1. Assessment of Oxygenation

2. 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

3. 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?

4. 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?

5. 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?)

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

7. 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

8. 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

9. 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

10. 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)

11. 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)

12. 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

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

14. 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

15. 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)

16. 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

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