
Radioactive gas
Pulmonary Angiography
PET SCAN

31. Diagnostic Studies Endoscopic Examinations Lung Biopsy
Bronchoscopy
Mediastinoscopy
Lung Biopsy
Thoracentesis (needle)
Pulmonary Function Tests
Exercise testing