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

Anatomy of Respiratory System

Assessment of respiratory system cont.. 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)

Anatomy Respiratory tract extends from: (Mouth- Nose –nasopharynx-Larynx –Trachea-Bronchi –Bronchioles- Alveoli) * Upper airway filters airborne particles, humidifies and warms inspired gases * Lower airway serves for gas exchange

Technique for Respiratory Exam 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) Inspection Palpation Percussion Auscultation 24 شباط، 19

Initial Respiratory Survey Observe the client’s breathing pattern Rate (normal or increased/decreased) Depth (shallow or deep) Effort (any sign of accessory muscle use, inspect neck) Assess the client’s skin color e.g. cyanosis

Normal Respiratory Rates Infant (birth – 2 years)30-60 Toddler (2-3 years) 24-40 Preschooler (3-4 years) 22-34 School-age child (6-12 years) 18-30 Adolescent (13-19 years) 12-16 Adult (years20-40 )16-20

Assessment of respiratory system cont.. 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, 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). Assess for abnormality of configuration, e.g. pigeon chest, funnel chest, spinal deformities.

Assess ribs and inter spaces on respiration – may give you in formation 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 / children – breathe diaphragmatically and Women breathe thoracically or costally. Tachypnea: respiratory rate over than 20/m. Bradypnea: respiratory rate less than 10/m. * Palpation: palpate areas of chest especially areas of abnormalities. If clients complains: all chest areas must palpated carefully for tenderness, bulges, or al movements

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 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: (vibration perceptible on palpation). * Subcutaneous emphysema: you must palpate tissue, audible cracking sounds are heard – these sounds are termed “Crepitations”.

Anterior Assess thoracic expansion

Posterior Assess thoracic expansion

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

Auscultation cont.. 12 anterior locations 14 posterior locations Auscultate symmetrically Should listen to at least 6 locations anteriorly and posteriorly

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

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

* Important points when Auscultate rales: Rale: is short, discrete, interrupted, crackling or bubbling sound that most commonly heard during inspiration “similar to sounds, produced by hairs being rolled between 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

* Rhonchi: 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 ) Causes of Decreased or Absent Breath Sounds Asthma COPD Pleural Effusion Pneumothorax Atelectasis

Common Respiratory Disorders Pneumonia: Community-acquired pneumonia Hospital-acquired pneumonia Bacteria Viruses Mycoplasma Fungi Chemical

Common Respiratory Disorders cont.. Pleural 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.. Pneumothorax: Sudden onset of pleuritic chest pain Dyspnea, shortness of breath, increased work of breathing Diagnostic test CXR Management Oxygen Possible placement of chest tube

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

Common Respiratory Disorders cont.. COPD (Chronic Obstructive Pulmonary Disease) HistoryExposure to risk factors,co-morbidities, current medical treatment (beta blockers) Tests Spirometry, ABGs Management Oxygen, education, drug therapy, nutrition, exercise, surgical intervention

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

Common Respiratory Disorders cont.. Acute Respiratory Failure: * A sudden and life–threatening deterioration in gas exchange Type I – Acute hypoxemic respiratory failure Type II - Acute hypercapnic respiratory failure Type III – Combined hypoxemic and hypercapnic failure Tests ABGs, CXR, CT, thoracentesis Management Correction of gases, oxygen therapy Reversal of any narcotics Possible mechanical ventilation

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