Skills III Theory Respiratory (1).pptx

Respiratory Nursing Skills III NCSI-1191B Instructor – Taylor Blackmore OBJECTIVES o Respiratory rate, rhythm, depth & effort o O2 saturation & supplemental O2 o History o Positioning o Bilateral assessment (posterior, lateral, anterior) o Inspection o Palpation o Auscultation...

Respiratory Nursing Skills III NCSI-1191B Instructor – Taylor Blackmore OBJECTIVES o Respiratory rate, rhythm, depth & effort o O2 saturation & supplemental O2 o History o Positioning o Bilateral assessment (posterior, lateral, anterior) o Inspection o Palpation o Auscultation  Anatomy Review The lungs are paired but not precisely symmetrical The left lung contains only two lobes upper and lower which separates ~ 6th rib The left lung is smaller as there is space taken up by the heart The right lung contains upper, middle and lower lobes with the middle lobe lying from the 4th – 6th rib The apex of lung is ~ 3 cm above the clavicle pointing close to the substernal notch The base of the lungs lies at ~  Assessing Respirations o Respirations is the exchange of O2 and CO2 between cells of the body and the atmosphere o There are 3 processes of respiration ( ventilation, diffusion & perfusion) o Ventilation is assessed by observing the rate, depth & rhythm of respiratory movements (On inspiration the diaphragm contracts and the abd. Organs move down to increase the size of the chest cavity-at the same time the sternum/ribs lift outward to promote lung expansion. On expiration the diaphragm relaxes upward and the ribs/sternum return to a relaxed position) o Respirations are normally passive, diaphragmatic, and regular (12-20/min in the adult) with symmetrical expansion o Normal breath sounds are clear to auscultation and equal bilaterally (air flowing without interference or obstruction)  Assessing Respirations o Assess for risk factors of respiratory alterations (Fever, pain, diseases of chest wall/muscles, abd. Incisions, chronic pulmonary disease, injury, chest tube, respiratory infection, pulmonary edema/emboli, head injury with injury to brain stem) o Assess for S/S of respiratory alterations (Cyanosis, restlessness, confusion, pain during inspiration, laboured/difficult breathing, orthopnea, use of accessory muscles, adventitious breath sounds, thick frothy blood- tinged sputum/copius sputum) o Assess factors that influence characteristics of respirations (Exercise, anxiety, acute pain, smoking, meds, positioning, neuro injury) o Assess pertinent lab values (ABG’s SpO2, CBC)  Respiratory Assessment Before you even begin your assessment, knowing the basic landmarks of the chest and lungs is very important! Landmarks will help you to perform an accurate assessment and will be necessary when reporting and documenting your findings. Anterior Thoracic Landmarks: Nipple line Angle of Louis Suprasternal notch Costal angle Midsternal line Midclavicular line Anterior axillary line Lateral Thoracic Landmarks: Midaxillary line Posterior Thoracic Landmarks: Posterior axillary line Vertebral line Scapular line Respiratory Assessment Respiratory Assessment Respiratory Assessment -Significant Hx Disease Lifestyle choices (Tobacco/Marijuana use) Cough (Is it chronic? Productive → sputum characteristics, non- productive) Activity Intolerance Chest pain & SOB Reoccurring attacks of bronchitis or pneumonia Do they work/have worked in an environment containing pollutants Chronic hoarseness? Hx of HIV or TB Review family history -Position your patient for assessment (If they are bedridden elevate HOB 45- 90 degrees & if unable to tolerate sitting use supine and side-lying positions) -Remove drape/gown/clothing but keep front of chest and legs covered, continue to move gown from the area being assessed (Don’t forget to explain assessment to pt & encourage the patient to breathe normally through mouth) Remember… Assess in order of posterior, lateral, anterior (inspect, palpate, and auscultate the posterior chest, move to lateral chest and repeat all 3, move to anterior chest and repeat all 3). Always ensure side-to-side comparison as you move through your assessment Respiratory Assessment -Inspection Size, shape & configuration Respiratory rate & effort (12 -20, eupneic, dyspnea) Positioning (normal, tripod) Use of pursed lip breathing/accessory muscles Skin color (pink, ashen, gray, cyanotic) Symmetrical expansion (If possible, stand behind pt as well inspecting thorax for shape and symmetry) In an adult the AP is 1/3 to ½ of side-to-side diameter (Chronic lung disease causes ribs to be more horizontal and increases AP diameter, resulting in a “barrel chest” Anteroposterio r & Side-to- side diameter Respiratory Assessment -Palpate the entire chest wall noting: (This is a good time to count resp.) Tenderness (Do not palpate painful areas deeply) Temperature Moisture Texture Superficial lumps or bumps Masses or pulsations/unusual movement (If there is a suspicious mass noted, palpate lightly for shape, size, and qualities) Lesions Crepitus – a coarse crackling sensation that is palpable over the chest due to s/c emphysema (air escapes the lungs and enters s/c tissue) Respiratory Assessment -Palpation - Confirming symmetrical chest expansion: Stand behind pt and place warmed hands at T10/Tenth rib with thumbs pointed toward spine and fingers pointing laterally (Palms lightly contacting posterolateral surfaces) Pinch a small fold of skin between thumbs and keep thumbs about 5cm apart Ask patient to exhale and then inhale, noting movement between thumbs (Should move symmetrically with no lag or unequal expansion) Unequal expansion is indicative of pneumothorax, # ribs, pneumonia or trauma Anterolateral assessment – place hands along coastal margins with thumbs pointing toward xiphoid process (Thumbs should move apart symmetrically 3-5 cm when the patient inhales deeply) Assessing Chest Expansion  Respiratory Assessment -Palpation – Assessing tactile fremitus Tactile fremitus is a palpation vibration that can be felt using the palmar aspect of the hand It is most prominent between the scapulae and around the sternum, sites where the major bronchi are closest to the chest wall and decreases as you progress down Decreased fremitus occurs when anything obstructs transmission of vibrations – effusions, pneumothorax, emphysema Increased fremitus occurs with compression or consolidation of lung tissue – pneumonia Note the placement of the hands used for palpating for a vibration Have the patient state “99” or “blue moon” to detect changes in the intensity of the vibration Tactile Fremitus  Respiratory Assessment Breath Sounds As air passes through the tracheobronchial tree, it creates a characteristic set of audible sounds There are 3 types of breath sounds – bronchial, bronchovesicular and vesicular These normal breath sounds become: Decreased or absent when obstructed by secretions or loss of lung elasticity Increased (louder) breath sounds are louder than normal and occur with consolidation or fluid (pneumonia), this enhances the bronchial sound as it moves through the lung fields  Respiratory Assessment Breath Sounds (Normal) Bronchial – high pitched, loud, heard on insp and exp over the trachea and larynx. Best heard over the trachea. Bronchovesicular – medium pitched and blowing sounds of medium intensity. Heard on insp and exp over the major bronchi where fewer alveoli are located at upper sternum anteriorly, and posteriorly between the scapulae (esp right side). Vesicular – low pitched soft sounds heard on insp and exp, sounds like wind rustling in the trees, best heard over peripheral lung fields (except over scapula) where air flows through smaller alveoli and bronchioles. Anterior Breath Posterior Breath Sounds Sounds Adventitious Sounds AKA Abnormal Sounds To auscultate the lungs, you will use the diaphragm of your stethoscope!  Respiratory Assessment Auscultation To assess lung sounds, the patient should be sitting, leaning slightly forward, with arms resting across the lap Instruct the patient to breathe slowly in through the mouth a bit deeper than usual – careful not to have the patient hyperventilate The posterior, lateral, and anterior must be auscultated in a sequential manner – at intercostal spaces, comparing bilaterally throughout the lung fields For an adult, place diaphragm of the stethoscope firmly on the chest wall over intercostal spaces Listen to an entire inspiration and expiration at each stethoscope position (If the sounds you hear are faint, such as in an obese person, you can ask them to breathe harder & faster temporarily) Compare breath sounds over the right and left sides listening for normal vs adventitious sounds Respiratory Assessment Auscultating the Lungs Ensure to auscultate bilaterally Do not confuse background noise with lung sounds: -Stethoscope tubing rubbing together -Hair/Garments rubbing on stethoscope -Breathing on the tubing -Pt shivering If you do hear an adventitious sound, have the patient cough and listen again to determine if sound has cleared with coughing (Rhonchi often are eliminated/altered with coughing but crackles/wheezes are not)  Respiratory Assessment Auscultating the Lungs Do not listen over bone but rather the intercostal spaces Have the client in a fowlers position if possible Ask pt to take a big breath in and out through the mouth each time they feel the stethoscope placed/moved to a new landmark If female, have pt reposition breast for better placement anteriorly  Respiratory Assessment Posterior Lateral Anterior  Respiratory Assessment Landmarking the lobes of the lungs: It is imperative that you know how to determine which lobe of the lung you are listening to!  Respiratory Assessment Anterior Lung Landmarks: Apex of the lungs (the highest point) begins 3-4 cm above the clavicle. Base of the lungs (the lowest point) sits at the diaphragm, approximately the 7th rib. Respiratory Assessment Lateral Lung Landmarks:  Respiratory Assessment Posterior Lung Landmarks: Apex of the lungs is marked by the 7th cervical vertebra (C7), which is the “big bump” and the top of the spine Base of the lungs sits at approximately the 10 th thoracic spine (T10), this extends to approximately T12 on inspiration. In the posterior, the lungs are primarily lower lobes! The upper lobes are accessible from apex at C7, to T3 where the oblique fissures begin.. Questions ?  Works Cited Perry, A. G., Potter, P. A., Ostendorf, W. R., & Cobbett, S. L. (2020). Canadian Clinical Nursing Skills + Techniques (First). Elsevier.