2Concept Overview Oxygenation: Processes that facilitate and impair oxygenation.Adequate perfusion is necessary to deliver oxygenated blood to tissues and remove metabolic waste.Intracranial regulation supports oxygenation.Adequate oxygenation needed to support intracranial function.Interrelationship necessary.
3Anatomy and Physiology The primary purpose of the respiratory system is to supply oxygen to cells and remove carbon dioxide .This purpose is accomplished using the process of ventilation and diffusion.Ventilation is the process of moving gases in and out of the lungs by inspiration and expiration.Diffusion is the process by which oxygen and carbon dioxide move from areas of high concentration to areas of lower concentration.After inspiration oxygen concentration is higher in the alveoli than in the pulmonary capillaries. This difference in concentration causes oxygen to move or diffuse from the alveoli across the alveoli-capillary membrane to the adjacent pulmonary capillaries. It is then carried by the erythrocytes (RBC’S) to the cells.
4Structures in the Thorax: Mediastinum Three main structures within thorax or chest:Mediastinum and right and left pleural cavities.Mediastinum positioned in middle of chest. Within it are:HeartArch of aortaSuperior vena cavaLower esophagusLower part of trachea
8Structures in the Thorax: Pleural Cavities Pleural cavities contain lungs.These cavities lined with two types of serous membranes:Parietal pleuraVisceral pleuraChest wall and diaphragm are protected by parietal pleura, and lungs are protected by visceral pleura.Small amount of fluid lubricates space between pleurae to reduce friction as lungs move during inspiration and expiration.
9Health History:Tobacco use (amount, duration, Pack year index) ½ pack/day x 30 years = 15 year smoking history3rd hand smoke exposure2nd hand smoke exposureOccupation/Exposure to pulmonary irritantsChemicals, vapors, dust, allergens, animals, smoke, asbestos, arsenic, coal dust, radiation)PMH/FH of respiratory illness/disease/cancer or allergiesPneumonia, TB, COPD, asthma, lung cancerPneumonia or influenza vaccine received?
10Health History: TB Risk factors for TB: HIV, substance abuse, low income or homeless, resident of nursing home, shelter or prison, immigrant from country with high TB rate
11Health History cont. : Do you have any shortness of breath? (Dyspnea) rest, with exercise, lying flat?Have you heard any wheezing?Do you have a cough?Dry, productive, barking, etc..Amount, color,& consistency of sputum. Presence of odor.Hemoptysis- coughing up blood (varies from blood streaked phlegm to frank blood)Do you have chest pain with breathing?Have you recently had any pain in calves or been on any long car or plane rides?
12Inspection:Observe symmetry, rate, rhythm, depth and effort of breathingSymmetry: Chest wall movement equal bilaterallyRate: Adult resp/min is normalBradypnea: Slow (<12 per minute)Tachypnea: Rapid (>20 per minute)Rhythm: Regular vs. irregularCheyne-Stokes, Kussmaul’s respirations, Biot’sDepthHypoventilation–rate slow, depthHyperventilation–rate rapid, depth deepRespirations 16/min, symmetrical,relaxed and even
13Inspection cont.:Observe symmetry, rate, rhythm, depth and effort of breathingSymmetry: Chest wall movement equal bilaterallyRate: Adult resp/min is normalBradypnea: Slow (<12 per minute)Tachypnea: Rapid (>20 per minute)Rhythm: Regular vs. irregularCheyne-Stokes, Kussmaul’s respirations, Biot’sDepthHypoventilation–rate slow, depthHyperventilation–rate rapid, depth deepRespirations 16/min, symmetrical,relaxed and even
14Inspection cont.: Body position Color of skin, lips, nail beds Relaxed vs. Upright/Tripod positionColor of skin, lips, nail bedsEven skin tone vs. cyanoticPresence of clubbingPatient relaxed. Skin and mucous membrane pink. Nail beds pink without clubbing in upper and lower extremities.Pictures of finger clubbing pg. 108
15Inspect/Palpate Trachea Position Should be midlinePalpateFor tracheal shiftPlace finger in sternal notch and slip to each side.Trachea midline.
16Inspection Documentation: Wounds, scars, drains, tubes, dressingsDocumentation must include location, size, amount of drainage and discharge if present, and signs of inflammation.Additional terms to describe location:Supraclavicular- Above the claviclesInfraclavicular- Below claviclesInterscapular- Between scapulaInfrascapular- Below scapulaMidaxillary line- Along line of armpitMidclavicular- Along line in middle of clavicleNo wounds, scars, drains, tubes, or dressings.Or- No lesions.
17Inspection: Shape of Thorax Shape of Chest :DeformitiesSymmetrical vs. asymmetricalPectus carniatum, Pectus excavatum, Spinal deformitiiesNormal AP diameter vs.. increased AP diameterOval vs. barrel chestRibs slope downward vs. more horizontalBarrel chest appears as if patient in continuous inspiratory positionChest symmetrical without deformities. AP < transverse. Refer to pictures on pg. 207 for examples of the above deformities and abnormals.
18Palpation Assess for masses, tenderness, or crepitus Subcutaneous emphysema- air escapes form lungs into subcutaneous tissueAssess chest expansionPosteriorly place thumbs at level of 10th rib & place palms on posterolateral chest.Approx 2 inches apart before inspiration. Feel thoracic expansion during quiet & deep inspiration. Look for symmetry.Chest expansion symmetrical. No masses or tenderness.
19Palpation Tactile Fremitus Palpable vibrations transmitted through bronchopulmonary tree to chest when patient speaksHave patient repeat 99 or 1, 1, 1 while palpate with ulnar surface or ball of handDecreased or absent when vibration impeded by obstructed bronchus, tumor, or separation of pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), or air (pneumothorax)Increased with gross compression or consolidation (lobular pneumonia) without bronchus obstructionTactile fremitus equal bilaterally.
20PercussionTapping of an chest to set chest wall and underlying tissues into motionHelps to establish if underlying tissue air-filled, fluid-filled, or solidNormal sound is resonanceResonant to percussion over all lung fields.Review pictures on pg. 204 for locations for percussion and auscultation: Anterior, Posterior and Lateral views.
22Auscultation Use diaphragm of stethoscope and have patient breath out of their mouth.Peds- use smaller pediatric diaphragmPlace stethoscope firmly on skin. Avoid movement because it may produce confusing sounds (i.e. clothing)Auscultate at least one complete respirationMove from one side to the otherObserve for hyperventilation, allow to rest if neededPeds- transmission of sounds enhanced, harder to localize sounds
23Auscultation (con’t) Hairy chest men: Put stethoscope on skin Hold stethoscope firmly over chest hairPrevents moving over and giving false soundsPut stethoscope on skin(seasoned nurses and MD’s may put over light shirt because of expert status)
25Auscultation Adventitious Breath Sounds Wheezes (Sibilant wheeze) High pitched, musical sound heard during inhalation or exhalationMild, moderate, severeRhonchi (Sonorous wheeze)Low pitch snoring sound during inspiration or exhalation, but louder on exhalationMay clear with coughingAsthma
26Auscultation Crackles/Rales Popping sounds heard on inhalation Fine High pitched fine, short, interrupted crackling sounds heard during end of inspirationMediumLower, more moist sounds heard during middle of inspirationCourseLoud, bubbly sounds heard during inspiration
27AuscultationStridorHigh pitched, harsh sound heard on inspiration when trachea or larynx is obstructedCroup, foreign body, large airway tumor
28Auscultation Cont.: Voice Sounds Bronchophony Whispered Pectoriloquy Normal- MuffledAbnormal- ClearWhispered PectoriloquyWhisper “1,2,3”Normal- faint and indistinctAbnormal- clear and distinctEgophony“eeeeeeee”NormalAbnormal “aaaaaa”
29Auscultation Documentation: Breath sounds vesicular without adventitious sounds.Or- Lungs sounds CTA in all lung fields without wheezes, rales, rhonchi, or rubs
31pneumothorax Also known as collapsed lung Treatment is Chest tube: SpontaneousTraumaticTensionTreatment is Chest tube:
32Summary: Bringing it all together Important to get good historyIf smokes offer smoking cessation classesHistory asthmaWhat is current treatment?If has c/o chronic cough ask about history and exposure so MD can rule out (r/o):Birds including chickens r/o TBSmoker r/o cancerChemicals/asbestos r/o cancer
33Summary (continued) Shortness of breath and recent travel: Pulmonary embolismSwelling of legs: DVTProper auscultationPercussionMultiple problems & concerns
34Summary Continued Asthma Atelectasis Bronchitis Cancer Croup Emphysema HemothoraxPleural EffusionPneumoniaPneumothoraxTuberculosis