Respiratory Assessment NUR 310 PDF
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Summary
This document provides a comprehensive overview of respiratory assessment procedures, including anatomical landmarks, preliminary assessment techniques, and various breath sounds. The information covers topics such as anterior and posterior anatomical landmarks, preliminary assessment, and different types of breath sounds. It's organized to facilitate understanding for students in healthcare and nursing courses.
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# Respiratory Assessment NUR 310 ## **Anterior Anatomy** - **Landmarks** - Suprasternal notch/clavicle - 5th rib - Xiphoid process ## **Posterior Anatomy** - **Landmarks** - Cervicothorasic junction - T9-T10 ## **Preliminary Assessment (PP 255-256)** - Do they appear distr...
# Respiratory Assessment NUR 310 ## **Anterior Anatomy** - **Landmarks** - Suprasternal notch/clavicle - 5th rib - Xiphoid process ## **Posterior Anatomy** - **Landmarks** - Cervicothorasic junction - T9-T10 ## **Preliminary Assessment (PP 255-256)** - Do they appear distressed? - Sweating, strained look, noisy breathing - Position and work of breathing - Tripod position, retractions of ICS, use of accessory muscles - Level of consciousness - Ask questions; is pt anxious/agitated/confused? - Signs of hypoxia - Inspect skin color & condition, look for pallor or cyanosis - Respiratory rate - Even, smooth, silent, rate 12-20 - Pulse oximetry - Greater than or equal to 95% ## **Assessment - Posterior & Lateral** ## **Inspection (PP 258-259)** - Slope of ribs - downward 45* (horizontal may indicate emphysema) - Bilateral chest wall expansion - uneven may indicate chest wall trauma - Barrel chest - rounded appearance, slight kyphosis, prominent sternal angle - Kyphosis - exaggerated posterior curve of the THORACIC spine - Lordosis - inward curvature of the LUMBAR spine - Pectus excavatum - markedly sunken sternum/adj cartilage; "funnel chest" - Pectus carinatum - marked forward protrusion of sternum; "pigeon breast" - Scoliosis - lateral S-shaped curvature of the THORACIC & LUMBAR spine ## **Palpation (PP 260-261)** - Tenderness - Masses - Sinus tracts - passages under the skin, filled with fluid or air - Crepitus - air has escaped from lung and entered SQ tissues; feels crunchy - Symmetric respiratory excursion - Landmark T9-T10 - Vocal or tactile fremitus - Use palmar surface of hand - Heard best between scapulae - Increased with compression/consolidation of lung tissue - Decreased with obstructions to vibration ## **Percussion (P 262)** - **Sounds** - Resonance - air-filled space; loud in intensity and low in pitch - Dull-indicates solid or fluid filled area (tumor/pneumonia/effusion/atelectasis) - Hyperresonance - indicated over-inflated alveoli; a high-pitched sound - **Technique** - Don't hold it like a hammer! - Slight movement of the wrist ## **Auscultation - Sequence (P 263)** - Let patient breathe at their own rate! - Continue to assess in side-to-side fashion; then moving down ICS ## **Types of Breath Sounds (P 264)** - Bronchial/Trachael - (ant only) - loud & high-pitched; located over the trachea and major bronchi - Bronchovesicular - moderate pitch; located between scapulae & one either side of sternum in 1st & 2nd ICS - Vesicular - soft, low-pitched, rustling sounds in the periphery - Decreased/absent - the bronchial tree is obstructed ## **Adventitious Breath Sounds (P 265)** - Crackles (rales) - intermittent rattling, popping, bubbling noises when air is travelling through area with increased moisture; usually on inspiration - Fine - soft, high-pitched; sounds like hairs being rubbed together - Coarse - louder & lower in pitch - Wheezes - high-pitched, whistling sounds; air passing through narrowed small airway; can be heard on inspiration or expiration - Rhonchi - continuous, coarse, snoring sound; louder & lower than crackles; narrowed larger airways; can be heard on inspiration or expiration; may clear with coughing - Pleural friction rub - crackling or grating sound when pleura rub together; heard on inspiration & expiration - Stridor - MEDICAL EMERGENCY; high-pitched and loud; caused by obstruction of upper airway; heard on inspiration ## **Assessment - Anterior** ## **Inspection (PP 266-268)** - **Respiratory rate & rhythm** - Tachypnea - Bradypnea - Apnea - Hypernea - Hyperventilation - Cheyne-stokes - Ataxic (Biots) - Kussmaul's - **Costal angle** - Less than or equal to 90 - **AP-to-lateral ratio** - About 1:2 - Increased in older adult - Increased in barrel chest - Increased in pectus carinatum ## **Palpation (P 269)** - Tenderness - Masses - Sinus tracts - Crepitus ## **Percussion (P 270)** - **Sounds** - Remember that the precordium will elicit dullness - **Technique** ## **Auscultation (P 270)** - Remember to displace breast tissue and listen directly to chest wall - Also, the anterior is where you will hear the bronchial/tracheal sounds as well as bronchovesicular and vesicular!
