1. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 29 Assessment of the Respiratory System

2. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 29 Assessment of the Respiratory System Learning Outcomes 1. Teach patients and family members about what to expect during tests and procedures to assess respiratory function and respiratory disease. 2. Use concepts of anatomy and appropriate psychomotor skills to apply respiratory assessment techniques correctly. 3. Perform a clinical respiratory assessment, including health history, genetic risk, physical assessment, and psychosocial assessment.

3. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 29 Assessment of the Respiratory System Learning Outcomes (Continued) 4. Distinguish between normal and abnormal (adventitious) breath sounds. 5. Explain the respiratory changes associated with aging. 6. Calculate the pack-year smoking history for the patient who smokes or who has ever smoked cigarettes. 7. Interpret arterial blood gas values to assess the patient's respiratory status. 8. Explain nursing care needs for the patient after bronchoscopy or open lung biopsy.

4. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Anatomy & Physiology Review Upper respiratory tract Lower respiratory tract Oxygen delivery and the oxygen- hemoglobin dissociation curve Figure 29-8

5. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Role of the Respiratory System

6. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Patient Health 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

7. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment of the Nose & Sinuses External nose—deformities or tumors Nares—symmetry of size and shape Nasal cavity—color, swelling, drainage, bleeding

8. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment of the Nose & Sinuses (cont’d) Mucous membranes—abnormalities Septal deviation Nasal polyps

9. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment of the Nose & Sinuses (cont’d)

10. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment of the Pharynx, Trachea, & Larynx Mouth Neck—symmetry, alignment, masses, swelling, bruises, use of accessory neck muscles for breathing Trachea—palpate for position, mobility, tenderness, masses

11. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment of the Pharynx, Trachea, & Larynx (cont’d)

12. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 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

13. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 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

14. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment of the Lungs & Thorax (cont’d) Diaphragmatic excursion Lung sounds Table 29-4 – Bronchial – Bronchovesicular – Vesicular

15. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment of the Lungs & Thorax (cont’d) Adventitious sounds Table 29-5 – Crackles – Wheezes – Rhonchi – Pleural friction rub

16. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment of the Lungs & Thorax (cont’d)

17. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment of the Lungs & Thorax (cont’d)

18. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Other Indicators of Respiratory Adequacy Clubbing Weight loss Unevenly developed muscles Skin and mucous membrane changes General appearance Endurance

19. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 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

20. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Study Chart 29-1 Changes in the Respiratory System Related to Aging Alveoli Lungs Pharynx and Larynx Pulmonary Vasculature Exercise Tolerance Muscle Strength Susceptibility to Infection Chest Wall

21. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Laboratory Tests Blood Sputum Standard chest x-rays, CT Pulse oximetry (noninvasive)

22. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Pulmonary Function Testing Noninvasive Evaluate lung function and breathing problems

23. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Capnometry & Capnography Noninvasive Measure amount of carbon dioxide present in exhaled air

24. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Other Noninvasive Testing Exercise testing Skin testing

25. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 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

26. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Position for Thoracentesis

27. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Lung Biopsy Invasive Obtain tissue to diagnose for cancer, infection, inflammation or other lung diseases May be performed in OR or radiology department depending on the type of biopsy done

28. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 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

29. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 1 Which of these is an expected outcome for the older adult related to the natural aging process of the respiratory system? A.Tightening of the vocal cords B.Decrease in the anteroposterior diameter C.Decrease in respiratory muscle strength D.Decrease in residual volume

30. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 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/articl e/004011.htm)

31. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 2 Under normal physiologic conditions of tissue perfusion, what percent of oxygen dissociates from the hemoglobin molecule? A.25% B.50% C.75% D.100%

32. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 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.)

33. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 3 Which is considered a main sign of lung disease? A.Dyspnea B.Cough C.Sputum production D.Chest pain

34. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 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.