Health Assessment (Respiratory) PDF

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The Respiratory System Chapter 13 ! - Anterior/ Posterior Lung Tissue ! - Pathology (fluid, pneumonia) ! - Typically in the lower lobes of lung tissue ! - Pleura ! - Serous membrane that forms an envelope between the lungs and the chest wall! - Visceral Pleurae ! - Lines the outside of the lungs ! - Parietal Pleurae ! - Lines the inside of the chest wall ! - Lungs slide smoothly and noiselessly up and down during respiration, lubricated by a few milliliters of fluid ! - Pleural space could abnormally fill with air or fluid and cause a decrease in lung expansion ! - Pleural friction rub can occur with dehydration !

- Trachea ! - Anterior to the esophagus 10-11 cm long ! - Trachea and brachia transport gases “dead space: (filled with air but not available for gas exchange) ! - Transport gases between the environment and lung ! - Bronchi are lined with goblet cells, which secrete mucus that entraps particles ! - Column like cells in respiratory tract make mucus ! - COPD, asthma , bronchitis and emphysema make Mega Mucous ! - Branch lined with cilia, which sweep particles upward where they can be expelled ! - Protects alveoli from small particles inhaled from the air ! - Cilia line primary bronchus remove microbes and debris from the interior of the lung ! Major Functions fo the Respiratory System ! - supplying oxygen to the body for energy production ! - Removing carbon dioxide as a waster product of energy reactions ! - Maintaining homeostasis (acid-base balance) of arterial blood ! - By suppling oxygen to blood and eliminating excess carbon dioxide, respirator maintains pH or acid-baed balance of blood ! Control of Respiration ! - our breathing patterns changes without out awareness in response to cellular demand ! - Mediated by respiratory center in brainstem (pons and medulla)! - major feedback loop is a change in carbon dioxide and oxygen levels in blood ! - Normal stimulus to breathe for most of us is an increase in carbon dioxide in blood or (hypercapnia)! - Decrees of oxygen on blood (hypoxemia) also increase respirations but less effective than hypercapnia ! Mechanics of Respiration ! - Inspiration (air rushes into lungs and chest size increases)! - Increases the size of the thorax and creates slightly negative pressure to relation to the atmosphere, therefore air rushed in to fill the partial vacuum ! - Expiration (air expelled from lungs and cheat recoils)! - Primarily passive, as the diaphragm relaxes, positive pressure is created within the thorax as well as the alveoli, and air flows out ! - Forced Inspiration (after heavy exercise or occurring pathologically with respiratory distress) ! - Use of the accessory neck muscles to heave up sternum and rib cage !

Developmental !

- Infants ! - During first 5 weeks of fetal life- primitive lung bug emerges ! - By 16- weeks conducting airways reach same number as in adults ! - At 32 weeks, surfactant, complex lipid substance needed for sustained inflation of air sacs, is present !

- At birth- lungs have 70 million primitive alveoli ready to start job or respiration !

- Aging Adults ! - Respiratory muscle strength declines after the age of 50 and continues to decrease into the 70’s !

- Decrease in elastic properties within lungs, more rigid structure that is harder to inflate (stiffer lungs) less elasticity !

- Decreased vital capacity: maximum amount of air we expel from the lungs ! - Increased residual volume ! - Think of patients after surgery ! Subjective Data ! - Cough ! - Do you have a cough?! - When did it start?! - Continuous throughout day- acute illness (respiratory infection)! - Afternoon/Evening- may be exposure to irritants at work ! - Night- postnasal drip, sinusitis ! - Early Morning- chronic bronchial inflammation of smokers ! - Gradual or Sudden?! - How often?! - Any mucus?! - White or clear mucus -> colds, bronchitis, viral infections ! - Yellow or green -> bacterial vs viral infection ! - Rust colored: TB -> pneumococcal pneumonia ! - Pink, frothy-> pulmonary edema ! - Any blood?! - Coughing up blood ! - Dry, hoarse, congested?! - Shortness of Breath ! - Ever had any shortness of breath or difficulty breathing?! - What brings it on? How severe is it? How long does it last?! - Or cough, chest pain, or bluish color around lips or nails? Wheezing sound?! - Do episodes seem to be related to food, pollen, dust, animals, season or emotion?! - What do you do in a heard-breathing attack? Take a special position, or use pursed-lip breathing? Do you use any oxygen, inhalers, or medications? ! - Pursed-lip breathing ! - Exhaling through pursed lips and inhaling through nose with mouth closed ! - Purpose is to create pressure inside airways in order to splint them open. In doing so it makes the work of breathing easier ! - Pursed lip breathing is one of the signs that nurses can use to detect possible chronic obstructive pulmonary disease (COPD) in patients !

COPD Breathing ! - Diaphragm is the largest muscle beneath your lungs and does 80% of the work of breathing. Normally the diaphragm moves downward to take fresh air in and upward to push stale air out. - COPD stale air gets trapped in the lungs and forces the diaphragm to flatten from the retained air and does not move up and down; becomes immobile.! Subjective Data ! - Respiratory Infections ! - History of respiratory infections ! - Any past history of breathing trouble or lung disease such as bronchitis, emphysema, asthma, or pneumonia? ! - Any usually frequent or usually severe colds?! - Any family history of allergies, TB, or asthma?! - Smoking history ! - Environmental Exposure ! - Are there any environmental conditions that may affect your breathing?! - Where do you work?! - At a factory, chemical plant, cool mine, farming, outdoors in a heavy traffic area?! - Self-Care Behaviors ! - When was your las TB skin test ! - Chest x-ray study ! - Pneumonia or Influenza Immunization ! Objective Data Inspection ! - note position person takes to breathe ! - General shape of chest wall ( abnormal, symmetrical) ! - Includes relaxed posture or ability to support one’s own weight with arms comfortably at side or in lap ! - Assess skin color and condition ! - Color should be consistent with person’s genetic background, with NO cyanosis or pallor should be present ! - Inspect ! - While assessing nail beds(finger nail beds) assess for profile sign to detect clubbing. Normal nail bed has an angle of 160 degrees ! - Note position persons takes to breathe ! - Postion ! - Accessory muscles ! - Symmetric Expansion ! - Confirms symmetric chest expansion by placing your warmed hands on posterolateral chest wall with thumbs at level of T9 or T10 ! - Slide your hands medially to pinch up a small fold of skin between your thumbs; ask person to take a deep breath ! - Your hands serve as mechanical amplifiers; as person inhales deeply, your thumbs should move apart symmetrically ! - Palpate the Posterior Chest ! - Sounds generated from larynx are transmitted through patient bronchi and through lung parenchyma to chest wall- you feel them as vibrations ! - Touch person’s posterior chest while he/she repeats words “99” or “blue moon”! - These are resonant phrases that generate strong vibrations ! - With too much air in lungs will not feel vibrations ! - With consolidation; mass- exaggerated !

- Percussion ! - Percuss band of normally resonant tissue across tops of both shoulders, side to side, note symmetry !

- Normal healthy lungs produce a resonance should which is low-pitched, clear, hollow sound !

- Abnormal! - Dullness ! - fluid, solid mass (tumor, pneumonia) ! - Hyper resonance ! - Too much air in the lungs (emphysema) !

- Auscultation ! - Instruct person to sit upright breathe slowly through the mouth ! - Use diaphragm of stethoscope and hold it firmly on patients chest wall ! - Listen to at least one full respiration in each location ! - Side-to-side comparison is most important ! - Do not confuse background noise with lung sounds; ! - Shivering,hairy chest, clothing to table paper, tubing ! - Normal Breath Sounds! - 3 types of normal breath sounds ! - Bronchial/ Tracheal ! - Location; trachea and larynx high pitch harsh tubular over trachea ! - Bronchovesicular! - Location; over major bronchi (major airways) where fewer alveoli are located; -

posterior, between scapulae especially on right; anterior, around upper sternum in 1st and 2nd intercostal spaces medium pitch ! Vesicular ! - Location; over peripheral lung fields where air flows through smaller bronchioles and alveoli, low pitch slow rustling “like wind through the trees” !

- Adventitious Sounds ! - Sounds that are not normally heard in lunch ! - Sounds you may Hear! - Crackles or Rales ! - Presence of fluid ( possible heart failure) crackling sounds ! - Wheeze ! - Edematous airway airflow obstruction high pitch whistling sounds ! - Rhonchi ! - Thick secretions think excess mucus usually larger airways (bronchi) ! - Stridor ! - Obstruction in larynx or trachea upper airway common with toddlers (medical emergency) !

- Objective Data voice sounds ! - Voice sounds can be auscultated over chest wall ! - Bronchophony! - Ask person to repeat a phrase such as “99” which you listen over chest wall ! - Normal ! - Voice transmission is soft, muffles and symmetrical ! - Pathology ! - Increase lung density enhances transmission of voice sounds,(can hear “99” very clearly) !

- Sound travels better through consolidation than air !

- Assess Quality of Respirations! - Normal breathing is relaxed, automatic and effortless, regular or even, and produces no

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noise ! Chest expands symmetrically with each inspiration ! No retraction or bulging of interspace with inspiration ! No accessory muscles used ! Respiratory rate is within normal limits for person’s age and pattern of breathing is regular ! Occasional sighs normally punctuate breathing ! Measurement of Oxygen Saturation ! - Healthy person with no lung disease and no anemia normally has an SpO2 of 97% to 98% ! - Greater than 95% acceptable ! - Finger probe spring loaded and feels like clothespin attached to finger but does not hurt ! - Patients with respiratory disease of SpO2 of less than 90% should have supplemental oxygen if ordered ! Nasal Cannula ! - Nasal cannula can be rapidly and comfortably placed on most patients ! - Patients on long-term oxygen therapy most commonly use nasal cannula ! - Usually well tolerated, allows speech and eating/drinking, is non-claustrophibc! Developmental Competence (infants and children)! - Newborns first respiratory assessment is part of APGAR scoring system-measures successful transition to extrauterine life ! - Infant breathes through nose rather than mouth and is obligate noise breather till 3 months ! - Normal; no flaring of nostrils and no sternal reaction of intercostal reactions occur ! - Abnormal: flared nostrils, sternal retraction, intercostal retraction ! Diaphragm is newborn’s major respiratory muscle - Intercostal muscles are not well developed; thus you observe abdomen bulge with each inspiration! - Count respiratory rate for 1 full minute; normal rates for newborn are 30 to 60 per minute! - Brief periods of apnea less than 10 or 15 seconds are common; this periodic breathing more common in premature infants! - Because newborn’s chest wall is so thin, transmission of sounds is enhanced and sound is heard easily all over chest, making localization of breath sounds a problem! - Even bowel sounds are easily heard in chest! - Try using smaller pediatric diaphragm endpiece, or place bell over infant’s interspaces and not over ribs!

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Respiratory Patterns ! - tachypnea ! - Increased rate >24, rapid shallow ! - Bradypnea ! - Decreased rate...