1. The Respiratory System Jean M. Wilson, BSN, RN, CCE

2. Assessment of the Chest and Lungs Equipment needed: Tape measure Stethoscope Blanket or drape Ruler

3. A & P Position of the Patient: Sitting = best; Allows for inspection of both the back and the chest for: the 3 S’s Size Shape Symmetry

4. Landmarks Landmarks: Clavicle Trachea Intercostal spaces (ICS) Midclavicular lines Axillary lines

5. Landmarks Continued Midsternal line Sternum Xiphoid process

6. Anterior Chest Lungs: Right upper lobe Left upper lobe Right middle lobe Left lower lobe Right lower lobe

7. Posterior Chest Vertebral line Right and left lobes Scapula Scapula line

8. Assesessment Anteroposterior Diameter = half of the transverse diameter Unexpected findings: Barrel chest Pigeon chest Funnel chest Deviations

9. Assessment Assess the patient’s; Lips: color, pursed lips Nails: clubbing, cyanosis Nares: flaring Oxygen saturation Breath: odor Patients overall color

10. Respirations Expected: Rhythm and pattern: even & easy with no distress Repiration rate: 12-20 breaths per minute Ratio of HR/RR: 1 to 4

11. Respirations Unexpected: Shortness of Breath (SOB) Tachypnea Orthopnea Use of accessory muscles Retractions

12. Patterns of Respirations Normal: regular 12-20 per minute Bradypnea: slow, < 12 Tachypena: fast, > 20 Hyperpnea (hyperventilation) faster, >20 and deep Sighing: sigh/deep breath

13. Patterns of Respirations Air trapping: increase difference in the air getting out Cheyne Stokes: increase in depth with periods of apnea Kussmauls: rapid, deep, and labored Biots: apnea and disorganized breathing

14. Patterns of Respirations Ataxic: irregular, with varying depths

15. Listening Two types of breath sounds; normal and abnormal Normal are called; bronchial, bronchial vesicular, and vesicular Abnormal are also called; adventitious

16. Listening Review the proper use of the stethoscope

17. Normal Breath Sounds Bronchial: trachea, anterior only, and high pitch Bronchovesicular: main bronchus, anterior and posterior, medium pitch Vesicular: heard over most of the lung fields, bases, low pitch

18. Adventicious Breath Sounds Crackles: fine, medium, and coarse Fine: not cleared by coughing, heard at the end of inspiration Medium: lower, moist, heard during inspiration, not cleared by cough Coarse: loud, bubbly, heard on inspiration, can be cleared by coughing

19. Adventicious Breath Sounds Wheezes: musical note, squeaky, heard on inspiration or expiration Rhonci: sunorous wheeze, loud, low, inspiration or expiration, coughing may clear, due to mucous accumulation Stridor: bark, no air exchange Pleural friction rub: rubbing, dry, grating sound, inspiration or expiration, anterior

20. Abnormalities Pulsations Tenderness Bulges Depressions Unusual movement Unusual positions

21. Thoracic Expansion Stand behind the patient Place palms lightly on patient’s back with thumbs at the 10 th rib Have patient breathe & watch thumbs with each breath Symmetric expantions should be seen Repeat anteriorly under the xiphoid process

22. Trachea Midline Palpate gently with index finger about suprasternal notch A slight deviation to the right is normal Should be non-tender Pulsations = abnormal

23. Chest Percussion Direct: Indirect: Percuss all areas anteriorly and posteriorly

24. Percussion Tones Resonant: low pitch, hollow, loud, long Flat: soft, extremely dull, short, high pitch Dull: medium, medium-high pitch, thudlike Tympanic: loud, high pitch, drumlike Hyperresonant: very loud, very low pitch, long, booming sound

25. Vocal Resonance Have patient recite numbers or words as you listen to all lung fields (99) Muffled sound should be heard

26. Abnormalities Cancer Infections: upper respiratory, sputum production Asthma Chronic Obstructive Pulmonary Disease (COPD)

27. Abnormalities Continued Emphysema Pneumonai Barrel Chest Productive (sputum)/non-productive coughing Long expirations

28. Cough Descriptions Dry Moist Non-productive Productive: assess sputum color; yellow, green, rust, clear, purrulent, blood streaked, thick(viscous) or thin

29. Coughs Assess: Onset Frequency Regularity; certain time of day or activities Postural changes Smoker/non-smoker Environmental/work related issues

30. References Schilling, J. A. et al (2007). Health assessment made incredibly visual! Philadelphia: Lippincott, Williams, & Williams.