Physical Assessment of the Respiratory System Day 2A
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 • i Cardiac output – Nrs management • Murmurs Inspection • Pigeon chest – Sternum protrudes outward – anterior-posterior diameter • h Inspection • Scoliosis – Lateral curvature of thoracic spine – Assessment • Shoulders elevated? – Complications • Lung & heart damage • Back problems • Body image Quiz? • A. B. C. D. How many hours a day should a child wear a brace for treating scoliosis? 8 hr 12 hr 23 hr 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 – 12-20 / min • Tachypnea – h rate – Pnuemonia, pulm edema, acidosis, septicemia, pain • Bradypnea – i rate – h ICP, drug OD Inspection: Breathing patterns Depth • Hyperpnea – h depth • Hyperventilation – h depth & rate • Hypoventilation – i depth & rate Inspection: Breathing patterns Depth • Kussmaul's – h 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 – h rate & depth w/ abrupt pauses – Assoc w/ h 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 1st & 2nd 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 h 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. B. C. D. A child with difficulty breathing and a “barking” cough id displaying signs associated with which condition? Asthma Croup Cystic fibrosis Epiglottitis Quiz? • A. B. C. D. E. When assessing the lung sounds of a child with asthma, which sound are you most likely to hear? Murmurs Sonorous Wheezing Sibilant Wheezing Crackles 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. B. C. D. Restlessness, yawning & tachycardia Dyspnea, confusion & bradycardia Bradycardia, hypotension dyspnea 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 – h pressure – Rt ventricle h work – Rt. Vent damage Dyspnea • Nrs Management – Find cause – Give O2 – HOB h – 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 • h water • Nebulizer • Humidifier • • • • TCDB No smoking Oral care h 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 – i 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 • 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
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