Respiratory Assessment Study Guide PDF
Document Details
Tags
Summary
This document is a study guide for respiratory assessment. It covers topics like respiratory assessment, oxygenation, lung lobes, preliminary findings, and expected/unexpected findings. It's intended for students in a health-related field.
Full Transcript
Respiratory Assessment An assessment should be done q8h Be sure to differentiate between patient with chronic respiratory conditions and those w/o ○ Ex: patients w/COPD normally have a barrel chest but barrel chest is not normal for those w/o COPD Understanding the...
Respiratory Assessment An assessment should be done q8h Be sure to differentiate between patient with chronic respiratory conditions and those w/o ○ Ex: patients w/COPD normally have a barrel chest but barrel chest is not normal for those w/o COPD Understanding the client baseline is key to detecting subtle changes ○ If they deviate from baseline complete a focused assessment Check for other symptoms ○ Chest pain ○ SOB ○ Dyspnea ○ Cough ○ Sputum color changes Oxygenation Process that facilitates & impairs oxygenation Necessary to deliver oxygenated blood to tissues & remove metabolic waste Oxygenation is needed to support intracranial function Lung Lobes The right mainstem bronchus is wider, straighter, & shorter than the left ○ This increases the risk of aspiration on the right side Lung airways divide from: bronchi→ bronchioles→ alveoli Lung has a double wall pleura: ○ Visceral wall- attached to outer surface of lung ○ Parietal wall- attached to thoracic cavity & diaphragm ○ ***liquid between the pleura decreases friction*** Preliminary Findings Observe client for: ○ General appearance ○ Posture (sitting up/leaning forward) ○ Breathing (rhythm / depth / quality / pattern) ○ Sweaty ○ Noisy breathing Look for LOC ○ If LOC is low, they may be agitated or confused bc of hypoxia Inspect nails, skin, lips for color ○ Look at skin/ fingers for hypoxia, cyanosis, pallor Expected Preliminary Findings ○ Relaxed posture, no distress Expected Variations in Preliminary Findings ○ Position of breathing (thoracic-female; abdominal/diaphragmatic-male) Unexpected Findings in Preliminary Findings ○ Tripod position- issues breathing so client is leaning forward w/hands on knees ○ Abdominal, Intercostal Muscles at Use- ribs pulled in w/breathing effort ○ Muscle retractions of the supraclavicular & infraclavicular Retractions- tugging during respiratory distress Assessment Assess LOC & hypoxia Unexpected ○ Confused, agitated, anxious ○ Increase sighing Hyperventilating RR ○ Eupnea / Tachypnea / Bradypnea Pulse Oximetry ○ Usually 95%-100% ○
