Assessment of the Respiratory System Chapter 29 Assessment of the Respiratory System

Anatomy & Physiology Review Upper respiratory tract Lower respiratory tract Lungs Accessory muscles of respiration Oxygen delivery and the oxygen-hemoglobin dissociation curve Respiratory changes associated with aging

Role of the Respiratory System

Patient History Family and personal data Smoking (pack-years) Drug use Allergies Travel, geographic area of residence Nutritional status Cough, sputum production, chest pain, dyspnea, PND, orthopnea

Assessment of the Nose & Sinuses External nose—deformities or tumors Nares—symmetry of size and shape Nasal cavity—color, swelling, drainage, bleeding

Assessment of the Nose & Sinuses (cont’d) Mucous membranes—abnormalities Septal deviation Turbinates

Assessment of the Nose & Sinuses (cont’d) The paranasal sinuses.

Assessment of the Pharynx, Trachea, & Larynx Mouth Posterior pharynx Neck—symmetry, alignment, masses, swelling, bruises, use of accessory neck muscles for breathing Trachea—palpate for position, mobility, tenderness, masses

Assessment of the Pharynx, Trachea, & Larynx (cont’d) Left: Structures of the larynx. Right: Detail of the glottis (two vocal folds and the intervening space, the rima glottidis).

Assessment of the Lungs & Thorax Inspect thorax with patient sitting up Observe chest, compare one side with the other Work from the apex, move downward toward base (from side to side) Rate, rhythm, depth of inspiration as well as symmetry of chest movement

Assessment of the Lungs & Thorax (cont’d) Examine AP diameter with lateral diameter Distance between ribs (intercostal space) Palpate to assess respiratory movement, symmetry Crepitus

Assessment of the Lungs & Thorax (cont’d) Diaphragmatic excursion Lung sounds Bronchial Bronchovesicular Vesicular

Assessment of the Lungs & Thorax (cont’d) Adventitious sounds Crackles Wheezes Rhonchi Pleural friction rub

Assessment of the Lungs & Thorax (cont’d) Anterior and posterior chest landmarks.

Assessment of the Lungs & Thorax (cont’d) Sequence for percussion and auscultation.

Other Indicators of Respiratory Adequacy Clubbing Weight loss Unevenly developed muscles Skin and mucous membrane changes General appearance Endurance

Psychosocial Assessment Stress may worsen some respiratory problems Chronic respiratory disease may cause changes in family roles, social isolation, financial problems due to unemployment or disability Discuss coping mechanisms, offer access to support systems

Laboratory Tests Blood Sputum Standard chest x-rays, digital chest radiography, CT Ventilation and perfusion scan Pulse oximetry (noninvasive)

Pulmonary Function Testing Noninvasive Evaluate lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, distribution of ventilation

Capnometry & Capnography Noninvasive Measure amount of carbon dioxide present in exhaled air Normal pressure of PETCO2 is between 20 and 40 mm Hg

Other Noninvasive Testing Exercise testing Skin testing

Invasive Diagnostic Tests Endoscopy Thoracentesis—aspiration of pleural fluid or air from pleural space Stinging sensation and feeling of pressure Correct position Motionless patient Follow-up assessment for complications

Position for Thoracentesis

Lung Biopsy Invasive Obtain tissue for histologic analysis, culture, cytologic examination May be performed in patient’s room

Lung Biopsy (cont’d) Follow-up care: Assess vital signs, breath sounds at least every 4 hours for 24 hours Assess for respiratory distress Report reduced/absent breath sounds immediately Monitor for hemoptysis

Audience Response System Questions Chapter 29 Audience Response System Questions 26

Question 1 Which of these is an expected outcome for the older adult related to the natural aging process of the respiratory system? Tightening of the vocal cords Decrease in the anteroposterior diameter Decrease in respiratory muscle strength Decrease in residual volume Answer: C Rationale: As a person ages, vocal cords become slack, changing the quality and strength of the voice, the anteroposterior diameter increases, respiratory muscle strength decreases, and the residual volume increases. (Source: Accessed August 1, 2011, from http://www.nlm.nih.gov/medlineplus/ency/article/004011.htm)

Question 2 Under normal physiologic conditions of tissue perfusion, what percent of oxygen dissociates from the hemoglobin molecule? 25% 50% 75% 100% Answer: B Rationale: Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules when blood perfuses tissues that have an oxygen tension (concentration) of 26 mm Hg. This is considered a “normal” point at which 50% of hemoglobin molecules are no longer saturated with oxygen. (See Figure 29-8.)

Question 3 Which is considered a main sign of lung disease? Dyspnea Cough Sputum production Chest pain Answer: B Rationale: Cough is a main sign of lung disease. Dyspnea (difficulty in breathing or breathlessness) is a subjective perception and varies among patients. A patient’s feeling of dyspnea may not be consistent with the severity of the presenting problem. Sputum production may be associated with coughing and indicate an acute or chronic lung condition. Chest pain can occur with other health problems, as well as with lung problems.