1. Respiratory Assessment
Wednesday, September 19, 2018
Respiratory Assessment
Hajni Hideg
Practice Education Sister
CTICU
FCCNC, 2017
Jane Roe B5s ICU May 2007

2. By the end of session learners will:
Know the importance/significance of respiratory assessment
Have an understanding of the components of respiratory assessment

3. Why do we assess? To ensure safety
To have a baseline that we can build our goals and management (identify issues)
To prevent or identify problems
Respiratory system is responsible for external and internal respiration (gas exchange)
To administer most appropriate treatment
To evaluate treatment’s response

4. Components of respiratory assessment
1. Initial quick assessment
Patient responsive? (Unresponsive BLS)
Talking in full sentences? Words? Can not talk?
2. History
PMH, medication, allergies
3. Patient Assessment
Look (Inspection/observation)
Listen (Auscultation)
Feel (Palpation)
4. Patient Monitoring
Vital signs – pulse, temperature, blood pressure, respiration
Pulse Oximetry / SpO2
Arterial blood gas analysis
Interventions - CXR
5. Documentation

5. 1. Initial Assessment Patient responsive? (Unresponsive BLS)
Wednesday, September 19, 2018
1. Initial Assessment
Patient responsive? (Unresponsive BLS)
Talking in full sentences? Words? Can not talk?
Breathlessness
Level of consciousness
Distress/accessory muscles
Colour
General appearance
Mannerisms / Posture
Speech
Facial expression
Vital signs, ventilator screen
Jane Roe B5s ICU May 2007

6. 2. History Presenting complaint and health Past medical history
Wednesday, September 19, 2018
2. History
Presenting complaint and health
Past medical history
Current medication, allergies
Cough? Sputum? (colour, consistency, amount?)
Shortness of breath (SOB)
Chest pain associated with breathing
Smoking history
Environmental exposure
Family health history
Travel history
Jane Roe B5s ICU May 2007

7. Wednesday, September 19, 2018
2. History
In critical care usually have to look for data sources other than patient
Relatives / friends
GP letters
Previous notes / nursing records
Casualty notes and records
Previous investigations undertaken
Jane Roe B5s ICU May 2007

8. 3. Patient assessment
LOOK LISTEN FEEL

9. LOOK Chest – movements, shape, scar Tracheal position Position
Accessory muscle use
Respiration – rate, rhythm, depth, pattern
Work of Breathing
Skin colour
Hands
Breathlessness/ Distress
General appearance/ Facial expression
Mental status/ Level of consciousness

10. Skin colour, hands

11. Chest Chest – movements, shape (Barrell chest, scoliosis), scars
Wednesday, September 19, 2018
Chest
Chest – movements, shape (Barrell chest, scoliosis), scars
Position of patient
In medical terms, barrel chest is a condition in which a person's chest appears to be partially inflated all the time, with the rib cage broadened. COPD
Jane Roe B5s ICU May 2007

12. Chest

13. Accessory Muscles

14. Breathing Patterns Rate, Depth, Regularity Ataxic breathing Normal
Wednesday, September 19, 2018
Breathing Patterns
Rate, Depth, Regularity
Normal
Adults:12-20/min
Ataxic breathing
Biot’s breathing
Irregularly irregular
Tachypnea
Rapid, shallow breathing
Cheyne-Stokes breathing
Regular rate, irregular depth
MAY be normal
Hyperypnea
Rapid, deep breathing
Hyperventilation
Kussmaul breathing
C-S-Heart failure and stroke, sleep apnoea syndrome Ataxic- damage to the medulla oblongata due to strokes or trauma.
Sighs
Hyperventilation syndrome
1 sigh per 200 breaths
Bradypnea
Jane Roe B5s ICU May 2007

15. Wednesday, September 19, 2018
Osteoarthropathy-primary Secondary  fibrosis, interstitial lung disease, Chronic lung or heart disease and hypoxia
Jane Roe B5s ICU May 2007

16. Clubbing

17. LISTEN
Speech
Noisy respirations - Stridor, wheeze, rattly chest, gurgling, snoring
Auscultation (normal, reduced, absent)
? added abnormal sounds (pleural rub, crackles, wheeze)

18. Chest Auscultation Movement of air in & out of airways
Flow and airway size dependent
Normal sounds / Added abnormal sounds
Interpretation / differential diagnosis  Practice!

19. How to auscultate? Directly on chest Both anterior and posterior
Patient sitting up if possible
Inspiration and expiration

20. Bones and landmarks

21. The lungs and lobes

22. The lungs and lobes / Where to listen?

23. Where to auscultate?

24. AUSCULTATION DIMINISHED / REDUCED / ABSENT
Can’t hear - Obesity
-  tidal volumes
 transmission - Pleural effusion
No air entry - Occluded airway + collapse
 airflow - Hyperinflation
- Pneumothorax

25. FEEL Tracheal position – usually midline
Shifted – Tension pneumothorax, large nodes, masses
Chest palpation - use of hands and fingers, compare left & right sides
Chest percussion - causes the chest wall & underlying tissues to move
(Hyper-resonance -emphysema, pneumothorax
Dense sound - lung consolidation, pleural effusion)

26. 4. Patient monitoring Vital signs: Pulse Blood pressure Temperature
Respiration rate, (rhythm and depth)
Sp02
Parameters on ventilator

27. Pulse oximetry / SpO2

28. CHEST X-RAY - NORMAL Name & date Technical quality Exposure AP / PA
Orientation / Rotation
Degree of inspiration
Methodically review film

29. CONSOLIDATION

30. PULMONARY OEDEMA

31. ARDS ‘Ground glass’ opacity Both lung fields involved
Normal diaphragms

32. CXR - COLLAPSE  opacity Shift of structures
ETT down (R) main bronchus

33. HYPERINFLATION Over inflation Flattened diaphragms
Wednesday, September 19, 2018
HYPERINFLATION
Over inflation
Flattened diaphragms
Darkened lung fields
 lung markings
Jane Roe B5s ICU May 2007

34. Not documented  NOT DONE!
5. Documentation
Not documented  NOT DONE!

35. In summary: Assessment essential part of critical care nursing!
Components of respiratory assessment:
Initial quick assessment
History
Patient Assessment(Look, Listen, Feel)
Patient Monitoring
Vital signs – pulse, temperature, blood pressure, respiration
SpO2
ABG analysis
Imaging
Documentation

36. Reading:
Mallett, J. (2013) Critical Care Manual of Clinical Procedures and Competencies
Jevon, P. and Ewens, B. (2012) Monitoring the critically ill patient, (3rd Ed)

37. Wednesday, September 19, 2018
Jane Roe B5s ICU May 2007