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

2. 2 Anatomy of Respiratory System NasopharynxNasopharynx LarynxLarynx TracheaTrachea BronchiBronchi BronchiolesBronchioles AlveoliAlveoli

3. 3 Anatomy Respiratory tract extends from mouth/nose to alveoli: Upper airway filters airborne particles, humidifies and warms inspired gases Lower airway serves for gas exchange

4. 4 Assessment of respiratory system 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)

5. 5 Technique for Respiratory Exam Before beginning, if possible: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) InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation

6. 6 Initial Respiratory Survey Observe the patient’s breathing patternObserve the patient’s breathing pattern –Rate (normal vs. increased/decreased) –Depth (shallow vs. deep) –Effort (any sign of accessory muscle use, inspect neck) Assess the patient’s color (ex. cyanosis)Assess the patient’s color (ex. cyanosis)

7. 7 Normal Respiratory Rates –Infant 30-60 –Toddler 24-40 –Preschooler 22-34 –School-age child 18-30 –Adolescent 12-16 –Adult 16-20

8. 8 *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, and 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).

9. -Assess for abnormality of configuration, e.g. pigeon chest (a deformity of the chest characterized by a protrusion of the sternum and ribs), funnel chest (Several ribs and the sternum grow abnormally and produce a caved-in or sunken appearance of the chest), spinal deformities (Kyphosis, scoliosis, lordosis). 9

10. Pigeon chest 10

11. Funnel chest 11

12. 12 Assess ribs and inter-spaces on respiration – may give you information 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 and children – breathe diaphragmatically and Women breathe thoracically or costally. Tachypnea: respiratory rate over than 20/m. Bradypnea: respiratory rate less than 10/m. -Palpate areas of chest especially areas of abnormalities. If a client complains: all chest areas must be palpated carefully for tenderness, bulges, or abnormal movements

13. 13 *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 the 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: which is vibration perceptible on palpation". * In subcutaneous emphysema: you must palpate the tissue, audible cracking sounds are heard – these sounds are termed “Crepitation”.

14. Anterior assessment 14

15. Posterior assessment 15

16. 16 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 and anterior and lateral aspects of chest with all directions, and with about “5”cms intervals. *Auscultation: To obtain 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

17. 17 Auscultation cont.. 12 anterior locations12 anterior locations 14 posterior locations14 posterior locations Auscultate symmetricallyAuscultate symmetrically Should listen to at least 6 locations anteriorly and posteriorlyShould listen to at least 6 locations anteriorly and posteriorly

18. 18 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

19. 19 Normal Breath Sounds TrachealTracheal –Very loud, high pitched sound –Inspiratory = Expiratory sound duration –Heard over trachea BronchialBronchial –Loud, high pitched sound –Expiratory sounds > Inspiratory sounds –Heard over manubrium of sternum –If heard in any other location suggestive of consolidation

20. 20 Rale: is short, discrete, interrupted, crackling or bubbling sound that most commonly heard during inspiration “similar to sounds, produced by hairs being rolled between the 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

21. 21 * Rhonchi: are 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 * 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 )

22. 22 Causes of decreased or absent breath sounds AsthmaAsthma COPDCOPD Pleural EffusionPleural Effusion PneumothoraxPneumothorax AtelectasisAtelectasis

23. 23 Pneumonia: Community-acquired pneumoniaPneumonia: Community-acquired pneumonia Hospital-acquired pneumoniaHospital-acquired pneumonia BacteriaBacteria VirusesViruses MycoplasmaMycoplasma FungiFungi ChemicalChemical Common Respiratory Disorders

24. 24 Pleural Effusion Accumulation of pleural fluid secondary to increased fluid formationPleural 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 Common Respiratory Disorders cont..

25. 25 Common Respiratory Disorders cont.. Pneumothorax: Sudden onset of pleuritic chest painPneumothorax: Sudden onset of pleuritic chest pain –Dyspnea, shortness of breath, increased work of breathing Diagnostic testDiagnostic test –CXR ManagementManagement –Oxygen –Possible placement of chest tube

26. 26 Common Respiratory Disorders cont.. Pulmonary Embolism Part of a deep vein thrombosis that has traveled and lodged in the pulmonary arteriesPulmonary Embolism Part of a deep vein thrombosis that has traveled and lodged in the pulmonary arteries Severity depends on the extent of occlusionSeverity depends on the extent of occlusion Mismatch of ventilation and perfusionMismatch of ventilation and perfusion Testing ( pulmonary angiogram)Testing ( pulmonary angiogram)

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28. 28 COPD HistoryCOPD History –Exposure to risk factors, co-morbidities, current medical treatment (beta blockers) TestsTests –Spirometry, ABGs ManagementManagement –Oxygen, education, drug therapy, nutrition, exercise, surgical intervention Common Respiratory Disorders cont..

29. 29 Asthma A chronic inflammatory disease of the airwaysAsthma A chronic inflammatory disease of the airways Airway hyper responsivenessAirway hyper responsiveness Variable airway obstructionVariable airway obstruction Resolves spontaneously or after using a bronchodilatorResolves spontaneously or after using a bronchodilator Testing :Testing : –Spirometry –Pulmonary function testing ManagementManagement –Education, prevent exacerbation, optimize pharmacotherapy Common Respiratory Disorders cont..

30. 30 Acute Respiratory Failure A sudden and life–threatening deterioration in gas exchangeAcute Respiratory Failure A sudden and life–threatening deterioration in gas exchange Type I – Acute hypoxemic respiratory failureType I – Acute hypoxemic respiratory failure Type II - Acute hypercapnic respiratory failureType II - Acute hypercapnic respiratory failure Type III – Combined hypoxemic and hypercapnic failureType III – Combined hypoxemic and hypercapnic failure *Hypercapnia: is a condition where there is too much carbon dioxide (CO 2 ) in the blood. TestsTests –ABGs, CXR, CT, thoracentesis ManagementManagement –Correction of gases, oxygen therapy –Reversal of any narcotics –Possible mechanical ventilation Common Respiratory Disorders cont..

31. 31 The end Thank you