Respiratory System Anatomy & Physiology

• Respiratory Assessment focuses on assessing the thorax and lungs.
• Learning objectives involve identifying the respiratory system structure and function.
• Recognize thoracic region anatomical landmarks.
• Obtain subjective data related to the respiratory system.
• Discuss the steps of respiratory assessment; inspection, palpation, percussion & auscultation of the anterior & posterior chest
• Identify nursing diagnoses for selected abnormalities.

Anatomical Landmarks

• The thoracic cage is a bony structure featuring a conical shape.
• Thoracic cage is defined by the sternum, 12 pairs of ribs, and 12 thoracic vertebrae.
• The diaphragm is the "floor" of the thoracic cage.
• The diaphragm is dome shaped
• Anterior Thoracic landmarks include the Suprasternal notch, Sternum angle, and Costal angle.
• Posterior Thoracic Landmarks include the vertebral prominence, spinous process, and the inferior border of the scapula and twelfth rib.
• Mediastinum is the thoracic cavity's middle section, containing the esophagus, trachea, heart, and great vessels.

Reference Lines

• Anterior, Posterior and Lateral Reference Lines serve as anatomical landmarks during assessment.
• Anterior Reference Lines consists of the midsternal line and the midclavicular line.
• Anterior reference lines are forward of the axial.
• Posterior Reference Lines consists of the vertebral line, and scapular line.
• Lateral Reference Lines consists of the anterior axillary line, posterior axillary line and the midaxillary line.

Location of Lungs

• Lung areas extend from the apices at C7 to the bases around T10.
• Lung areas are located laterally from the axilla down to the 7th and 8th rib.
• There is no lung that extends more than the 8th rib

Structures of Respiratory System

• The trachea lies anterior to the esophagus.
• The trachea starts at the level of the cricoid cartilage.
• Trachea then bifurcates just below the sternal angle into the right and the left main bronchi.
• The trachea and bronchi transport gases between the environment and lungs.
• Alveoli are clustered like grapes around each alveolar duct.
• This clustering of alveoli arrangement creates a surface area for gas exchange.

Mechanism of Respiration

• Breathing happens through inspiration and expiration.
• Respiration involves inhaling and exhaling.
• Involuntary control of respiration is mediated by the respiratory center in the brain stem.
• Normal stimulus to breathe increases CO₂ (hypercapnia) and decreases O₂ in the blood (hypoxemia), (less effective).

Data Collection

• Important subjective data includes; chest pain with breathing, a cough, shortness of breath, and a history of respiratory infections.
• Also important is information about Smoking history, environmental exposure and self-care behaviors
• Objective Assessment includes a physical examination involving inspection, palpation, percussion and auscultation.

Subjective Assessment: Chest Pain

• Chest pain of thoracic origin includes muscle soreness from coughing or inflammation.
• Determine if the patient is experiencing any chest pain with breathing.
• Ask the patient to point to the exact location of the pain.
• Determine the factors that increase and decrease the pain.
• Describe the pain, assess the timing of the pain, and ask what measures have been taken to alleviate the pain.
• Determine if the pain is associated with fever, deep breathing, and unequal chest inflation.

Subjective Assessment: Cough

• Determine if the patient has a cough and when it started.
• Determine if the cough came on gradually or suddenly
• Determine how often the patient coughs.
• Determine if there is a special time of day the patient coughs, such as the morning or at night.
• Determine if the cough wakes the patient up at night.
• Timing assessment includes
• Early morning is chronic bronchial inflammation of smokers, afternoon/evening is exposure to irritants.
• Asking about cough at night is associated with post nasal drip/sinusitis.
• Coughing throughout the day is associated with acute respiratory tract infection (RTI)

Subjective Assessment: Cough

• Type includes dry and productive.
• Characteristics of the sputum from a cough include; color, amount, presence of blood, or foul odor
• Sputum containing blood is hemoptysis
• White/clear mucoid sputum is associated with colds, bronchitis, or viral infection.
• Yellow/green sputum is associated with bacterial infection.
• Rust colored sputum is associated with TB and pneumonia
• Pink and frothy colored sputum is associated with pulmonary edema
• Quality questions include asking the patient to describe the cough; hacking, dry, barking , and congested (wet)

Subjective Assessment: Shortness of Breath

• Determine if the patient has had any shortness of breath.
• Identify what brings on the shortness of breath, its severity, and whether it is affected by position.
• Determine if onset occurs at any specific time, and whether any activity precipitates the symptom.
• Orthopnea: difficult breathing when supine.
• Paroxysmal nocturnal dyspnea: awakening from sleep with shortness of breath, needing to be upright.
• Determine if the SOB episodes are associated with any factors; such as night sweats, cough, chest pain, wheezing.
• Determine if the SOB is related to food, pollens, dust, animals, season, or emotions.
• Cyanosis: bluish color around lips and/or nails, and signals hypoxia.
• Determine what the patient does in a hard breathing attack.
• Ask the patient about relieving measures of hard breathing attacks.
• Determine how shortness of breath affects the patient's work or activity of daily living

Subjective Assessment: History of Respiratory Infections

• Ask the patients about any past history of breathing trouble or lung diseases, such as Bronchitis, Emphysema, Pneumonia, Atelectasis, Pleural Effusion, Asthma.
• Determine if the patient has any unusual frequent or severe colds.
• Check if there is any Family history of Tuberculosis, Asthma, Allergies

Subjective Assessment: Smoking History

• Determine if the patient smokes cigarettes or cigars
• Determine at what age the patient started smoking
• Determine the amount smoked expressed in packs per day.
• Determine if the patient has any quitting attempts.
• Ask about passive smoking, and if the patient if they live with someone else who smokes.

Subjective Assessment: Environmental Exposure

• Evaluate of there are any any environmental conditions that may affect the breathing.
• Determine where the patient works; in a factory, chemical plant, farming, in heavy traffic area
• Determine if the patient wears masks or have the ventilator system checked.

Subjective Assessment: Self Care Behaviors

• Determine if the patient has had a TB skin test, Chest X ray, Pneumonia and Influenza immunization

Objective Assessment: Preparation

• Proper preparation includes asking the person to sit upright.
• Ask a man to disrobe to the waist.
• Ask a woman to leave gown on & open at the back, when examining anterior chest, lift the gown up and drape it on her shoulder.
• Ensure the room is warm with the diaphragm end piece, the patient should be in a private room with no interruption.
• Perform Inspect- palpate- percuss- auscultate; on posterior chest, then move to face and repeat the same maneuver on the anterior chest
• Necessary equipment: Stethoscope and alcohol swap.

Objective Assessment: Posterior Chest INSPECTION

• Inspect shape and configuration to identify deviations.
• Configuration includes normal neck (trapezius) muscles.
• Symmetric thorax, in an elliptical (oval) shape.
• Note the configuration of the thorax, and the ratio of anteroposterior (AP) diameter to transverse diameter.
• Anteroposterior diameter to transverse measure should be 1:2
• Straight spinous process.
• Symmetrically placed scapulae.
• Inspect if person takes to breathe with a relaxed posture with arms comfortably at the sides.
• Assess the skin color and condition, and compare with patient's background.
• there should be no cyanosis or pallor present.
• Note any presence of lesions.

Objective Assessment: Abnormal Configuration

• Abnormal anterior configuration consists of a "Barrel chest"
• Barrel chest is the result of when the AP diameter = Transverse diameter
• Thoracic Deformities include barrel chest, scoliosis and kyphosis
• Barrel chest shows equal anteroposterior-to-transverse diameter
• Scoliosis shows lateral curvature of the thoracic and lumbar spine
• Kyphosis shows posterior curvature of thoracic spine causing pain and limited mobility

Objective Assessment: Posterior Chest PALPATION

• Using the fingers, gently palpate over the entire chest wall for; tenderness, moisture, skin temperature and superficial lumps or masses.
• For symmetric expansion, place your hands on the posterolateral chest wall, at the level of T9 or T10. pinch skin fold .
• Ask the person to take a deep breath. Thumbs should normally move apart
• Normal finding is symmetrical expansion.
• Unequal chest expansion occurs with atelectasis, pneumonia, trauma, and fractured ribs.
• Tactile (Vocal) Fremitus is a palpable vibration generated from larynx and transmitted through bronchi and lung to chest wall.
• Use palmar base of the fingers or ulnar edge of one hand and touch person's while he repeats resonant phrases ("ninety-nine" or "blue-moon)
• Normal: vibration is same in all areas (symmetry)

Objective Assessment: Posterior Chest PERCUSSION

• Determine the predominant note over the lung fields.
• Start at the apices, then in the interspaces.
• Make side to side comparison all the way down the lung field.
• Avoid scapula and ribs.
• Normal: note resonance sound.

Percussion Notes

• Resonance: Normal/Healthy, Clear and hollow sound, loud.
• Resonance predominates in healthy lung tissue.
• Hyper-resonance: Too much air is present / normal in Children.
• Booming sound, loud; when too much air is present.
• Dull note: Abnormal, it indicates tumor / Pneumonia
• Soft sound, signals abnormal density in the lung; tumor, pneumonia.

Objective Assessment: Posterior Chest AUSCULTATION

• Use the diaphragm of the stethoscope and hold it firmly over the person's chest.
• Listen to at least one full respiration in each location, making side to side comparisons.
• Become familiar with the extraneous noises
• Ask the person to sit and lean forward slightly, rest arms comfortably over the lap, and take a deep breath through the mouth, but stop if feeling dizzy due to hyperventilation.
• Assess the presence and quality of breath sounds.
• Listen to the lung areas from the apices at C7 to the bases (around) T10, laterally from the axilla down to 7th & 8th rib.
• One expects to hear one of the normal breath sounds.
• Listen for breast sounds and adventitious sounds.

Objective Assessment: Common extraneous noises

• Equipment artifact from Stethoscope tubing bumping together Patient condition includes
• Patient's shivering.
• Patient's hairy chest.
• Environment includes Rustling of paper gown or paper drape.
• You want to listen to correct sound properly

Location of Normal Breath Sounds

• Listen for vesicular sounds peripherally.
• Locate bronchovesicular sounds anteriorly between the peripheral areas.

Characteristics of Normal Breath Sounds

• Breath sound classifications include:
  • Bronchial (tracheal).
  • Bronchovesicular.
  • Vesicular.
• Each breath sound location has respective qualities that indicate where and how they should sound to make sure lungs are healthy

Objective Assessment: Adventitious Sounds

• Sounds that are not normally heard in the lungs.
• Crackles (rales): High pitch-short popping sound heard over inspiration, note cleared by coughing
• Crackles are commonly found in patients with pneumonia.
• Wheezes - High-pitched, musical sound - Heard over expiration but may occur in both.
• Air is squeezed through narrowed to closure passageways by swelling or collapsing.
• Stridor - High pitched, crowing, snoring sound, louder in the neck than over the chest wall - originates at the larynx or trachea as evidence by upper airway obstruction

Objective Assessment: Anterior Chest INSPECTION

• Assess the quality of respiration by observing relaxed breathing, and if it is automatic, effortless, regular and even, produces no noise.
• Anterior Chest should expand symmetrically with each inspiration.
• Accessory muscles should not be used.
• Inspect for symmetrical interspaces, ribs sloping downwards, a relaxed patient and note any cyanosis.
• Respiratory rate should be within normal limits (10-20 breath/min) for the person's age

Objective Assessment: Abnormal Anterior Chest Findings

• Noisy breathing.
• Lung not working or- ribs fractured not allowing lung to expand causes Unequal chest expansion.
• Accessory muscles being used and retraction.
• Tachypnea (Increase RR above 20/min).
• Hyperventilation increase the depth of breathing, and may be due to anxiety or exertion.
• Bradypnea (decrease RR below 10/min).
• Hypoventilation (decrease depth of breathing).
• Tense, strained, tired face.
• Clubbing of fingers

Objective Assessment: Anterior Chest PALPATION

• Gently palpate the skin the mobility and turgor, temperature, and moisture
• Feel for tenderness and superficial lumps or masses.
• Check area with thumb to see how thumbs are being propelled, it should feel smooth and symetrical

Objective Assessment: Anterior Chest Percussion

• Percuss over the lung apices in the supraclavicular areas, interspaces, and compare one side to the other.

Objective Assessment: Anterior Chest Expected Percussions

• Note the borders of cardiac dullness normally on the anterior chest.
• On the right side, the upper border of liver dullness is located in the 5th intercostal space (ICS) in the Rt MCL.
• On the left, tympany is evident over the gastric space.

###Objective Assessment: Anterior Chest AUSCULTATION

• Auscultate from the apices at the supraclavicular area down to the 6th rib
• Avoid percussing over female breast tissue, shift the hand slightly.
• Normally, there is a presence of normal breast sounds

Nursing Diagnois

• Potential nursing diagnoses include; impaired gas exchange, ineffective airway clearance, and ineffective breathing pattern. Examples:
• Impaired gas exchange relates to inadequate oxygen perfusion.
• Ineffective airway clearance is related to excessive mucus.
• Ineffective breathing patterns related to inflammation of the lungs. -Activity intolerance is related to exhaustion associated with sleep pattern interruption.

Questions cover key aspects of the respiratory system. Topics include lung anatomy, trachea and bronchi function, gas exchange, respiratory control mechanisms. Also covers physical examination techniques and adventitious lung sounds.