Respiratory Assessment Lecture Transcription PDF

Respiratory Assessment Transcription Okay, so you're going to be doing COPD as an opponent for tuberculosis. There are all the different things that you're going to be working on this week. Functions of the Respiratory System: We have ventilation, respiration, acid base balance, speech, sense of...

Respiratory Assessment Transcription Okay, so you're going to be doing COPD as an opponent for tuberculosis. There are all the different things that you're going to be working on this week. Functions of the Respiratory System: We have ventilation, respiration, acid base balance, speech, sense of smell, and fluid balance. Ventilation: Ventilation occurs as air moves in and out of the respiratory system. This process is called inspiration and exhalation. Respiration: Respiration is the process of gas exchange, where oxygen and carbon dioxide are exchanged at the alveolar level in the body. (I’ll have some pictures for you in a minute for that.) After respiration occurs, the circulatory system is responsible for transporting oxygenated blood to the tissues of the body. The movement of oxygenated blood into the tissues is known as—anybody? Perfusion! (Yeah, I can’t hear you, but yes, it’s called perfusion.) The circulatory system provides oxygenated blood and then returns deoxygenated blood back to the lungs for reoxygenation through the process of respiration. Acid Base Balance: In addition to respiration and ventilation, the respiratory system is responsible for acid base balance. This involves the exchange of carbon dioxide for oxygen in the lungs. The renal system also plays a role by secreting bicarbonate (bicarb), which neutralizes acid. Speech: The movement of air through the vocal cords allows for the vocalization of words. Sense of Smell: Air movement through the nose enables individuals to detect odors in the environment. Without the sense of smell, the sense of taste is also impaired. (That doesn’t directly relate to respiration, but I had to throw that out there.) Fluid Balance: Water is excreted as vapor through the exhalation process, which helps maintain the body’s fluid balance. Anatomy of the Respiratory System: Here’s a picture of what your respiratory system looks like in a simplified but detailed way: 1. Head Region: Includes adenoids, eustachian tubes (connected to your ears), tonsils, and pharynx. The nasal cavity has multiple chambers. 2. Upper Respiratory Tract: Structures include the hyoid bone, glottis, and cricoid cartilage. Air travels from the nose through these structures down to the bronchi, which lead into the lungs. 3. Lower Respiratory Tract: The bronchi branch into smaller airways, forming a "treelike" structure that ends in the alveoli. The alveoli are where gas exchange occurs, with arteries and veins facilitating the exchange of oxygen and carbon dioxide. Visualizing the Lungs: Think of the lungs like a tree in full bloom during summer. The large bronchi resemble tree branches, and the smaller branches lead to the alveoli, which are like tiny leaves or "balls" at the ends. This structure facilitates gas exchange. Sometimes, when the pleura (the lining of the lungs) rubs together during expansion, it can create a pleural friction rub, which may cause pain. Unlike the heart, the lungs have fewer pain receptors, so pain in the lungs often signals a serious issue that requires medical attention. Sinus Anatomy and Issues: Your nasal cavity includes the frontal sinus, which, when inflamed (e.g., during a sinus infection), causes pain across the forehead. Excess mucus in the sinuses leads to congestion and pain because the sinus cavity is rigid and cannot expand to accommodate the fluid. Key Structures to Palpate: Epiglottis: Located at the very top. Hyoid bone: Can be felt for self assessment. Trachea: You can feel its ridges and cartilage as you move down the neck. You can assess yourself and see. So, you have your true vocal cords and your false vocal cords (also called vestibular folds). The true vocal cords are responsible for producing sound. Air moves back and forth through them, enabling us to speak, make sounds, and verbalize words. The false vocal cords (vestibular folds) hold the true vocal cords in place, allowing them to open and close. However, without the true vocal cords, you wouldn’t be able to make sound. Does that make sense? Okay. This section also shows the interior of your vocal cords, how they’re connected, and the glottis located in the back. The glottis opens and closes as a safety mechanism. What does it prevent? Answer: Aspiration. Yes, that’s exactly its purpose—preventing aspiration. Physiology of the Respiratory System: This includes respiration, inspiration, expiration, dead space, shunt, ventilation, perfusion, and mismatches. Let’s break it down: Inspiration: For ventilation to occur, the diaphragm must move. The diaphragm is located below the lung bases, and it moves down and up repeatedly to facilitate breathing. This process works automatically, controlled by the brainstem. If someone sustains a high neck injury (C1 or C2 level), the respiration centers in the brainstem can no longer control breathing, requiring a ventilator to sustain life. Inspiration occurs when the phrenic nerve stimulates the diaphragm. Contraction of the diaphragm lowers it, compressing the abdominal contents and pulling the parietal pleura down, expanding the chest cavity. This expansion of the chest cavity increases the lungs’ volume and decreases pressure within the lungs to below atmospheric pressure, causing air to rush in. Expiration: Expiration is a passive process. As the diaphragm relaxes, pressure is exerted on the lungs by the chest and abdominal cavity. The thoracic cavity decreases in size, causing lung pressure to exceed atmospheric pressure, and air exits the lungs. Respiration: Respiration is the exchange of oxygen and carbon dioxide at the alveolar level. The respiratory bronchioles, alveolar ducts, and alveolar sacs (lined with alveoli) participate in this process. Each alveolus is covered in a capillary membrane where gas exchange occurs: o Deoxygenated blood from the systemic system is exchanged for oxygen. o The oxygenated blood is transported throughout the body to tissues via red blood cells, while the deoxygenated blood (with carbon dioxide) is returned to the lungs to be exhaled. This process is continuous: oxygen is delivered to the body, carbon dioxide is removed, and the cycle repeats. Dead Space: Dead space refers to areas of the respiratory tract (like the trachea) where no gas exchange occurs. In pulmonary function tests (PFTs), this concept is important. PFTs measure how much air you blow off and assess ventilation perfusion mismatch. During PFTs, you exhale all the air you think you have, then exhale further to measure the unused air. Anatomy Review: The lobes of the lungs include: Right lung: Three lobes (upper, middle, and lower).  Left lung: Two lobes. Why? The left lung accommodates the heart. When performing assessments, remember the placement of the stethoscope for proper lung auscultation. Mucus secreting Cells: The lungs contain mucus secreting cells that protect against foreign particles. For example, during events like wildfires (e.g., in California), people’s lungs are overworking. The mucus secreting cells go into overdrive to expel smoke and other irritants from the lungs And they’re just going to keep on—probably going to have some bad coughs after this. Like, your body does create mucus, and you all know this. You know, when you’re trying to clear your throat or get mucus up, it’s because your lungs are trying to catch anything that doesn’t belong there and sweep it back up. Cilia play an important role in this process. Your cilia sweep debris and mucus out of your lungs. Every time I see someone exposed to smoke, I think, “You’re killing your cilia, you know that?” You don’t want to kill your cilia because they help you get rid of harmful substances in your lungs. You need to keep them healthy. Mucus and Cilia: The mucus layer is the top layer that traps debris and particles. Beneath it is the mucociliary layer, where cilia work to sweep trapped particles and germs out of the lungs. If there are germs present, goblet cells will attack them. This system helps protect the lungs from infectious diseases like tuberculosis and other bacteria or viruses. Its effectiveness depends on the level of exposure to harmful agents. Respiratory Structures: This is the terminal bronchiole system: The bronchiole branches divide into multiple terminal branches. At the end of these branches are thousands—if not millions—of tiny structures resembling "little balls," which are alveoli. Alveoli are highly vascularized and serve as the site for oxygen and carbon dioxide exchange. Pleural Space: The pleural space is located between the lungs and chest wall and contains the following: 1. Parietal pleura: The outer layer, which lines the chest wall. 2. Visceral pleura: The inner layer, which directly covers the lungs. The rib cage (visible as white spots in images) protects this area. If anything happens in this space—such as infection, a tear, or fluid accumulation—it can cause pain. In cases of fluid accumulation, a procedure called thoracentesis may be performed to drain the fluid. Diaphragm and Respiration: The diaphragm plays a central role in respiration: Inhalation: The diaphragm moves downward, expanding the lungs and decreasing pressure, allowing air to flow in. Exhalation: The diaphragm relaxes and moves upward, causing the lungs to expel air. This process is passive and automatic unless there is an injury to the neck or brainstem. Venous Blood and Gas Exchange: Venous blood is deoxygenated and travels to the lungs, where: 1. Oxygen is exchanged at the alveolar level. 2. Oxygen enters the alveoli and is absorbed into the blood. 3. Oxygenated blood is transported throughout the body, and carbon dioxide is expelled during exhalation. Pulmonary Embolism: This image shows a pulmonary embolism, which is a blockage in the pulmonary artery or alveolar capillaries. A pulmonary embolism causes severe pain and can be life threatening. It activates neurological responses, often prompting patients to seek immediate medical attention. Treatment may include: 1. TPA (tissue plasminogen activator): A medication that dissolves clots. 2. Other interventions depend on the severity and location of the clot. However, TPA also carries risks, as it can break down other clots that may stabilize injuries in the body. Right, so you have to be really careful with that. History of Present Illness: When someone comes in with a cold, flu, respiratory infection, or shortness of breath, you need to ask specific questions: Factors that exacerbate or improve symptoms: What makes the symptoms worse? What makes them better? Pain:  Do you have pain? What does the pain feel like (stabbing, aching, etc.)? On a scale of 0 to 10, what number is your pain? Cough: Is it productive or nonproductive? Is it dry? Is it heavy? Changes in weight: Have you experienced any weight changes? Usually, has there been weight loss? Dyspnea (shortness of breath): How long have you had it? Have you experienced COPD or breathing difficulties in the past? Do you have asthma or other underlying respiratory conditions that could worsen symptoms? Environmental Factors: For people with respiratory issues (e.g., asthma, COPD), environmental factors can worsen symptoms. Example: In California, people with asthma are likely struggling due to smoke filling their lungs. Even when wearing masks, like KN95s, they may still inhale particles that exacerbate their condition. Detailed History: Once the nurse evaluates the patient’s physical condition, a detailed history should be obtained, including: Current medications: Are they taking respiratory medications for asthma or COPD? Are these medications part of their daily routine? Allergies: Do they have allergies to grass, pollen, or other environmental triggers? Allergies can be worsened by environmental problems like air quality issues in California. Family and Occupational History: Family history: Is there a family history of COPD or pulmonary conditions? Certain genetic conditions can predispose individuals to lung diseases (e.g., alpha1 antitrypsin deficiency). Occupational exposure: Have they worked in environments with asbestos, chemicals, or other lung irritants? Example: Asbestos, though a great insulator, can cause severe lung problems when airborne. Note: Asbestos is still present in many floors, like tiles, but it’s not airborne unless disturbed (e.g., during demolition). That’s why some flooring professionals recommend leaving asbestos tiles undisturbed if they’re covered. Social History: Smoking history: Have they smoked in the past or currently? Travel history: Have they recently traveled to other countries? Travel can introduce exposure to new infections or diseases. Physical Examination: Speech: Can the patient speak in complete sentences without stopping to catch their breath? Are they able to articulate words clearly? Clubbing of fingers: Inspect for clubbing, which can indicate chronic respiratory issues. Mouth: Inspect the mouth for sores, bleeding, masses, or obstructions. Check the mucosa: Is it pink and moist? Is it cracked or sticky? Sticky membranes may indicate dehydration. So you also want to check for cyanosis, right? What’s cyanosis? It’s the blueness or purplish discoloration of the skin, which can indicate hypoxia in someone who is short of breath. Neck Assessment: Check the neck for swelling and palpate for any lumps or bumps. Thorax Assessment: You can assess the thorax from behind. To assess respiration, place your hands on the patient’s back, right below the ribcage. Ask them to inhale and exhale. The hands should move symmetrically in the same direction during breathing.  Any uneven movement may indicate an issue. Vital Signs: Observe the patient’s respiratory pattern, including: Rate Depth Effort used to breathe. The patient should ideally be unaware that their respirations are being checked. To avoid influencing their breathing, you can stand behind the patient or pretend to check their pulse while discreetly counting respirations. Patients may unintentionally alter their breathing if they know they are being observed. Normal respiratory rate: Anything over 20 breaths per minute is considered tachypnea. Anything under 12 breaths per minute is bradypnea. To measure oxygen saturation, use a pulse oximeter. Fingernail Assessment: A normal fingernail has a smooth, slightly curved appearance. Clubbing of fingers is seen in long term conditions like COPD or tuberculosis. o Clubbing results from chronic oxygen deficiency and takes time to develop. o It indicates a chronic disease process. Physical Assessment: 1. Back Inspection: Check for abnormalities like scoliosis, which can cause the lungs to deviate to one side. Conditions like kyphosis can shorten lung fields, while lordosis typically affects areas below the ribcage and has less impact on the lung bases. 2. Abdominal Issues: A large hernia or abdominal aneurysm can push the lung bases upward, reducing lung capacity. Surgical correction of such issues can sometimes worsen lung function by shortening lung fields. Palpation: 1. Trachea: Palpate lightly to ensure the trachea is midline and nontender. Avoid causing or exacerbating pain during palpation. 2. Crepitus:  Crepitus occurs when air escapes from the lungs and gets trapped under the skin. It feels like "snap, crackle, pop," similar to the sound of cereal. It may indicate air leakage and should be carefully noted. 3. Thorax: During palpation, assess for equal expansion of the lungs by placing your hands on the patient’s back and observing movement during inhalation and exhalation. Equal expansion indicates normal lung function. Lung Auscultation: Have the patient say “99” while you auscultate their lung fields. The sound should be clear and not muffled. Uneven or abnormal sounds may indicate underlying respiratory issues. It should be clear. Percussion: You all know this—it should be dull, right? You shouldn’t hear any tympany or other abnormal sounds. Auscultation: Use the diaphragm of the stethoscope to auscultate the patient. Compare sounds as you go: one, two, three, four. Start at the apex of the lungs (top) and move down. Avoid auscultating over bony prominences. Instead, go in between the bones and spine where there’s a “meatier” area to hear sounds better. Bedridden Patients: If the patient is on bed rest and cannot be moved, how would you auscultate? Answer: Do anterior auscultation (listen to the front of the chest). Optimal Position: The best way to listen to lung sounds is when the patient is sitting upright. Review of Lung Sounds: Posterior lobes: You should hear soft, low pitched sounds in healthy patients. Inspiration is slightly longer than expiration. Lower lobes generally have these soft, low pitched sounds, reflecting normal breathing. Arterial Blood Gases (ABGs): Review the normal values for arterial blood gases: pH: 7.35 to 7.45 PaCO₂: 35 to 45 mmHg HCO₃⁻ (bicarbonate): 22 to 26 mEq/L PaO₂: 92 to 100 mmHg For patients with COPD or severe asthma, their PaO₂ may live around 88 to 89 mmHg and still be considered normal for them. Oxygen Saturation (SpO₂): Using a pulse oximeter, you measure oxygen saturation levels. Normal SpO₂: 95% to 100% A person with COPD may have SpO₂ levels around 88% to 89% and still function normally. Why? Because their body has adapted over time to lower oxygen levels. Effects of Low Oxygen Saturation: For a healthy person, a sudden drop in oxygen saturation (e.g., to 88%) could cause: Confusion Dizziness Sweating (diaphoresis) General malaise COPD Progression: COPD doesn’t develop overnight—it’s a progressive disease that worsens over years. Patients adapt to lower oxygen levels as their condition gradually declines. Personal Example: My mother is an example of this. She has lived with COPD for 18 years after having part of her lung removed due to lung cancer. Over the years, her oxygen saturation stabilized at around 88%, and she lives with it. When she needed a hip replacement, her COPD became a concern because patients with COPD often have difficulty recovering from surgeries that require intubation or anesthesia. When I say to Dr. Penn, "I'm going to put them on the ventilator," okay? But when you have to do a replacement, you're going under general anesthesia, so they have to put you on the ventilator. When she came out of it, she was in the intensive care unit, but they couldn’t get her oxygen saturation past 87%, and they were freaking out. I told them, "She was never anything more than 88%. She’s fine." But they were yelling at her, "Breathe harder through your nose, breathe harder through your nose!" And I’m thinking, seriously? Patient History: The moral of the story is to always consider your patient’s history. If they have a chronic condition like COPD, you need to know they’ll live at a lower oxygen saturation level than normal. Nurses need to understand this so they don’t unnecessarily panic over expected readings. Pulse Oximetry: Normal saturation levels: 90-99%, ideally between 95-99%. Patients with disease processes, like COPD, may live with saturation levels around 88% and still function normally. Capnography: Capnography monitors PCO₂ levels and is often used with PCA pumps. What happens with PCA pumps? The medication decreases the patient’s respiration rate. As a result, they retain more carbon dioxide. Capnography ensures the patient’s CO₂ levels don’t drop below a safe level. If levels fall, the monitor will alarm, alerting the nurse to intervene. Sputum Collection: If a patient comes in coughing up mucus, here's the procedure: 1. Collect the sputum for cultures. 2. Identify the microorganism to determine appropriate treatment. 3. Start with a broadspectrum antibiotic until the culture results identify a specific drug for treatment. 4. Check for: Tuberculosis (TB) Malignancies (cancer) It’s important to collect sputum directly from the lungs, not saliva. Types of Pneumonia: 1. Viral Pneumonia: Typically not treated with antibiotics. Viruses usually run their course within 10 days. By the time the diagnosis is confirmed, symptoms may already be resolving. Treatment focuses on symptom management (e.g., addressing cough, reducing fluid in the lungs with Lasix). 2. Bacterial Pneumonia: Treated with antibiotics. 3. Fungal Pneumonia: Treated with antifungal medications. Fungal infections are severe and require specific treatment. Can you kill a virus? No. Viruses live inside cells, so killing the virus often means killing the host cell. This is why viruses, like HIV, were initially so difficult to treat. Modern drugs for HIV are much more effective compared to treatments in the 1980s, but viruses generally remain hard to eliminate. Diagnostic Studies: 1. Chest Xrays: Identify problems with the lungs, heart, or pleural cavity. Chest Xray’s look at solid structures and can detect abnormalities like: Consolidation in the lungs (e.g., fluid). Enlarged or abnormal heart outlines. Fluid buildup in the pleural spaces, which appear as dark areas or bulges. 2. Pneumonia or TB Detection: X rays are commonly used to detect pneumonia or TB. TB typically presents as walled off nodules in the lungs. These nodules mean the disease is no longer airborne. Can TB occur outside the lungs? Yes, TB can affect other parts of the body, but the lungs are the primary site of infection. But you can get TB anywhere. It just depends on how it gets into your body and how it travels through. Usually, it walls itself off right away. If you get sick, and your immune system weakens due to another illness, your TB can become active again. At that point, you can become contagious and spread it to others. This is something to be aware of. If you have had TB or a positive test (PPD or blood test), it’s important to inform your healthcare provider, especially if you visit a doctor for any lung related issues. Pulmonary Function Tests (PFTs): Pulmonary function tests measure lung capacity and function: Purpose: To evaluate lung volume and determine how well the lungs are working. Procedure: The patient inhales and exhales into a tube. This measures the air they exhale, including residual air and reserve volume. The test helps assess how much air remains in the lungs after exhaling. This provides insight into the patient’s lung capacity. Diagnostic Studies: 1. Bronchoscopy: Purpose: Direct visualization of the respiratory tract down to the level of the secondary bronchi. Types: Flexible bronchoscopy: Used to collect specimens or place an endotracheal tube. Rigid bronchoscopy: Used to remove obstructions or large secretions from the respiratory tract. Specimen Analysis: Any tissue removed can be sent to the lab to test for cancer or other diseases. 2. Thoracentesis: Purpose: To remove fluid or air from the pleural space. Can also be used as a diagnostic test to analyze fluid for malignancies or infections. Use Cases: To relieve third spacing fluid caused by liver disease. To improve patient comfort when fluid buildup is severe. 3. Lung Biopsy: Purpose: To remove and analyze a small piece of lung tissue under a microscope.  Methods: Percutaneous biopsy: Tissue is taken using a needle through the skin. Open procedure: Rarely performed today but involves surgically opening the chest to obtain lung tissue. Lung wash: Fluid is introduced into the lungs, collected, and sent to the lab for analysis. Case Study: Mr. Thomas: Weight: 220 pounds (no change from his visit six months ago). Smoking History: Occasionally smokes cigarettes. Medical History: Chronic obstructive pulmonary disease (COPD). Hypertension. (These conditions often occur together.) Immunization Status: Unsure if he has ever received a PPD skin test for tuberculosis. Denies receiving a flu shot. Surgical History: Denies any past surgeries. Allergies: Denies medication, food, or environmental allergies.