Physical Assessment of the Respiratory System

Day 2A

History
Physical problems Function problems Life style Smoking Family Hx Occupation hx Allergens en!ironment Recreational exposure Anxiety S"S

 #he nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal $e!elopment% &hich characteristic is associate$ 'ith babies born to mothers 'ho smoke$ $uring pregnancy( A%Lo' birth 'eight )%Large for gestational age *%Preterm birth+ but appropriate si,e for gestation D%-ro'th retar$ation in 'eight an$ length

.nspection
/ormal chest
Slight retraction of intercostal spaces 2x as 'i$e as $eep Anterior posterior $iameter
012

.nspection
)arrel chest
D t o!er inflation of lungs anterior2posterior $iameter
212

.nspection
Funnel chest
Depression of the lo'er portion of the sternum *omplications
Heart $amage *ar$iac output

/rs management
3urmurs

.nspection
Pigeon chest
Sternum protru$es out'ar$ anterior2posterior $iameter

.nspection
Scoliosis
Lateral cur!ature of thoracic spine Assessment
Shoul$ers ele!ate$(

*omplications
Lung " heart $amage )ack problems )o$y image

4ui,(
A% )% *% D% Ho' many hours a $ay shoul$ a chil$ 'ear a brace for treating scoliosis( 5 hr 02 hr 26 hr 27 hr

.nspection
8yphosis
A8A
Hunchback

Abnormal cur!ature of the thoracic spine

.nspection
Lor$osis
A8A
S'ay2back

Abnormal cur!ature of the lumbar spine

.nspection
9niform expansion of the chest
Pneumonia Pleural effusion Pneumothorax

)ulging intercostal spaces

Obstruction :mphysema

.nspection
3arke$ retraction of intercostal spaces
)lockage

Shoul$er rise Accessory muscles Posture

.nspection1 )reathing patterns

Rate :upnea
/ormal 0222; min

#achypnea
rate Pnuemonia+ pulm e$ema+ aci$osis+ septicemia+ pain

)ra$ypnea
rate .*P+ $rug OD

.nspection1 )reathing patterns

Depth Hyperpnea
$epth

Hyper!entilation
$epth " rate

Hypo!entilation
$epth " rate

.nspection1 )reathing patterns

Depth 8ussmaul<s
rate " $epth Assoc% 'ith se!er aci$osis

Apneustic
Prolonge$ gasping . follo'ing by short

.nspection1 )reathing patterns

Rhythm Apnea
/ot breathing

*heyne2stokes
=arying $epth f b apnea Death rattles Death rales

.nspection1 )reathing patterns

Rhythm )iots
rate " $epth ' abrupt pauses Assoc ' .*P

.nspection1
#rachea
( De!iation
Pleural effusion #ension pneumothorax Atelectasis

*olor LO* :motional state

Palpation
#3L
#en$erness >#? 3asses >3? Lesions >L?

Sinuses
Palpate belo' eyebro' " *heekbone

*repitus
Subcutaneous emphysema Air leaks into the sub2@ tissue

Percussion
Rational #o $etermine if un$erlying tissue is fille$ 'ith air or soli$ material Proce$ure Pt sitting #ap starting at shoul$er compare rt to lf

Percussion1 results
Resonance $rum like
/ormal

Hyper2resonance
#oo much air :mphysema

Flatness $ull
Flui$ or soli$ Pleural effusion Pneumonia #umor

Auscultation
Purpose Asses air flo' through bronchial tree Proce$ure Diaphragm of stethoscope Superior inferior *ompare rt to lf

Auscultation1 Results
/ormal =esicular
Lung fiel$ Soft an$ lo'

)ronchial
#rachea " bronchi Hollo'

)roncho!esicular
3ixe$ )et'een scapulae Si$e of sternum 0st " 2n$ intercostal space

Auscultation1 Results
A$!entitious *rackles
Rales air bronchi 'ith secretions

Fine crackles
Air su$$enly reinflate$

*ourse *rackles
3oist

Auscultation1 Results
&hee,es
Sonorous 'hee,es
Deep lo' pitche$ Snoring A: *ause$ by air narro'e$ passages D t secretions

Sibilant &hee,es
High pitche$ &histle2like .": *ause$ by air narro'e$ passages D t constriction
Asthma

Auscultation1 Results
Pleural friction rub
D t inflammation of pleural membranes -rating+ creaking .": )est hear$
Anterior+ Lo'er+ lateral area

Auscultation1 Results
Stri$or
*ro'ing Partial obstruction of the larynx or trachea

4ui,(
A chil$ 'ith $ifficulty breathing an$ a barking cough i$ $isplaying signs associate$ 'ith 'hich con$ition( Asthma *roup *ystic fibrosis :piglottitis

A% )% *% D%

4ui,(
A% )% *% D% :% &hen assessing the lung soun$s of a chil$ 'ith asthma+ 'hich soun$ are you most likely to hear( 3urmurs Sonorous &hee,ing Sibilant &hee,ing *rackles Pleural friction rub

:arly " late signs of hypoxia

Anxiety )ra$ycar$ia *yanosis Depresse$ respirations Diaphoresis Disorientation Dyspnea Restlessness Hea$ache Agitation Poor Bu$gment Retraction #achycar$ia #achypnea

#he nurse recogni,es 'hich of the follo'ing as an early sign of hypoxia( A% Restlessness+ ya'ning " tachycar$ia )% Dyspnea+ confusion " bra$ycar$ia *% )ra$ycar$ia+ hypotension $yspnea D% Dyspnea+ restlessness+ hypotension

Dyspnea
Definition
SO)

SOB, flat affect, BS x 4

Dyspnea
Significance
*ommon 'ith car$iac " resp% $isease Su$$en onset C healthy person
Pneumothorax

Su$$en onset ill+ post2op or inBury

Pulmonary emboli

Dyspnea
Orthopnea
Sit up to breath
*OPD *HF

Dyspnea
Right !entricle
.f chronic air'ay resistance pressure Rt !entricle 'ork Rt% =ent $amage

Dyspnea
/rs 3anagement
Fin$ cause -i!e O2 HO) *ommunication
8.SS

*ough
Definition
#o expel air from the lungs su$$enly .rritation of mucous membrane

*ough
Significance
.nfection .rritants Protecti!e mechanism Dry+ irritating
9R#

*ough D chest pain

Pleural or musculoskeletal

*ough
/rs management
Assess Describe Directe$ Pain control
Splinting

.nfection control Suppressants Anti2tussi!es

Sputum Pro$uction
Definition 3atter $ischarge$ from resp% track that contains mucus an$ pus+ bloo$+ fibrin+ or bacteria

Sputum Pro$uction
Significance Purulent
#hick+ yello' green )acteria

Rusty
Strep or staph

#hin+ mucous
=iral

Sputum Pro$uction
Pink2tinge$
Lung *A #)

Pink tinge$+ profuse+ frothy

Pulmonary e$ema

3alo$orous
Lung abscess

Sputum Pro$uction
/rs 3anagement #hick
Hy$rate
'ater /ebuli,er Humi$ifier

#*D) /o smoking Oral care Appetite

Do Eou 8no'(((((
&hat breath soun$ 'oul$ you expect to hear on a patient 'ith increase$ sputum pro$uction( A% =esicular )% *rackles *% Sonorous 'hee,es D% Sibilant 'hee,es

Obtaining a sputum specimen

:xplain
From lungs

Sterile cup Deep breath x 6 *ough $eeply :xpectorate )est time for specimen collection(
A3

A nurse is to collect a sputum specimen for aci$2 fast bacillus >AF)? from a client% &hich action shoul$ the nurse take first( A%Ask client to cough sputum into container )%Ha!e the client take se!eral $eep breaths *%Pro!i$e a appropriate specimen container D%Assist 'ith oral hygiene

*hest pain
Definition *ar$iac or pulmonary

*hest pain
Significance *A >late stage? Pneumonia Pulmonary embolism Pleurisy

*hest pain
Pleurisy
.nflammation of pleura Sharp 'ith breath breath soun$s

&hat(((((
&hat breath soun$ 'oul$ you expect to hear on a patient suffering from pleurisy( A% *rackles )% Sonorous 'hee,es *% Sibilant 'hee,es D% Pleural Friction Rub

*hest pain
/rs 3anagement Assess Analgesics O8+ but Position for pain
Affecte$ si$e Splint

*lubbe$ fingers
Definition Sponginess of the nail be$ Loss of the nail be$ angle Finger tip is roun$ an$ bulbous

*lubbe$ Finger
Significance chronic hypoxia /rs 3anagement 3arker

3r% *a!eman1

3r% *a!eman enters the :R unconscious follo'ing an Automobile acci$ent% #he parame$ics report that his O2 sats are 5FG% Eou note that 3r% *a!eman has clubbe$ fingers% &hat $oes this tell you(

Hemoptysis
Definition :xpectoration of bloo$ from the respiratory tract

Hemoptysis
Significance Pulm or car$iac *ommon causes
Pulm infection *A of lungs Pulm% :mboli Pulm% .nfarction #)

Hemoptysis
Hemoptysis
Definition(
*oughe$ up bloo$

Hematemesis
Definition(
=omite$ bloo$

From(
Pulm hemorrhage

From(
Stomach -.

Description
Pink+ re$+ mixe$ 'ith sputum

Description
*offee groun$

)loo$ pH
Alkaline bloo$

)loo$ ph
Aci$ic bloo$

Hemoptysis
/rs 3anagement Determine source Serious

*yanosis
Definition )luish coloring of skin

*yanosis
Significance =ery late in$icator of hypoxia Appears 'hen O2 sats H 5IG /O# a reliable sign of hypoxia
:sp% 'ith anemia

*yanosis
O2 sat $efinition
G of hemoglobin carrying oxygen compare$ to total J of hemoglobin

*yanosis
/ormal
)reath 0;; O2 molecules K5 cross into bloo$ )loo$1 0;; Hgb O2 SA#S
K5G /o cyanosis

*yanosis
Hypoxia
)reath 0;; O2 molecules LI cross into bloo$ )loo$1 0;; Hgb O2 SA#S
LIG *yanosis

*yanosis
Anemic an$ hypoxic
)reath 0;; O2 molecules LI cross into bloo$ )loo$1 LI Hgb O2 SA#S
0;;G /o *yanosis

*yanosis
/rs% 3anagement 8no' color of Pt% skin Assess color of tongue " lips Fingernail polish African2American =asoconstriction >col$ 'eather? peripheral cyanosis