NSB103 Health Assessment PDF

Learning This Week NSB103 Health Assessment Respiratory Assessment...

Learning This Week NSB103 Health Assessment Respiratory Assessment Overview of the Respiratory System General Approach to Patient Assessment Paul Jarrett Focused Respiratory Assessment Vital signs: Respirations and Oxygen Saturations Acknowledgement: 4 Assessment Techniques Karen Wynne Lifespan Approach to Respiratory Assessment Pauline Gillan (UC) Common Respiratory Problems Clinical Reasoning Cycle en-la-computadora-portatil-grande_1253706.htm 1 2 Structure of the Respiratory System Anatomy and Physiology of the Purpose: To maintain an adequate oxygen level in the blood Respiratory System to support cellular life Functions: Supply oxygen Eliminate Carbon dioxide Gas exchange and humidifier Consists of: Upper Respiratory Tract: Nose Mouth Throat (Pharynx) Larynx Lower Respiratory Tract: Trachea Thorax Ribs and Intercostal spaces Lungs (Primary Bronchi; Bronchioles; Alveoli; Pleurae) https://nurseslabs.com/respiratory-system/ 3 4 Anatomy of the Lungs Surfaces and Borders of Lungs Pleura and lung cavity 2 layers membrane– fluid between Cone-shaped organs that fill the lateral Outer layer – chest cavity chamber of the thoracic cavity Inner layer – lungs Do not stick together Right lung has three lobes Left lung has two lobes Pleural fluid Lubricates the surfaces The lobes of the lungs are divided by Reduces friction grooves called fissures. Adhesive characteristic Pleura: Creates surface tension to maintain lung position parietal pleura visceral pleura Alveoli Mediastinum – space between 2 lungs Middle thorax Mediastinum or interpleural space: Diaphragm Between left and right pleural sacs trachea. Bronchi: External intercostal Diaphragm https://opentextbc.ca/anatomyandphysiology/chapter/22-2-the-lungs/ right muscles Muscle that both lung bases rest left. Accessory muscles. Concave shape Separates chest cavity from abdominal cavity 5 6 1  Respiratory System Lung Parenchyma Terminal Bronchioles Vasculature Each lung – one pulmonary artery and 2 pulmonary veins Alveoli Innervation – branches of the vagus nerve and phrenic nerve Tiny air filled balloon like sacs Elasticity – tendency to try to maintain its shape – recoil Primary functioning of lungs Vital role in gas exchange Bronchi and bronchioles – bronchial tree Walls lined with pulmonary surfactant Trachea reaches lungs and divides to bronchi Bronchi divide to bronchioles Vital role in surface tension to prevent collapse Which branch into terminal bronchioles Keeps lung shape Each lung has about 30,000 bronchioles 1mm in diameter Each lung will have 400 million to 700 million Connective tissue, smooth muscles Can cover 70 square meters https://www.therespiratorysystem.com/bronchioles/ Further divide into alveoli Alveoli encircled by pulmonary vessels http://scalar.usc.edu/works/lope/respiratory-system-diagram 7 8 Alveolar Epithelium and Gas Exchange Diaphragm Function and Breathing Is both voluntary and involuntary muscle Alveolar epithelium: https://antranik.org/the-respiratory-system/ Main function One cell thick walls Control lung volume Type 1 squamous alveolar epithelial cells 95% surface Contraction – flattens towards abdomen Process of gas exchange Drags pleura (membrane around lungs) Type 2 great alveolar epithelial cells Reduces air pressure within lungs 5% of surface https://medical-dictionary.thefreedictionary.com/alveolar-capillary+membrane Air from outside rushes in secreting surfactant Maintain elastic recoil Gas exchange occurs in alveoli CO2/ O2 Diaphragm relaxes and pushes air out https://www.therespiratorysystem.com/diaphragm/ https://www.therespiratorysystem.com/alveoli/ 9 10 Respiratory Assessment: Remember The Respiratory System: Defence Mechanisms Handwashing! Upper respiratory tract mucosa Every physical assessment begins with hand Temperature, humidify, traps, removes hygiene Nasal hairs and turbinates Alcohol-based hand rub Traps, removes Non-antimicrobial soap and water Antimicrobial soap and water Figure 4.4 page 84 Mucous blanket Figure 4.3 page 84 Protects trachea and bronchi, traps Cilia Propel mucous blanket, traps Five critical moments of hand Alveolar macrophages washing are? Ingest, remove – phagocytosis https://bronchiectasisnewstoday.com/2016/06/14/primary-ciliary-dyskinesia- should-regularly-be-considered-in-bronchiectasis-study-finds/ Irritant receptors in nostrils, trachea and large airways Stimulation by chemical or mechanical – triggers sneeze 11 12 2  Equipment for Respiratory Assessment Preparing for a Physical Assessment Introduce yourself; Explain what you plan to do and how long it will take and why it may take time performing this assessment Maintain privacy; ensure patient comfort throughout procedure; warm all equipment; https://www.staples.co.uk/gel-pens/cbs/297924951.html If the patient complains of fatigue, continue the assessment later https://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUK Position patient; Ensure the patient is accessible from both sides of the bed or examination table; If a bed is used, raise the bed to an appropriate height Proceed using a systematic approach; e.g. the head-to-toe approach. https://www.ebay.com/itm/ADC-Blood-Pressure-Monitor-Aneroid-Sphygmomanometer Thank the patient when the exam is concluded Thoroughly document findings / https://communityleadership.org.uk/volunteering/frequently-asked-questions/question-mark-picture 13 14 Focussed Health Assessment of the Respiratory System Subjective Data: Health History Patient profile General survey (appearance) Subjective data (Health history etc) Chief complaint Assessment of airway entry (rapid Primary survey: A, B) https://www.neura.edu.au/project/upper-airway-reflexes-muscle-control/ Objective data Past health history (Medical history/surgical history) Vital signs (Respirations) Allergies Oxygen saturation (o2 Saturations) Family health history 4 assessment techniques (Inspection; Palpation; Auscultation; Percussion) Social history 15 16 Presenting Complaint – Current Symptoms The Primary Survey Airway patent, blockages, decreased air entry Rapid assessment Dyspnoea Patient and their Breathing changes in exercise tolerance (esp. heart failure and COPD) environment Increased respiratory effort Associated manifestations (palpations, faintness, coughing, diaphoresis….) Accessory muscle use Aggravating factors (smoking, poor ventilation….) important cues sternocleidomastoid & scalene neck muscles Alleviating factors (medications, positioning, resting….) (Robeiro et al, 2017, Tachypnea Setting / timing p. 37). Decreased speech tolerance Cough Associated manifestations (SOB, pain, wheezing, sputum….) Circulation Aggravating factors (smoking, exercise….) Purpose - is to identify: Pallor or cyanosis Alleviating factors (medications, humidity, cool air….) Abnormalities or Hypoxia Setting / timing issues/concerns Sputum Deterioration of Disability Quality – colour, consistency, odour patient Paradoxal breathing Quantity Modifications to Altered level of consciousness Associated manifestations, aggravating factors, alleviating factors, etc…… current care plan PAIN https://bmjopen.bmj.com/content/3/11/e003304 Exposure P, Q, R, S, T (Provoking, Quality, Radiation, Severity, Time) Clothing Chest pain (heart attack, pulmonary embolism) 17 18 3  Vital signs Positioning for Respiratory Assessment High Fowler’s (90o) Respirations (A- Airway patent; B- Breathing) Semi-Fowler’s (45o) Oxygen Saturations (B- Breathing) Supine Prone Blood pressure (manual) Dorsal Recumbent http://slideplayer.com/slide/7636553/ Pulse (radial) Temperature https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing https://en.wikipedia.org/wiki/Supine_position https://en.wikipedia.org/wiki/Prone_position 19 20 Assessing Respirations Assessment of Respirations Position patient (sitting or lying, head of bed elevated to 45-60o) Perform hand hygiene Symmetry Ensure visibility of chest, maintain privacy Position patient’s arm (across abdomen or lower chest); nurse’s hand (over upper abdomen) Audibility Observe complete respiratory cycle (one inspiration, one expiration) Look at watches second hand, begin to count rate, counting one with first respiratory cycle If rhythm is regular count for 30 seconds and multiply by 2 Patient position (orthopnoea) If rhythm is irregular or count is 20 count for full minute Note depth of respirations; rhythm of respirations Mode of breathing Reposition; hand hygiene; compare and document findings (Crisp et al 2021, p. 398) https://www.ndsu.edu/pubweb/bismarcknursing/basic/skill/H006.html 21 22 Normal Respiration Rates Respirations Rate adult per minute: Eupnea: 12–20 Tachypnoea: >20 Bradypnea: apnoea) Ataxic (biots) (irregular respiratory pattern) Apneustic gasping inspiration and inefficient expiration – injury to pons Agonal irregular respirations/depth and pattern – impending death 23 24 4  Vital Signs – Assessing Oxygen Saturation (SpO2) Oxygen Saturation (SpO2) Pulse oximetry can be used to: Oxygen saturation is recorded as a Pulse oximeters: Identify clinical situations where hypoxaemia may be a factor percentage (%) Continuously monitor a patient during anaesthesia/sedation Diagnose obstructive sleep apnoea The probe is Estimate arterial usually applied t o a Replace arterial blood gas analysis when PaCO2 or acid-base state is not required Normal oxygen haemoglobin saturation is >95% finger or toe to oxygen saturation gather the reading Determine effectiveness of supplemental oxygen therapy Monitor neonates http://www.nonin.com/What-is-Pulse-Oximetry 25 26 Understanding Oxygen Saturation (Pulse Oximetry) Taking a Patient’s Pulse Oximetry Oxygen saturation refers to the percentage of haemoglobin molecules saturated with oxygen in arterial blood. Select the appropriate probe and ensure the digit is clean Measurement – pulse oximetry Sp02 (remove nail polish); Position the probe on the chosen site Normal Range - 95 – 99% oxygen when the person is breathing air. If a finger probe is used, support the hand if necessary Chronic respiratory disease may have lower Newborns are narrower (95-97%) Allow at least 30 seconds for the pulse oximeter to detect the pulse and calculate the oxygen saturation In accuracies. Poor or weak pulses Look for a displayed waveform. Vasoconstriction‘ Anaemia A waveform is required to get an accurate reading Cold fingers or toes https://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images Movement or shivering Light Emitting Diodes (LED) Read off the displayed oxygen saturation and pulse rate. Use caution in Irregular heartbeat interpreting results where a dramatic change in readings occurs. If in Red and infrared lights - translucent part of the doubt, rely on your clinical judgment. Suitable assessment places body Fingers Ratio of light absorbed during systole and diastole Toes (Estes et al 2016 p. 157) Record the pulse oximetry reading accurately. Earlobes Feet on newborns 27 28 Upper and Lower Respiratory Tract Assessment: Respiratory Physical Assessment Inspection Usually the first assessment technique used during the assessment process 4 physical assessment techniques: Use of vision and smell to observe patient Inspection Visual inspection requires full exposure of the body part being inspected (chest), maintain privacy, adequate lighting Palpation Percussion Visualise underlying anatomic structures to permit accurate description of Auscultation any pathology Always compare right and left sides Use a systematic approach https://slideplayer.com/slide/5716054/ 29 30 5  Assessment of the Mouth Assessment of the Nose and Sinuses https://health.clevelandclinic.org/7-surprising-facts-nose/ Buccal Nose and Sinuses mucosa Inspection, Palpation and percussion Tongue Gums Normal Findings: Nose Located in midline of face No swelling, bleeding, Lips Teeth lesions, or masses Both nostrils patent Septum midline Nasal mucosa is pink or dull red. Breath Inspection: Palate No discomfort during palpation or percussion Resonance heard on percussion. 31 32 Assessment of the Mouth and Throat Lower Respiration Tract Assessment: Inspection - Trachea Normal findings: Normal central position Breath is fresh Pink, moist lips Deviation due to Tongue midline, symmetrical, with adequate movement Tongue has no lesions Air in pleural space – pneumothorax Tongue, gums, buccal mucosa are pink, moist, smooth. Draw trachea to affected lung space Colour of buccal mucosa and gums may vary by race Pushes mediastinum No pockets between gums and teeth Obstruct venous return (tension No bleeding pneumothorax ) Smooth, white teeth; proper alignment, no dental caries. Soft palate and uvula rise as patient says ‘ah’ Fluid in pleural space – pleural effusion Uvula midline Pressure on lungs Throat pink and vascular No swelling, exudate or lesions Gag reflex present. https://jamanetwork.com/journals/jama/fullarticle/2653738 Helen Donovan 33 34 Thoracic Lower Respiration Tract Assessment: Inspection - Thorax Landmarks for Shape of the thorax Assessment Symmetry of chest wall Angle of ribs Intercostal spaces Anterior axillary line Muscles of respiration Midspinal (vertebral) line Abnormalities: Midsternal line Barrel chest Air trapped in alveoli – COPD Posterior axillary line Lung hyperinflation Scapular line. Pectus carinatum Pigeon chest – sternum protrusion Pectus excavatum Funnel chest –sternum depression Kyphosis Excessive convexity http://www.timehd.net/barrel-chest-copd.html Scoliosis Estes et al 2016 , p. 386 Lateral curvature 35 36 6  The act of touching the Palpation patient in a therapeutic Palpation – Assessing Fremitus manner to elicit information. Depress 1cm below surface Tactile or vocal fremitus Symmetry of thorax – compare left and right Vibration of the chest wall produced when spoken Explore painful or abnormal areas first Anterior, posterior, lateral chest Pulsations – absent 3 different hand techniques Masses – should be absent Palmer bases of the fingers Tenderness – should be absent Ulnar (pinky side) aspect of hand Crepitus – should be absent https://ha2.page.tl/Thorax.htm Ulnar aspect of closed fist Subcutaneous emphysema – crackling skin Ask the patient to speak – say “99” You will feel vibratory sensation = FREMITUS Chest expansion position hands – 10th vertebra, or https://forum.facmedicine.com/threads/ch xiphoid process FREMITUS est-examination-overview.26811/ have patient inhale deeply Increase with consolidation – solids conduct sound better Hands lift out laterally Decrease in the absence of air filled lung tissue – pneumothorax, emphysema, asthma Pleural effusion – blocks transmission – decreased sound https://www.mdedge.com/ccjm/article/152915/pulmonology/diagnos tic-value-physical-examination-patients-dyspnea/page/0/1 37 38 A, Posterior View. B, Anterior View. C, Lateral View. Percussion Percussion Techniques Checking for air, fluid, solid Usual sound is resonant and hollow Direct, or immediate Dull note Medium in intensity and pitch Consolidation – pneumonia, tumour Effusion Hyper-resonance Indirect, or mediate High pitch Pneumothorax COPD – air trapping https://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd https://evolve.elsevier.com/objects/apply/RN/Mobility/RN_26-17.html Figure 4.10 (page 90 ) 39 40 Percussion Auscultation Anterior thoracic Patient upright sitting Shoulders back Posterior thoracic Patient crosses arms in front Anterior thoracic auscultation Sitting upright Posterior thoracic auscultation Slightly forward Lateral thoracic auscultation. Difficult to master Ignore heart sounds ie. Detect tone changes Listen to each lobe as the person breathes in and out Compare lobes https://atlclinicalworkshop.com/cpne-care-plan-questions-2/ Avoid bony prominances http://intranet.tdmu.edu.ua/data/kafedra/internal/distance/classes_stud/English/1course/He ath%20Assessment%20Practicum/Health%20Assessment%20Practicum/17.%20Respirato ry%2 41 42 7  Types of Auscultation Breath Sounds: Quality of Sounds Direct, or Listening with the unaided ear Flatness immediate: Dullness Resonance Indirect, or Listening with an amplification device; mediate: Hyper-resonance Examples: acoustic stethoscope, Tympany Doppler stethoscope Refer to Table 5.1 (Calleja et al., 2020, 115) for characteristics of percussion sounds. Estes et al 2016 , p. 91 43 44 Auscultation – Breath Sounds Breath Sounds There are five adventitious breath sounds: Fine crackle Coarse crackle Wheeze Pleural friction rub Stridor. 45 46 Auscultation – Breath Sounds Other Objective Measures: Spirometry Crackles – scratchy – Lung Function Test Fluid in alveoli and airways – pneumonia, Absence of sound Determines the level of respiratory function pulmonary oedema Chronic severe emphysema Finer crackles with f ibrosis Lung volume (forced expiratory volume) Small tidal volumes Lung capacity (forced vital capacity) Little air movement Rhonchi – gurgling Also severe asthma attack, Progression of respiratory disease Fluid in large and medium sized effusions, pneumothorax Response to therapy airways Bronchitis, pneumonia Pleural friction rub Positioning Low pitched grating and rubbing Standing Wheezing – whistling Inhale and exhale Sitting upright Loudest on expiration Pleural inflammation Air forced through narrow airways Inhale deeply – exhale quickly and for as long as possible Asthma Stridor – inspiratory whistling Tracheal narrowing Helen Donovan 47 48 8  Documentation!! Inspection of Sputum Document all your respiratory assessment findings: Colour Odour Primary survey (ABCDE) Amount Clinical history Consistency. Physical assessment (IPPA) Spirometry/Peak flow SpO2, respiration rate and the rest – BP, Pulse, temperature IF YOU DIDN’T DOCUMENT IT THEN IT DIDN’T HAPPEN!! Helen Donovan https://www.nursingcenter.com/clinical-resources/nursing-pocket-cards/nursing-documentation 49 50 Respiratory System: Changes across the lifespan- The Older Respiratory System: Changes across the Lifespan- the Child Adult Paediatric Older Adult Chest shape is round in shape for children Changes; alveolar gas exchange; regulation Rib placement to the spine is more horizontal rather than the downward of ventilation; lung defence mechanisms. position and the pull down during Degeneration of ligaments, joints and cartilage inspiration Young children rely primarily on diaphragm Decreased elastic recoil; close of some portion of for breathing -> abdominal distension can http://www.ent-surgery.com.au/the-eustachian-tube/ the airway; reduced surface area for gas exchange. impede diaphragmatic Airway cartilage is soft and compressible – Neurological changes – medulla less sensitive to highly reactive to stimuli carbon dioxide and oxygen levels Lung defence mechanisms reduced – less cilia and macrophage activity; reduced cough reflex and increased risk of aspiration. Helen Donovan https://healtheappointments.com/chapter-18-assessing-children-infancy-through-adolescence https://www.google.com/url 51 52 Potential Health Problems of the Respiratory System Goal. Reduce feelings of loneliness Goal. To improve Ineffective airway clearance related to: airway clearance Mucoid secretions by reducing the Activity intolerance related to: pain experienced. Pain Fatigue (inadequate oxygenation) Subjective Fatigue Pain Objective Data Bronchospasm Imbalanced nutrition related to: Fatigue Impaired gas exchanges related to: Obtaining, preparing, eating Lung tissue damage eg. smoking Reduced muscle tone and strength Loneliness related to: Compare the data Anxiety related to: Inability to travel outside of the home against normal parameters Dyspnoea Fear of suffocation Disturbed sleep patterns related to: Excessive coughing Goals: realistic, timely, achievable, collaborative. Identify Health Dyspnoea Problems Pain Use the ‘related to’ factor to direct your goals and ultimately the intervention. Goal. To improve sleep patterns May need to address other health problems to Realistic goals By reducing coughing solve one. Eg. An improvement in activity intolerance would (collaborative) experienced at night be necessary to address the loneliness experienced. during sleep periods. 53 54 9  3/31/22 References Calleja, P., Theobald, K., & Harvey, T. (2020). Health Assessment and Physical Examination. Australian and New Zealand (2nd Ed) Crisp, J., Taylor C., Douglas, C., Rebeiro, G., & Waters, D. (2021). Potter & Perry's Fundamentals of Nursing (5th Ed.) Sydney, Mosby Elsevier Hockenberry, M. J., & Wilson, D. (2019). Wong’s. Nursing care of Infants and Children. (11th Ed). Elsevier. Mosby. Lewis, P., & Foley, D. (2014). Health Assessment in Nursing 2e. Sydney AUS: Lippincott Williams & Wuikins. 55 10