The Respiratory System Thorax and Lungs Rachel S. Natividad, RN, MSN

Lobes and Landmarks

Performing the Assessment: Subjective Data ROS -Ask about dyspnea, cough, chest pain (PQRST format) ROS -Ask about dyspnea, cough, chest pain (PQRST format) Short interview sessions if resp. distress / tiring easily Short interview sessions if resp. distress / tiring easily Past health history Past health history –AllergiesMeds –ImmunizationsTravel history –Childhood illnessFamily history –HospitalizationsTB, smoking Psychosocial Assessment Psychosocial Assessment

Assessment Cont.: Objective Data Inspection… …Always first!!!

Assessment begins…. The moment you see the patient. The moment you see the patient. What position is most comfortable for him? Does he appear relaxed, anxious, uncomfortable? Is he having any trouble breathing? Tripod Position

Focused Assessment (con’t) Inspection Inspection Color, Size and shape & symmetry of chest, any lesions or scars Color, Size and shape & symmetry of chest, any lesions or scars –Anterior LateralPosterior

Altered size/shape: Barrel Chest Increased AP:Transverse Diameter Increased AP:Transverse Diameter Costal angle >90 degrees Costal angle >90 degrees 1:22:1

Barrel Chest

Asymmetrical chest Scoliosis

Normal Breathing

Intercostal Spaces and Muscles Retractions

Focused Assessment Cont… Resp. rate and depth Resp. rate and depth Pattern of respiration – regular rhythm Pattern of respiration – regular rhythm Abnormal patterns Abnormal patterns –Hyperventilation –Tachypnea vs. bradypnea –Stertorous (Noisy)

Looking at related structures Skin: cyanosis, pallor Skin: cyanosis, pallor Nails: Clubbing Nails: Clubbing –Spongy nail matrix and nail angle of greater than 160 degrees

Focused Assessment Cont.: Palpation Check for tenderness Check for tenderness (normally nontender) Crepitus – SQ air pockets Crepitus – SQ air pockets Tactile fremitus – increased with fluid accumulation Tactile fremitus – increased with fluid accumulation Abnormal if tumor, fractured ribs, chest tubes, wound site, fluid

Focused Assessment: Auscultation

Normal Breath Sounds

Adventitious/Abnormal Breath Sounds (T 11-2) p.132 Continuous sounds Wheezes Wheezes –Sibilant –Sonorous (Rhonchi) Discontinuous sounds Crackles (Rales) Crackles (Rales) –Fine –Course –*Atelectic crackles –Pleural friction rub

Wheezes (Continuous) Sibililant wheeze high-pitched musical sounds heard first when a patient exhales high-pitched musical sounds heard first when a patient exhales Partial blockage in airflow Partial blockage in airflow Sonorous wheeze (rhonchi) low pitched – snoring, rattling sound low pitched – snoring, rattling sound heard primarily when the pt exhales Air passes through large airways filled with fluid/ secretions Air passes through large airways filled with fluid/ secretions

Crackles (Discontinuous) FINE /COURSEFINE /COURSE Caused by collapsed or fluid- filled alveoli popping openCaused by collapsed or fluid- filled alveoli popping open usually heard in the lung bases during inhalation usually heard in the lung bases during inhalation Atelectic crackles Pleural friction rub – pericarditis

Abnormal Breath Sounds Diminished breath sounds Diminished breath sounds Absent breath sounds Absent breath sounds

Interpreting what you hear… Note whether the sound occur during inhalation or exhalation, or both. Note whether the sound occur during inhalation or exhalation, or both.

Assessment Guide: Gas Exchange –Respiratory Rate: 18 resp/min Rate: 18 resp/min Depth: deep, even, shallow Depth: deep, even, shallow Effort: labored, unlabored Effort: labored, unlabored –Breath Sounds Describe: clear, rhonchi, inspiratory/expiratory wheezes, crackles Describe: clear, rhonchi, inspiratory/expiratory wheezes, crackles Location: all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat. Location: all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat. Cough: present/not present Cough: present/not present Describe: productive, moist, nonproductive Describe: productive, moist, nonproductive Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum. Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.

Interventions in use: Interventions in use: Position, Turn, Cough, Deep breathe Position, Turn, Cough, Deep breathe O2 Method: nc, venti mask, rebreathing mask O2 Method: nc, venti mask, rebreathing mask –Flow rate: 2L/min; 3l/min –Humidity: yes/no Pulse Oximeter: continuous, spot monitoring Pulse Oximeter: continuous, spot monitoring Incentive Spirometer: in use, n/a Incentive Spirometer: in use, n/a –Time used: 10 am, 11 am, 1 pm, 3 pm –Volume: 500 cc, 500 cc, 600 cc, 800 cc Oropharyngeal Suctioning: Describe- moderate amount thick tan secretions Oropharyngeal Suctioning: Describe- moderate amount thick tan secretions Med List: Albuterol inhaler, Prednisone, Theophylline Med List: Albuterol inhaler, Prednisone, Theophylline