1. Islamic University of Gaza Faculty of Nursing Chapter 7 Assessment of respiratory system

2. Anatomy of Respiratory System

3. Assessment of respiratory system cont..
Subjective data: you must ask about:-
Coughing (productive, non productive)
Sputum (type & amount).
Allergies, dyspnea or SOB (at rest or on exertion).
Chest pain, history of asthma, bronchitis, emphysema, tuberculosis.
Cyanosis, pallor.
Exposure to environmental inhalants (chemicals, fumes).
History of smoking (amount and length of time)

4. Anatomy
Respiratory tract extends from: (Mouth- Nose –nasopharynx-Larynx –Trachea-Bronchi –Bronchioles- Alveoli)
* Upper airway filters airborne particles, humidifies and warms inspired gases
* Lower airway serves for gas exchange

5. Technique for Respiratory Exam
Before beginning, if possible:
Quiet environment
Proper positioning (patient sitting for posterior thorax exam, supine for anterior thorax exam)
Expose skin for auscultation
Patient comfort, warm hands and diaphragm of stethoscope, be considerate of women (drape sheet to cover chest)
Inspection
Palpation
Percussion
Auscultation
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6. Initial Respiratory Survey
Observe the client’s breathing pattern
Rate (normal or increased/decreased)
Depth (shallow or deep)
Effort (any sign of accessory muscle use, inspect neck)
Assess the client’s skin color e.g. cyanosis

7. Normal Respiratory Rates
Infant (birth – 2 years)30-60
Toddler (2-3 years) 24-40
Preschooler (3-4 years) 22-34
School-age child (6-12 years) 18-30
Adolescent (13-19 years) 12-16
Adult (years20-40 )16-20

8. Assessment of respiratory system cont..
Inspection for Measurement and assessment of respiration patterns.
Assess the skin and overall symmetry and integrity of the thorax.
Assess thoracic configuration.
Client must be uncovered to the waist, in sitting position without support.
- Observation of skin may give you knowledge about, nutritional status of the client.
Anterior- posterior diameter of thorax in normal person less than the transverse diameter = (1 – 2).
Assess for abnormality of configuration, e.g. pigeon chest, funnel chest, spinal deformities.

9. Assess ribs and inter spaces on respiration – may give you in formation about obstruction in air flow e.g. bulging of inter spaces on expiration may be from obstruction to air out flow “tumor, aneurysm, cardiac enlargement”
*Assess pattern of respiration:
Normally: men / children – breathe diaphragmatically and Women breathe thoracically or costally.
Tachypnea: respiratory rate over than 20/m.
Bradypnea: respiratory rate less than 10/m.
* Palpation: palpate areas of chest especially areas of abnormalities.
If clients complains: all chest areas must palpated carefully for tenderness, bulges, or al movements

10. Assess thoracic expansion:
Anterior – put your hands over anterior-lateral chest and thumbs extended along costal margin pointing to xiphoid process.
Posterior—thumbs placed at level of 10th rib with palms placed on posterior-lateral chest.
*By two ways – you feel amount of thoracic expansion during quiet and deep breathing, and symmetry of respiration between left and right hemi thoraces.
* Assessment of fremitus: (vibration perceptible on palpation).
* Subcutaneous emphysema: you must palpate tissue, audible cracking sounds are heard – these sounds are termed “Crepitations”.

11. Anterior Assess thoracic expansion

12. Posterior Assess thoracic expansion

13. Percussion of chest: to determine relative amounts of air, liquid, or solid material in the underlying lung, and to determine positions and boundaries of organs.
* Percussion done for posterior /anterior &lateral aspects of chest with all directions, and with about “5”cms intervals.
* Auscultation: To obtains information about the function of respiratory system & to detect any obstruction in the passages.
* Instruct the client to breathe through the mouth more deeply and slowly than in usual respiration before beginning
Auscultate all areas of chest for at least one complete respiration

14. Auscultation cont..
12 anterior locations
14 posterior locations
Auscultate symmetrically
Should listen to at least 6 locations anteriorly and posteriorly

15. Breathe sounds: are analyzed according to pitch, intensity, quality, and relative duration of inspiratory and expiratory phases.
* Bronchial breathe sounds: are normally heard over the trachea, if heard over lung tissue – indicate pathologic condition, these sounds “high- pitched, loud sounds with decrease inspiratory and lengthened increase expiratory phases.
Absent or decreased breath sounds can occur in:
Foreign body – in pleural space.
Bronchial obstruction.
Shallow breathing.
Emphysema

16. Normal Breath Sounds Tracheal Very loud, high pitched sound
Inspiratory = Expiratory sound duration
Heard over trachea
Bronchial
Loud, high pitched sound
Expiratory sounds > Inspiratory sounds
Heard over manubrium of sternum
If heard in any other location suggestive of consolidation

17. * Important points when Auscultate rales:
Rale: is short, discrete, interrupted, crackling or bubbling sound that most commonly heard during inspiration “similar to sounds, produced by hairs being rolled between fingers close to ear.”
* Important points when Auscultate rales:
low pitched, coarse rales, occurring early in inspiration means bronchitis “originate from bronchi”
Medium pitched rales in mid-inspiration means disease in small bronchi e.g. bronchiectasis.
High pitched, fine rales means disease affecting bronchioles and alveoli this occurs in late inspiration

18. * Rhonchi: continuous sounds produced by movements of air through narrowed passages in the tracheal- bronchial tree "musical sounds heard in expiration".
Low pitched rhonchi “Sonorous rhonchi usually heard in early expiration originate in larger bronchi”
High pitched: “Sibilant rhonchi or wheezes” – in late expiration, this originates in small bronchioles.
*Stridor
Inspiratory musical wheeze
Loudest over trachea
Suggests obstructed trachea or larynx
Medical emergency requiring immediate attention
Associated condition inhaled foreign body

19. * Pleural friction rub: is aloud dry, cracking or grating sound indicating of pleural irritation, heard over lateral and anterior lung in sitting position &not clear with coughing )
Causes of Decreased or Absent Breath Sounds
Asthma
COPD
Pleural Effusion
Pneumothorax
Atelectasis

20. Common Respiratory Disorders
Pneumonia:
Community-acquired pneumonia
Hospital-acquired pneumonia
Bacteria
Viruses
Mycoplasma
Fungi
Chemical

21. Common Respiratory Disorders cont..
Pleural Effusion:
Accumulation of pleural fluid secondary to increased fluid formation
Increased capillary permeability
Deceased colloid osmotic pressure of the blood
Increased intrapleural negative pressure
Impaired lymphatic drainage
Increased pressure in the capillaries or lymphatics

22. Common Respiratory Disorders cont..
Pneumothorax:
Sudden onset of pleuritic chest pain
Dyspnea, shortness of breath, increased work of breathing
Diagnostic test
CXR
Management
Oxygen
Possible placement of chest tube

23. Common Respiratory Disorders cont..
Pulmonary Embolism Part of a deep vein thrombosis that has traveled and lodged in the pulmonary arteries
Severity depends on the extent of occlusion
Mismatch of ventilation and perfusion
Testing ( pulmonary angiogram)

25. Common Respiratory Disorders cont..
COPD (Chronic Obstructive Pulmonary Disease)
HistoryExposure to risk factors,co-morbidities, current medical treatment (beta blockers)
Tests
Spirometry, ABGs
Management
Oxygen, education, drug therapy, nutrition, exercise, surgical intervention

26. Common Respiratory Disorders cont..
Asthma :
A chronic inflammatory disease of the airways
Airway hyper responsiveness
Variable airway obstruction
Resolves spontaneously or after using a bronchodilator
Testing :
Spirometry
Pulmonary function testing
Management
Education, prevent exacerbation, optimize pharmacotherapy

27. Common Respiratory Disorders cont..
Acute Respiratory Failure:
* A sudden and life–threatening deterioration in gas exchange
Type I – Acute hypoxemic respiratory failure
Type II - Acute hypercapnic respiratory failure
Type III – Combined hypoxemic and hypercapnic failure
Tests
ABGs, CXR, CT, thoracentesis
Management
Correction of gases, oxygen therapy
Reversal of any narcotics
Possible mechanical ventilation

28. Thank you