Physical Assessment of the Respiratory System Day 2A

History Physical problems Function problems Life style Smoking Family Hx Occupation hx Allergens / environment Recreational exposure Anxiety S&S

The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy? A.Low birth weight B.Large for gestational age C.Preterm birth, but appropriate size for gestation D.Growth retardation in weight and length

Inspection Normal chest – Slight retraction of intercostal spaces – 2x as wide as deep – Anterior/posterior diameter 1:2

Inspection Barrel chest – D/t over inflation of lungs – anterior-posterior diameter 2:2

Inspection Funnel chest – Depression of the lower portion of the sternum – Complications Heart damage  Cardiac output – Nrs management Murmurs

Inspection Pigeon chest – Sternum protrudes outward – anterior-posterior diameter 

Inspection Scoliosis – Lateral curvature of thoracic spine – Assessment Shoulders elevated? – Complications Lung & heart damage Back problems Body image

Quiz? How many hours a day should a child wear a brace for treating scoliosis? A.8 hr B.12 hr C.23 hr D.24 hr

Inspection Kyphosis – AKA Hunchback – Abnormal curvature of the thoracic spine

Inspection Lordosis – AKA Sway-back – Abnormal curvature of the lumbar spine

Inspection Uniform expansion of the chest – Pneumonia – Pleural effusion – Pneumothorax Bulging intercostal spaces – Obstruction – Emphysema

Inspection Marked retraction of intercostal spaces – Blockage Shoulder rise Accessory muscles Posture

Inspection: Breathing patterns Rate Eupnea – Normal – / min Tachypnea –  rate – Pnuemonia, pulm edema, acidosis, septicemia, pain Bradypnea –  rate –  ICP, drug OD

Inspection: Breathing patterns Depth Hyperpnea –  depth Hyperventilation –  depth & rate Hypoventilation –  depth & rate

Inspection: Breathing patterns Depth Kussmaul's –  rate & depth – Assoc. with sever acidosis Apneustic – Prolonged gasping I following by short

Inspection: Breathing patterns Rhythm Apnea – Not breathing Cheyne-stokes – Varying depth f/b apnea – Death rattles – Death rales

Inspection: Breathing patterns Rhythm Biot ’ s –  rate & depth w/ abrupt pauses – Assoc w/  ICP

Inspection: Trachea – ? Deviation Pleural effusion Tension pneumothorax Atelectasis Color LOC Emotional state

Palpation TML – Tenderness (T) – Masses (M) – Lesions (L) Sinuses – Palpate below eyebrow & Cheekbone Crepitus – Subcutaneous emphysema – Air leaks into the sub-q tissue

Percussion Rational To determine if underlying tissue is filled with air or solid material Procedure Pt sitting Tap starting at shoulder compare rt to lf

Percussion: results Resonance – drum like – Normal Hyper-resonance – Too much air – Emphysema Flatness / dull – Fluid or solid – Pleural effusion – Pneumonia – Tumor

Auscultation Purpose Asses air flow through bronchial tree Procedure Diaphragm of stethoscope Superior  inferior Compare rt to lf

Auscultation: Results Normal Vesicular – Lung field – Soft and low Bronchial – Trachea & bronchi – Hollow Bronchovesicular – Mixed – Between scapulae – Side of sternum – 1 st & 2 nd intercostal space

Auscultation: Results Adventitious Crackles – Rales – air  bronchi with secretions Fine crackles – Air  suddenly reinflated Course Crackles – Moist

Auscultation: Results Wheezes – Sonorous wheezes Deep low pitched Snoring > E Caused by air  narrowed passages D/t  secretions – Sibilant Wheezes High pitched Whistle-like I & E Caused by air  narrowed passages D/t constriction – Asthma

Auscultation: Results Pleural friction rub – D/t inflammation of pleural membranes – Grating, creaking – I & E – Best heard Anterior, Lower, lateral area

Auscultation: Results Stridor – Crowing – Partial obstruction of the larynx or trachea

Quiz? A child with difficulty breathing and a “ barking ” cough id displaying signs associated with which condition? A.Asthma B.Croup C.Cystic fibrosis D.Epiglottitis

Quiz? When assessing the lung sounds of a child with asthma, which sound are you most likely to hear? A.Murmurs B.Sonorous Wheezing C.Sibilant Wheezing D.Crackles E.Pleural friction rub

Early & late signs of hypoxia Anxiety Bradycardia Cyanosis Depressed respirations Diaphoresis Disorientation Dyspnea Restlessness Headache Agitation Poor judgment Retraction Tachycardia Tachypnea

The nurse recognizes which of the following as an early sign of hypoxia? A.Restlessness, yawning & tachycardia B.Dyspnea, confusion & bradycardia C.Bradycardia, hypotension dyspnea D.Dyspnea, restlessness, hypotension

Dyspnea Definition – SOB – SOB, flat affect, BS x 4

Dyspnea Significance – Common with cardiac & resp. disease – Sudden onset – healthy person  Pneumothorax – Sudden onset ill, post-op or injury  Pulmonary emboli

Dyspnea Orthopnea – Sit up to breath COPD CHF

Dyspnea Right ventricle – If chronic airway resistance  –  pressure  – Rt ventricle  work  – Rt. Vent damage

Dyspnea Nrs Management – Find cause – Give O 2 – HOB  – Communication KISS

Cough Definition – To expel air from the lungs suddenly – Irritation of mucous membrane

Cough Significance – Infection – Irritants – Protective mechanism – Dry, irritating URT – Cough + chest pain Pleural or musculoskeletal

Cough Nrs management – Assess – Describe – Directed – Pain control Splinting – Infection control – Suppressants / Anti-tussives

Sputum Production Definition Matter discharged from resp. track that contains mucus and pus, blood, fibrin, or bacteria

Sputum Production Significance Purulent – Thick, yellow/green – Bacteria Rusty – Strep or staph Thin, mucous – Viral

Sputum Production Pink-tinged – Lung CA – TB Pink tinged, profuse, frothy – Pulmonary edema Malodorous – Lung abscess

Sputum Production Nrs Management Thick – Hydrate  water Nebulizer Humidifier TCDB No smoking Oral care  Appetite

Do You Know????? What breath sound would you expect to hear on a patient with increased sputum production? A.Vesicular B.Crackles C.Sonorous wheezes D.Sibilant wheezes

Obtaining a sputum specimen Explain – From lungs Sterile cup Deep breath x 3  Cough deeply Expectorate Best time for specimen collection? – AM

A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A.Ask client to cough sputum into container B.Have the client take several deep breaths C.Provide a appropriate specimen container D.Assist with oral hygiene

Chest pain Definition Cardiac or pulmonary

Chest pain Significance CA (late stage) Pneumonia Pulmonary embolism Pleurisy

Chest pain Pleurisy – Inflammation of pleura – Sharp with breath –  breath sounds

What????? What breath sound would you expect to hear on a patient suffering from pleurisy? A.Crackles B.Sonorous wheezes C.Sibilant wheezes D.Pleural Friction Rub

Chest pain Nrs Management Assess Analgesics OK, but … Position for pain – Affected side – Splint

Clubbed fingers Definition Sponginess of the nail bed Loss of the nail bed angle Finger tip is round and bulbous

Clubbed Finger Significance chronic hypoxia Nrs Management Marker

Mr. Caveman: Mr. Caveman enters the ER unconscious following an Automobile accident. The paramedics report that his O2 sats are 86%. You note that Mr. Caveman has clubbed fingers. What does this tell you?

Hemoptysis Definition Expectoration of blood from the respiratory tract

Hemoptysis Significance Pulm or cardiac Common causes – Pulm infection – CA of lungs – Pulm. Emboli – Pulm. Infarction – TB

Hemoptysis – Definition? Coughed up blood – From? Pulm hemorrhage – Description Pink, red, mixed with sputum – Blood pH Alkaline blood Hematemesis – Definition? Vomited blood – From? Stomach / GI – Description “ Coffee ground ” – Blood ph Acidic blood

Hemoptysis Nrs Management Determine source Serious

Cyanosis Definition Bluish coloring of skin

Cyanosis Significance Very late indicator of hypoxia Appears when O2 sats < 85% NOT a reliable sign of hypoxia – Esp. with anemia

Cyanosis O2 sat definition – % of hemoglobin carrying oxygen compared to total # of hemoglobin

Cyanosis Normal Breath 100 O2 molecules  98 cross into blood Blood: 100 Hgb O2 SATS – 98% – No cyanosis

Cyanosis Hypoxia Breath 100 O2 molecules  75 cross into blood Blood: 100 Hgb O2 SATS – 75% – Cyanosis

Cyanosis Anemic and hypoxic Breath 100 O2 molecules  75 cross into blood Blood: 75 Hgb O2 SATS – 100% – No Cyanosis

Cyanosis Nrs. Management Know color of Pt. skin Assess color of tongue & lips Fingernail polish African-American Vasoconstriction (cold weather)  peripheral cyanosis