Assessment of Respiratory Function PDF

ASSESSMENT OF THE RESPIRATORY FUNCTION Prepared by: Joseph Christian G. Bacleon, RN BRUNNER & SUDDARTH’s TEXTBOOK OF MEDICAL-SURGICAL NURSING 15th EDITION  TABLE OF CONTENTS 01 02 ANATOMY and FUNCTION OF THE PHYSIOLOGY RESPIRATORY SYSTEM 03 04 ASS...

ASSESSMENT OF THE RESPIRATORY FUNCTION Prepared by: Joseph Christian G. Bacleon, RN BRUNNER & SUDDARTH’s TEXTBOOK OF MEDICAL-SURGICAL NURSING 15th EDITION  TABLE OF CONTENTS 01 02 ANATOMY and FUNCTION OF THE PHYSIOLOGY RESPIRATORY SYSTEM 03 04 ASSESSMENT DIAGNOSTIC TESTS  TABLE OF CONTENTS 05 06 IMAGING ENDOSCOPIC STUDIES PROCEDURES 07 BIOPSY  1 ANATOMY & PHYSIOLOGY OVERVIEW RESPIRATORY SYSTEM is composed of: ▪ UPPER RESPIRATORY TRACT (upper airway) ▪ warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange ▪ LOWER RESPIRATORY TRACTS GAS EXCHANGE involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration. UPPER & LOWER RESPIRATORY TRACTS are responsible for VENTILATION ▪ movement of air in and out of the airways OVERVIEW The respiratory system works in concert with the cardiovascular system RESPIRATORY SYSTEM ▪ responsible for ventilation and diffusion CARDIOVASCULAR SYSTEM ▪ is responsible for perfusion ANATOMY of the RESPIRATORY SYSTEM UPPER RESPIRATORY TRACT STRUCTURES: 1. NOSE 2. PARANASAL SINUSES 3. PHARYNX 4. TONSILS 5. ADENOIDS 6. LARYNX 7. TRACHEA NOSE ▪ serves as a passageway for air to pass to and from the lungs. ▪ filters impurities and humidifies and warms the air as it is inhaled. COMPOSITION: 1. EXTERNAL PORTION ▪ protrudes from the face and is supported by the nasal bones and cartilage ▪ anterior nares (nostrils) are the external openings of the nasal cavities 2. INTERNAL PORTION ▪ is a hollow cavity separated into the right and left nasal cavities by a narrow vertical divider, the septum. PARANASAL SINUSES ▪ four pairs of bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar epithelium. ✓ connected by a series of ducts that drain into the nasal cavity ▪ PRIMARY FUNCTION: serve as a resonating chamber in speech. ▪ The sinuses are a common site of infection ▪ NAMED BY THEIR LOCATION: ▪ FRONTAL ▪ ETHMOID ▪ SPHENOID ▪ MAXILLARY PHARYNX, TONSILS or ADENOIDS PHARYNX (or throat) ▪ a tubelike structure that connects the nasal and oral cavities to the larynx. ▪ divided into three regions: 1. NASAL (Nasopharynx) ▪ located posterior to the nose and above the soft palate. 2. ORAL (Oropharynx) ▪ houses the faucial, or palatine, tonsils. 3. LARYNGEAL (Laryngopharynx) ▪ extends from the hyoid bone to the cricoid cartilage. FUNCTIONS - PASSAGEWAY FOR THE RESPIRATORY AND DIGESTIVE TRACTS. PHARYNX, TONSILS or ADENOIDS ADENOIDS (PHARYNGEAL TONSILS) ▪ located in the roof of the nasopharynx. ▪ The tonsils, the adenoids, and other lymphoid tissue encircle the throat. ▪ These structures are important links in the chain of lymph nodes guarding the body from invasion by organisms entering the nose and the throat. LARYNX (voice box) ▪ cartilaginous epithelium-lined organ that connects the pharynx and the trachea and consists of the following: EPIGLOTTIS: a valve flap of cartilage that covers the opening to the larynx during swallowing GLOTTIS: the opening between the vocal cords in the larynx THYROID CARTILAGE: the largest of the cartilage structures; part of it forms the Adam’s apple CRICOID CARTILAGE: the only complete cartilaginous ring in the larynx (located below the thyroid cartilage) ARYTENOID CARTILAGES: used in vocal cord movement with the thyroid cartilage VOCAL CORDS: ligaments controlled by muscular movements that produce sounds; located in the lumen of the larynx LARYNX (voice box) MAJOR FUNCTION: vocalization ▪ also protects the lower airway from foreign substances ▪ facilitates coughing ▪ referred to as the “watchdog of the lungs” TRACHEA (windpipe) ▪ composed of smooth muscle with C-shaped rings of cartilage at regular intervals. ▪ serves as the passage between the larynx and the right and left main stem bronchi, which enter the lungs through an opening called the hilus. ANATOMY of the RESPIRATORY SYSTEM LOWER RESPIRATORY TRACT consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. LUNGS ▪ paired elastic structures enclosed in the thoracic cage ▪ an airtight chamber with distensible walls Each lung is divided into lobes: ▪ RIGHT LUNG: upper, middle, and lower lobes (3) ▪ LEFT LUNG: upper and lower lobes (2) LUNGS PLEURA ▪ a serous membrane that covers the lining of the lungs and wall of the thoracic cavity 1. VISCERAL PLEURA ▪ covers the lungs 2. PARIETAL PLEURA ▪ lines the thoracic cavity, lateral wall of the mediastinum, diaphragm, and inner aspects of the ribs. LUNGS PLEURA PLEURAL SPACE or CAVITY ▪ the thin space between parietal & visceral pleura ▪ Between these two membrane contains a small amount of pleural fluid (few milliliters in a normal human) - serve to lubricate the thorax and the lungs - permit smooth motion of the lungs within the thoracic cavity during inspiration and expiration. LUNGS MEDIASTINUM ▪ in the middle of the thorax, between the pleural sacs that contain the two lungs ▪ extends from the sternum to the vertebral column and contains all of the thoracic tissue outside the lungs (heart, thymus, the aorta and vena cava, and esophagus) BRONCHI AND BRONCHIOLES several divisions of the bronchi within each lobe of the lung BRONCHI (has cartilage) LOBAR BRONCHI (three in the right lung and two in the left lung) → divides into SEGMENTAL BRONCHI (10 on the right and 8 on the left) → divides into SUBSEGMENTAL BRONCHI → then branch into BRONCHIOLES BRONCHI AND BRONCHIOLES several divisions of the bronchi within each lobe of the lung BRONCHIOLES (no cartilage) - contains SUBMUCOSAL GLANDS ▪ produces mucus that covers the inside lining of the airways. BRONCHIOLES branches into → TERMINAL BRONCHIOLES → become RESPIRATORY BRONCHIOLES → PHYSIOLOGIC DEAD SPACE → lead into ALVEOLAR DUCTS & SACS → ALVEOLI BRONCHI AND BRONCHIOLES BRONCHIOLES (no cartilage) TERMS: RESPIRATORY BRONCHIOLES ▪ serves as transitional passageways between the conducting airways and the gas exchange airways. CONDUCTING AIRWAYS ▪ contain about 150 mL of air in the tracheobronchial tree that does not participate in gas exchange, known as physiologic dead space. BRONCHI AND BRONCHIOLES BRONCHI AND BRONCHIOLES: ▪ are lined with cells that have surfaces covered with cilia CILIA ▪ creates a constant whipping motion that propels mucus and foreign substances away from the lungs toward the larynx BRONCHI AND BRONCHIOLES ALVEOLI ▪ Major site for gas exchange ▪ The lung is made up of about 300 million alveoli, constituting a total surface area between 50 and 100 m2 (Norris, 2019) – approximately size of a tennis court THREE TYPES OF ALVEOLAR CELLS ▪ TYPE I ▪ TYPE II CELLS ▪ make up the ALVEOLAR EPITHELIUM ▪ ALVEOLAR MACROPHAGES ▪ phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. BRONCHI AND BRONCHIOLES ALVEOLI ALVEOLAR EPITHELIUM TISSUE: TYPE I CELLS: accounts for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface. TYPE II CELLS: account for only 5% of this area but are responsible for producing type I cells and SURFACTANT SURFACTANT ▪ reduces surface tension, thereby improving overall lung function  ANATOMY & PHYSIOLOGY REVIEW  2 FUNCTION OF THE RESPIRATORY SYSTEM INTRODUCTION The cells of the body derive the energy they need from the oxidation of carbohydrates, fats, and proteins. This process requires oxygen. Vital tissues, like the brain and the heart, cannot survive long without a continuous supply of oxygen. As a result of oxidation, carbon dioxide is produced and must be removed from the cells to prevent the buildup of acid waste products. The respiratory system performs this function by facilitating life-sustaining processes such as oxygen transport, respiration, ventilation, and gas exchange. OXYGEN TRANSPORT OXYGEN is supplied to cells → CARBON DIOXIDE is removed from cells ▪ by way of the circulating blood through the thin walls of the capillaries ▪ OXYGEN diffuses from the capillary through the capillary wall to the interstitial fluid. ▪ The movement of CARBON DIOXIDE occurs by diffusion in the opposite direction – from cell to blood. RESPIRATION After the oxygen & carbon dioxide transport: ▪ blood enters the systemic venous circulation and travels to the pulmonary circulation. PRINCIPLE: ▪ The oxygen concentration in blood within the capillaries of the lungs is lower than that in the lungs’ alveoli. ▪ Because of this concentration gradient, Oxygen diffuses from the alveoli to the blood. ▪ Carbon dioxide, which has a higher concentration in the blood than in the alveoli, diffuses from the blood into the alveoli. RESPIRATION ▪ Movement of air in and out of the airways continually replenishes the oxygen and removes the carbon dioxide from the airways and the lungs. ▪ This whole process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body is called RESPIRATION. VENTILATION ▪ This process requires movement of the walls of the thoracic cage and of its floor, the diaphragm. ▪ EFFECT: to alternately increase and decrease the capacity of the chest ▪ INSPIRATION PHASE: Chest is increased → air enters through the trachea and moves into the bronchi, bronchioles, and alveoli → inflates the lungs. ▪ normally requires energy ▪ EXPIRATION: chest wall and the diaphragm return to their previous positions → the lungs recoil and force the air out through the bronchi and the trachea. ▪ normally passive, requiring very little energy VENTILATION MECHANICS OF VENTILATION ▪ collective term referring to physical factors that govern airflow in and out of the lungs 1. AIR PRESSURE VARIANCES 2. RESISTANCE TO AIRFLOW 3. LUNG COMPLIANCE VENTILATION MECHANICS OF VENTILATION 1) AIR PRESSURE VARIANCES ▪ Physical Factor: Atmospheric Pressure PRINCIPLE: Air flows from a region of higher pressure to a region of lower pressure INSPIRATION: movements of the diaphragm and intercostal muscles enlarges the thoracic cavity → lowering the pressure inside the thorax to a level below that of atmospheric pressure ▪ As a result, air is drawn through the trachea and the bronchi into the alveoli. VENTILATION MECHANICS OF VENTILATION 1) AIR PRESSURE VARIANCES EXPIRATION: diaphragm relaxes and the lungs recoil, resulting in a decrease in the size of the thoracic cavity → the alveolar pressure then exceeds atmospheric pressure → air flows from the lungs into the atmosphere. VENTILATION MECHANICS OF VENTILATION 2) RESISTANCE TO AIRFLOW ▪ RESISTANCE is determined by the radius (size of the airway) through which the air is flowing. Any process that changes the bronchial diameter or width affects airway resistance → alters the rate of airflow for a given pressure gradient during respiration ▪ increased resistance = greater-than-normal respiratory effort is required to achieve normal levels of ventilation. CAUSES OF INCREASED AIRWAY RESISTANCE ▪ Common phenomena that may alter bronchial diameter, which affects airway resistance, include the following: ▪ Contraction of bronchial smooth muscle – as in asthma ▪ Thickening of bronchial mucosa – as in chronic bronchitis ▪ Obstruction of the airway – by mucus, a tumor, or a foreign body ▪ Loss of lung elasticity – as in emphysema, which is characterized by connective tissue encircling the airways, thereby keeping them open during both inspiration and expiration VENTILATION MECHANICS OF VENTILATION 3) LUNG COMPLIANCE ▪ COMPLIANCE is the elasticity and expandability of the lungs and thoracic structures. FACTORS THAT DETERMINES LUNG COMPLIANCE: 1. SURFACE TENSION OF THE ALVEOLI 2. CONNECTIVE TISSUE AND WATER CONTENT OF THE LUNGS 3. COMPLIANCE OF THE THORACIC CAVITY VENTILATION MECHANICS OF VENTILATION 3) LUNG COMPLIANCE NOTE: Lungs with decreased compliance require greater-than-normal energy expenditure by the patient to achieve normal levels of ventilation. LUNG FUNCTION, which reflects the MECHANICS OF VENTILATION, is viewed in terms of LUNG VOLUMES AND LUNG CAPACITIES LUNG VOLUMES AND CAPACITIES LUNG VOLUMES are categorized as: ▪ Tidal Volume ▪ Inspiratory Reserve Volume ▪ Expiratory Reserve Volume ▪ Residual Volume LUNG CAPACITY is evaluated in terms of: ▪ Vital Capacity ▪ Inspiratory Capacity ▪ Functional Residual Capacity ▪ Total Lung Capacity PULMONARY DIFFUSION & PERFUSION PULMONARY DIFFUSION ▪ process by which oxygen and carbon dioxide are exchanged from areas of high concentration to areas of low concentration at the air–blood interface. ALVEOLAR–CAPILLARY MEMBRANE ▪ the ideal site for pulmonary diffusion because of its thinness and large surface area. ▪ The diffusion is achieved because of the gas concentration gradient in the alveoli and capillaries. PULMONARY DIFFUSION & PERFUSION PULMONARY PERFUSION ▪ is the actual blood flow through the pulmonary vasculature. Blood is pumped into the lungs by the right ventricle through the pulmonary artery → pulmonary artery divides into the right and left branches to supply both lungs. PULMONARY CIRCULATION is considered a LOW-PRESSURE SYSTEM Systolic BP of Pulmonary Artery: 20 to 30 mm Hg Diastolic BP of Pulmonary Artery: 5 to 15 mm Hg PULMONARY DIFFUSION & PERFUSION PULMONARY PERFUSION NOTE: FACTORS THAT DETERMINES THE PATTERNS OF PERFUSION PULMONARY ARTERY PRESSURE GRAVITY ALVEOLAR PRESSURE In lung disease, these factors vary, and the perfusion of the lung may become abnormal. VENTILATION & PERFUSION BALANCE & IMBALANCE PRINCIPLE ADEQUATE GAS EXCHANGE depends on an ADEQUATE VENTILATION–PERFUSION (V./Q.) RATIO V/Q IMBALANCE ▪ occurs as a result of inadequate ventilation, inadequate perfusion, or both. VENTILATION & PERFUSION BALANCE & IMBALANCE FACTORS ALTERING VENTILATION (V): 1. AIRWAY BLOCKAGES 2. LOCAL CHANGES IN COMPLIANCE 3. GRAVITY FACTORS ALTERING PERFUSION (Q): 1. CHANGE IN THE PULMONARY ARTERY PRESSURE 2. ALVEOLAR PRESSURE 3. GRAVITY VENTILATION & PERFUSION BALANCE & IMBALANCE FOUR POSSIBLE (V./Q.) RATIO or STATES IN THE LUNG 1. NORMAL (V/Q) RATIO 2. LOW (V/Q) RATIO (shunt) 3. HIGH (V/Q) RATIO (dead space) 4. ABSENCE OF VENTILATION AND PERFUSION (silent unit)  VENTILATION – PERFUSION RATIOS NORMAL RATIO In the healthy lung, a given amount of blood passes an alveolus and is matched with an equal amount of gas. The ratio is 1:1 (ventilation matches perfusion).  VENTILATION – PERFUSION RATIOS LOW VENTILATION–PERFUSION RATIO: SHUNTS Low ventilation–perfusion states may be called shunt-producing disorders. When perfusion exceeds ventilation, a shunt exists. Blood bypasses the alveoli without gas exchange occurring. EXAMPLE: ▪ obstruction of the distal airways, such as with pneumonia, atelectasis, tumor, or a mucus plug.  VENTILATION – PERFUSION RATIOS HIGH VENTILATION–PERFUSION RATIO: DEAD SPACE When ventilation exceeds perfusion, dead space results. The alveoli do not have an adequate blood supply for gas ex- change to occur. EXAMPLE: characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.  VENTILATION – PERFUSION RATIOS SILENT UNIT In the absence of both ventilation and perfusion or with limited ventilation and perfusion, a condition known as a silent unit occurs. EXAMPLE: This is seen with pneumothorax and severe acute respiratory distress syndrome (Severe ARDS) NEUROLOGIC CONTROL OF VENTILATION RESPIRATORY CENTER ▪ The respiratory center is in the medulla oblongata and is involved in the minute-to-minute control of breathing. NEUROLOGIC CONTROL OF VENTILATION RESTING RESPIRATION ▪ the result of cyclic excitation of the respiratory muscles by the phrenic nerve. RHYTHM OF BREATHING ▪ controlled by respiratory centers in the brain. RATE AND DEPTH OF VENTILATION ▪ controlled by the inspiratory and expiratory centers in the medulla oblongata and pons ▪ GOAL: works to meet the body’s metabolic demands NEUROLOGIC CONTROL OF VENTILATION APNEUSTIC CENTER ▪ located in the lower pons ▪ stimulates the inspiratory medullary center to promote deep, prolonged inspirations PNEUMOTAXIC CENTER ▪ located in the upper pons ▪ control the pattern of respirations NEUROLOGIC CONTROL OF VENTILATION HERING-BREUER REFLEX ▪ is a reflex triggered to prevent the over-inflation of the lung. ▪ Pulmonary stretch receptors present on the wall of bronchi and bronchioles of the airways respond to excessive stretching of the lung during large inspirations. PROCESS: Reflex is activated by stretch receptors in the alveoli → When the lungs are distended → inspiration is inhibited → the lungs do not become overdistended.  GERONTOLOGIC CONSIDERATIONS  3 ASSESSMENT HEALTH HISTORY 1. Patient’s presenting problem and associated symptoms also known as ______ ▪ ONSET ▪ LOCATION ▪ DURATION ▪ CHARACTER ▪ AGGRAVATING & ALLEVIATING FACTORS ▪ RADIATION (if relevant) ▪ TIMING OF THE PRESENTING PROBLEM AND ASSOCIATED SIGNS AND SYMPTOMS. NOTE: Also assess on how these factors impact the patient’s activities of daily living, usual work and family activities, and quality of life. COMMON SYMPTOMS MAJOR SIGNS AND SYMPTOMS of respiratory disease: 1. DYSPNEA 2. COUGH 3. SPUTUM PRODUCTION 4. CHEST PAIN 5. WHEEZING 6. HEMOPTYSIS COMMON SYMPTOMS DYSPNEA ▪ subjective feeling of difficult or labored breathing, breathlessness, shortness of breath (SOB) ▪ Occurs during decreased lung compliance or increased airway resistance. ASSOCIATED SYMPTOMS: ORTHOPNEA ▪ inability to breathe easily except in an upright position STRIDOR ▪ high-pitched sound heard (usually on inspiration) + dyspnea COMMON SYMPTOMS COUGH ▪ a reflex that protects the lungs from the accumulation of secretions or the inhalation of foreign bodies. ▪ stimulated from the irritation of the mucous membranes anywhere in the respiratory tract by foreign bodies ✓ reflex may be impaired by weakness or paralysis of the respiratory muscles, prolonged inactivity, the presence of a nasogastric tube, or depressed function of the medullary centers in the brain (anesthesia, brain disorders) COMMON SYMPTOMS COUGH DESCRIPTIONS OF COUGH: 1. DRY or HACKING ▪ also known as non-productive cough ▪ characteristic of an upper respiratory tract infection of viral origin 2. BRASSY ▪ loud metallic barking cough ▪ the result of a tracheal lesion COMMON SYMPTOMS COUGH DESCRIPTIONS OF COUGH: 3. WHEEZING ▪ high-pitched whistling sound made while breathing 4. LOOSE or WET ▪ also known as productive cough ▪ cough that produces mucus (phlegm) 5. SEVERE ▪ may indicate bronchogenic carcinoma. COMMON SYMPTOMS SPUTUM PRODUCTION ▪ is the reaction of the lungs to any constantly recurring irritant. ▪ associated with a nasal discharge. COMMON SIGN OF A BACTERIAL INFECTION ▪ profuse amount of purulent sputum (thick and yellow, green, or rust colored) ▪ change in color of the sputum is a common sign of a bacterial infection. VIRAL BRONCHITIS ▪ Thin, mucoid sputum LUNG TUMOR ▪ Pink-tinged mucoid sputum COMMON SYMPTOMS SPUTUM PRODUCTION PULMONARY EDEMA ▪ Profuse, frothy, pink material LUNG ABSCESS & BRONCHIECTASIS ▪ Foul-smelling sputum COMMON SYMPTOMS CHEST PAIN ▪ associated with pulmonary conditions may be sharp, stabbing, and intermittent, or it may be dull, aching, and persistent. may occur with: ▪ PNEUMONIA ▪ PULMONARY INFARCTION ▪ PLEURISY ▪ LATE SYMPTOM OF BRONCHOGENIC CARCINOMA ▪ in carcinoma, the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine. COMMON SYMPTOMS CHEST PAIN NOTE: Lung disease does not always cause thoracic pain because the lungs and the VISCERAL PLEURA lack sensory nerves and are insensitive to pain stimuli. However, PARIETAL PLEURA have a rich supply of sensory nerves that are stimulated by inflammation and stretching of the membrane. COMMON SYMPTOMS CHEST PAIN PLEURITIC PAIN - Caused by the irritation of the parietal pleura - sharp pain - “catch” on inspiration; patients often describe it as being “like the stabbing of a knife.” COMMON SYMPTOMS WHEEZING ▪ a high-pitched, musical sound heard on either expiration (asthma) or inspiration (bronchitis). ▪ MAJOR CAUSE: bronchoconstriction or airway narrowing RHONCHI ▪ low-pitched continuous sounds heard over the lungs in partial airway obstruction. ▪ may be heard with or without stethoscope COMMON SYMPTOMS HEMOPTYSIS ▪ expectoration of blood from the respiratory tract. ▪ present as small to moderate blood-stained sputum to a large hemorrhage ▪ Onset: usually sudden The most common causes are: ▪ Pulmonary infection ▪ Carcinoma of the lung ▪ Abnormalities of the heart or blood vessels ▪ Pulmonary artery or vein abnormalities ▪ PE or infarction COMMON SYMPTOMS HEMOPTYSIS ▪ Potential sources of bleeding include ▪ the gums ▪ nasopharynx ▪ lungs ▪ stomach NURSING ASSESSMENTS FAMILY HISTORY ASSESSMENT SPECIFIC TO GENETIC RESPIRATORY DISORDERS ▪ Assess family history for three generations for family members with histories of respiratory impairment. ▪ Assess family history for individuals with early-onset chronic pulmonary disease and family history of hepatic disease in infants (clinical symptoms of alpha-1 antitrypsin deficiency). ▪ Inquire about family history of cystic fibrosis, an autosomal recessive inherited respiratory disorder. NURSING ASSESSMENTS PATIENT ASSESSMENT SPECIFIC TO GENETIC RESPIRATORY DISORDERS ▪ Assess for symptoms such as changes in respiratory status and triggers that precede changes in respiratory function. ▪ Frequency of respiratory tract infections or sinus infections ▪ Determine exposure to environmental risks (radon, asbestos) or occupational exposures (coal miner, sandblaster, painter) ▪ Determine presence of secondary risk factors (smoking or exposure or secondhand smoke) NURSING ASSESSMENTS PATIENT ASSESSMENT SPECIFIC TO GENETIC RESPIRATORY DISORDERS Assess for: ▪ Clubbing of fingers ▪ Assess for presence and frequency of: ▪ Wheezing or coughing ▪ Mucous production (frequency, amount and characteristics) ▪ Mucosal edema ▪ Assess for multisystem effects (gastrointestinal disorders, pancreatic insufficiency, liver or kidney disorders) PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM GENERAL APPEARANCE CLUBBING OF THE FINGERS ▪ a change in the normal nail bed. ▪ It appears as sponginess of the nail bed and loss of the nail bed angle FOUND IN PATIENTS WITH: Chronic Hypoxic Conditions Chronic Lung Infections Malignancies of the Lung PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM GENERAL APPEARANCE CYANOSIS ▪ a bluish coloring of the skin ▪ a very late indicator of hypoxia ▪ determined by the amount of unoxygenated hemoglobin in the blood CENTRAL CYANOSIS (assessed by observing the color of the tongue and lips) PERIPHERAL CYANOSIS (fingers, toes, or earlobes) PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM UPPER RESPIRATORY STRUCTURES - simple light source (penlight) NOSE AND SINUSES EXTERNAL NOSE: ▪ Inspect for lesions, asymmetry, or inflammation INTERNAL NOSE: ▪ inspect for swollen, bleeding mucosa, septal deviation PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM UPPER RESPIRATORY STRUCTURES NOSE AND SINUSES SINUSES: ▪ palpate the frontal and maxillary sinuses for tenderness ▪ TENDERNESS = INFLAMMATION FRONTAL AND MAXILLARY SINUSES: ▪ can be inspected by transillumination (passing a strong light through a bony area, such as the sinuses, to inspect the cavity. PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM UPPER RESPIRATORY STRUCTURES MOUTH AND PHARYNX ▪ anterior and posterior pillars, tonsils, uvula, and posterior pharynx inspects these structures for color, symmetry, and evidence of exudate, ulceration, or enlargement. PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM UPPER RESPIRATORY STRUCTURES TRACHEA ▪ position and mobility of the trachea are noted by direct palpation. placing the thumb and index finger of one hand on either side of the trachea just above the sternal notch. NORMAL: midline UNUSUAL: deviated (due to masses in the neck or mediastinum) PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING ▪ includes inspection, palpation, percussion, and auscultation of the thorax. ▪ Patient should be positioned as necessary prior to the assessment. PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION 1. Chest Configuration 2. Breathing Patterns and Respiratory Rates 3. Use of Accessory Muscles PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION Chest Configuration - Normal Ratio of APL diameter: 1:2 - FOUR MAIN DEFORMITIES (ALTERS THIS RATIO) a. Barrel Chest b. Funnel Chest (Pectus Excavatum) c. Pigeon Chest (Pectus Carinatum) d. Kyphoscoliosis PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION (Chest Configuration) BARREL CHEST ▪ result of overinflation of the lungs ▪ Occurs with aging ▪ Hallmark sign of emphysema & COPD ▪ APL Ratio: 1:1 PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION (Chest Configuration) FUNNEL CHEST (PECTUS EXCAVATUM) ▪ occurs when there is a depression in the lower portion of the sternum ▪ may compress the heart and great vessels, resulting in murmurs. PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION (Chest Configuration) PIGEON CHEST (PECTUS CARINATUM) ▪ occurs as a result of anterior displacement of the sternum ▪ there is an increase in the anteroposterior diameter PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION (Chest Configuration) KYPHOSCOLIOSIS ▪ characterized by elevation of the scapula and a corresponding S-shaped spine. ▪ this deformity limits lung expansion within the thorax. ▪ may occur with osteoporosis and other skeletal disorders that affect the thorax. PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION Breathing Patterns and Respiratory Rates NORMAL (eupnea) ▪ 12 to 20 breaths per minute ▪ Regular in depth and rhythm  PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION (Breathing Patterns and Respiratory Rates) APNEA ▪ temporary pauses of breathing OBSTRUCTIVE SLEEP APNEA ▪ apneas occur repeatedly during sleep, secondary to transient upper airway blockage PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION (Breathing Patterns and Respiratory Rates) BULGING OF THE INTERCOSTAL SPACES DURING EXPIRATION ▪ implies obstruction of expiratory airflow (emphysema) MARKED RETRACTION ON INSPIRATION ▪ implies blockage of a branch of the respiratory tree. PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION (Breathing Patterns and Respiratory Rates) ASYMMETRIC BULGING OF THE INTERCOSTAL SPACES ▪ on one side or the other ▪ created by an increase in pressure within the hemithorax → result of air trapped under pressure within the pleural cavity (pneumothorax), or the pressure of fluid within the pleural space (pleural effusion). PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING INSPECTION Use of Accessory Muscles During inspiration ▪ Observe for use of sternocleidomastoid, scalene & trapezius muscle During expiration ▪ Observe for use of abdominal & internal intercostal muscles PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING PALPATION ▪ Palpates the thorax for: ▪ TENDERNESS ▪ MASSES ▪ LESIONS ▪ RESPIRATORY EXCURSION ▪ VOCAL FREMITUS PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING PALPATION RESPIRATORY EXCURSION ▪ Is an estimation of thoracic expansion ▪ Information about thoracic movement during breathing ▪ Assesses the patient for range and symmetry of excursion DECREASED CHEST EXCURSION (chronic fibrotic disease) ASYMMETRIC EXCURSION (due to splinting secondary to pleurisy, fractured ribs, trauma, or unilateral bronchial obstruction) PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING PALPATION TACTIE FREMITUS ▪ the vibrations of the chest wall that result form speech detected on palpation ▪ Normally, sounds generated by the larynx travels distally along the bronchial tree to set the chest wall in resonant motion PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING PALPATION TACTIE FREMITUS PRINCIPLE: Air does not conduct sound well, but a solid substance such as tissue does, provided that it has elasticity and is not compressed. Therefore, an increase in solid tissue will enhance fremitus, and an increase in air per unit volume of lung impedes sound. PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING PALPATION TACTIE FREMITUS EXAMPLE OF THE PRINCIPLE: ▪ Decreased Tactile Fremitus: EMPHYSEMA ▪ Increased Tactile Fremitus: PNEUMONIA PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING PERCUSSION ▪ to determine whether underlying tissues are filled with air, fluid, or solid material. ▪ used to estimate the size and location of certain structures within the thorax (example: diaphragm, heart, liver). ▪ sets the chest wall and underlying structures in motion, producing audible and tactile vibrations. PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING PERCUSSION DIAPHRAGMATIC EXCURSION ▪ normal resonance of the lung stops at the diaphragm. ▪ position of the diaphragm is different during inspiration and expiration. DECREASED DIAPHRAGMATIC EXCURSION: pleural effusion and emphysema INCREASE IN INTRAABDOMINAL PRESSURE, as in pregnancy, atelectasis, diaphragmatic paralysis, obesity, or ascites, may account for a diaphragm that is positioned high in the thorax PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING AUSCULTATION ▪ Normal Breath Sounds ▪ Adventitious Sounds ▪ Voice Sounds SYSTEMATIC FLOW: Apices – Bases – along Midaxillary lines PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING AUSCULTATION ▪ It is often necessary to listen to two full inspirations and expirations at each anatomic location PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING AUSCULTATION BREATH SOUNDS Normal breath sounds are distinguished by their location over a specific area of the lung and are identified as: ▪ VESICULAR ▪ BRONCHOVESICULAR ▪ BRONCHIAL (TUBULAR) PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING AUSCULTATION ADVENTITIOUS SOUNDS ▪ An abnormal condition that affects the bronchial tree and alveoli ▪ may produce adventitious (additional) sounds. ▪ Divided into two categories: ▪ NON-CONTINUOUS SOUNDS (crackles) ▪ CONTINUOUS SOUNDS (wheezes) PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM LOWER RESPIRATORY STRUCTURES AND BREATHING AUSCULTATION VOICE SOUNDS ▪ The sound heard through the stethoscope as the patient speaks is known as vocal resonance. ▪ BRONCHOPHONY - intense and clearer than normal ▪ EGOPHONY - voice sounds that are distorted ▪ WHISPERED PECTORILOQUY - clearly & distinctly hear whispered sounds that should not be normally heard CLINICAL SIGNIFICANCE: Lung Consolidation (pneumonia, pleural effusion)  4 DIAGNOSTIC TESTS ARTERIAL BLOOD GAS ▪ a blood test that requires a sample from an artery in your body to measure the levels of oxygen and carbon dioxide in your blood. ▪ also checks the balance of acids and bases, known as the pH balance, in your blood. ARTERIAL BLOOD GAS An arterial blood gas test usually includes the following measurements: Oxygen content (O2) ▪ This measures the amount of oxygen in your blood. Oxygen saturation (O2Sat) ▪ This measures how much hemoglobin in your blood is carrying oxygen. Partial pressure of oxygen (PaO2): ▪ This measures the pressure of oxygen dissolved in your blood. It helps show how well oxygen moves from your lungs to your bloodstream. ARTERIAL BLOOD GAS Partial pressure of carbon dioxide (PaCO2): This measures the amount of carbon dioxide in your blood and how well carbon dioxide can move out of your body. pH: This measures the balance of acids and bases in your blood, known as your blood pH level. The pH of blood is usually between 7.35 and 7.45. If it’s lower than that, your blood is considered too acidic. If it’s higher than that range, your blood is considered too basic (alkaline). Bicarbonate (HCO3): This is calculated using the measured values of pH and PaCO2 to determine the amount of the basic compound made from carbon dioxide (CO2.) PULSE OXIMETRY ▪ a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). ▪ When oxygen saturation is measured with pulse oximetry, it is referred to as SpO2 Tabletop model with sensor attached. Memory permits Self contained digital fingertip tracking of heart rate & oxygen saturation over time. pulse oximeter CULTURES THROAT CULTURES & NASAL SWABS ▪ may be performed to identify organisms responsible for pharyngitis. ▪ assist in identifying organisms responsible for infection of the lower respiratory tract. SPUTUM STUDIES ▪ obtained for analysis to identify pathogenic organisms and to determine whether malignant cells are present.  5 IMAGING STUDIES CHEST X-RAY (CX-R) PRINCIPLE: Normal pulmonary tissue is radiolucent; therefore, densities produced by fluid, tumors, foreign bodies, and other pathologic conditions can be detected by x-ray examination. ROUTINE CX-R TWO VIEWS: 1. POSTEROANTERIOR PROJECTION (AP) 2. LATERAL PROJECTION (L) ▪ or both, called AP-L PROJECTION ▪ Detects gross body tissue density (bones, etc.) COMPUTED TOMOGRAPHY (CT) ▪ an imaging method in which the lungs are scanned in successive layers by a narrow-beam x-ray. ▪ The images produced provide a cross-sectional view of the chest ▪ May or may not be used with contrast agents Contrast is not suitable for patients with compromised kidney function, allergy to iodine dye or shellfish, pregnant, claustrophobic, or severe obesity. CLINICAL SIGNIFICANCE: ▪ used to define pulmonary nodules and small tumors adjacent to pleural surfaces that are not visible on routine chest x-rays MAGNETIC RESONANCE IMAGING (MRI) ▪ similar to CT except that magnetic fields and radiofrequency signals are used instead of a narrow-beam x- ray (radiation) ▪ More detailed than CT (visualizes soft tissues) CLINICAL SIGNIFICANCE: ▪ used to characterize pulmonary nodules ▪ help stage bronchogenic carcinoma (assessment of chest wall invasion) ▪ evaluate inflammatory activity in interstitial lung disease ▪ acute pulmonary embolism ▪ chronic thrombolytic pulmonary hypertension FLUOROSCOPIC STUDIES ▪ allows live x-ray images to be generated via a camera to a video screen ▪ used to assist with invasive procedures, such as a chest needle biopsy or transbronchial biopsy, that are performed to identify lesions. CLINICAL SIGNIFICANCE: ▪ used to study the movement of the chest wall, mediastinum, heart, and diaphragm ▪ to detect diaphragm paralysis ▪ to locate lung masses PULMONARY ANGIOGRAPHY ▪ involves the rapid injection of a radiopaque agent into the vasculature of the lungs for radiographic study of the pulmonary vessels ▪ uses needle or catheter SITES TO INJECT: a vein in one or both arms (simultaneously) femoral vein catheter that has been inserted in the main pulmonary artery or its branches or into the great veins proximal to the pulmonary artery PULMONARY ANGIOGRAPHY CLINICAL SIGNIFICANCE: most commonly used to investigate: ▪ thromboembolic disease of the lungs (pulmonary emboli) ▪ congenital abnormalities of the pulmonary vascular tree  6 ENDOSCOPIC PROCEDURES BRONCHOSCOPY ▪ direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope ▪ usually performed under local anesthesia or moderate sedation ▪ rigid bronchoscopy (GA is used) COMMONLY USED: ▪ Fiberoptic Scope TWO TYPES/PURPOSES: 1. Diagnostic Bronchoscopy 2. Therapeutic Bronchoscopy BRONCHOSCOPY DIAGNOSTIC BRONCHOSCOPY 1. To collect secretions (analysis) 2. To obtain a tissue sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy) 3. To determine the nature, location and extent of the pathologic process 4. To determine whether a tumor can be resected surgically 5. To diagnose bleeding sites (source of hemoptysis) BRONCHOSCOPY THERAPEUTIC BRONCHOSCOPY 1. Remove foreign bodies or secretions from the tracheobronchial tree when patient cannot clear them 2. Control bleeding 3. Treat postoperative atelectasis 4. Provide brachytherapy (endobronchial radiation therapy) 5. Used to insert stents to relieve airway obstruction caused by tumor BRONCHOSCOPY NURSING INTERVENTION (prior the procedure): 1. Signed consent form (from the patient) 2. NPO 4-8 hrs. prior the procedure (to prevent aspiration) 3. Explain the procedure to the patient (reduce anxiety) 4. Administers preoperative medications (usually atropine and a sedative or opioid) as prescribed to inhibit vagal stimulation (thereby guarding against bradycardia, dysrhythmias, and hypotension) suppress the cough reflex, sedate the patient and relieve anxiety 5. Instruct patient to remove dentures and other oral prostheses BRONCHOSCOPY NURSING INTERVENTION (after the procedure): 1. NPO until cough reflex returns offer ice chips and eventually fluids (once cough reflex is present) 2. Monitor respiratory status 3. Observes for hypoxia, hypotension, tachycardia, dysrhythmias, hemoptysis, and dyspnea 4. For elderly, assess for confusion and lethargy 5. Patient is not discharge from the Postanesthesia care unit (PACU) until adequate cough reflex and respiratory status is present. 6. For discharged patient, instruct family to report back to hospital for SOB & bleeding. BRONCHOSCOPY POSSIBLE COMPLICATIONS: ▪ Reaction to the local anesthetic ▪ Oversedation ▪ Infection ▪ Aspiration ▪ Laryngospasm ▪ Bronchospasm ▪ Hypoxemia (low blood oxygen level) ▪ Pneumothorax ▪ Bleeding ▪ Perforation THORACOSCOPY ▪ diagnostic procedure in which the pleural cavity is examined with an endoscope ▪ diagnostic evaluation & treatment of pleural effusions, pleural disease, and tumor staging, biopsy VIDEO-ASSISTED THORACOSCOPY (VATS) ▪ permits improved visualization of the lung CARBON DIOXIDE LASER ▪ removal of pulmonary blebs and bullae ▪ excision of peripheral pulmonary nodules THORACOSCOPY NURSING INTERVENTIONS (before the procedure) ▪ Informed Consent is obtained ▪ NPO NURSING INTERVENTIONS (after the procedure) ▪ Monitor vital signs, pain level, respiratory status, signs of bleeding or infection at the incisional site ▪ Monitoring the patient for shortness of breath ▪ which might indicate a pneumothorax THORACENTESIS ▪ aspiration of fluid or air from the pleural space ▪ Can be ultrasound-guided (much safer) PURPOSES: Removal of fluid and air from the pleural cavity Aspiration of pleural fluid for analysis Pleural biopsy o studies of pleural fluid include Gram stain culture and sensitivity, acid-fast staining and culture, differential cell count, cytology, pH, specific gravity, total protein, glucose, cancer markers Instillation of medication into the pleural space  7 BIOPSY PLEURAL BIOPSY ACCOMPLISHED BY: ▪ NEEDLE BIOPSY OF THE PLEURA ▪ PLEUROSCOPY ▪ a visual exploration through a fiberoptic bronchoscope inserted into the pleural space. INDICATIONS: ▪ pleural exudate of undetermined origin ▪ when there is a need to culture or stain the tissue to identify tuberculosis or fungi LUNG BIOPSY PROCEDURES ▪ to obtain lung tissue for examination to identify the nature of the lesion. NON-SURGICAL LUNG BIOPSY TECHNIQUES: Transcatheter Bronchial Brushing Transbronchial Lung Biopsy Percutaneous (through-the-skin) Needle Biopsy LUNG BIOPSY PROCEDURES NURSING INTERVENTIONS (after the procedure) ▪ Monitor for: ✓ shortness of breath ✓ visible bleeding ✓ redness of the biopsy site ✓ purulent drainage (pus) ▪ Post-Biopsy Care & Patient Education ▪ Anxiety due to the needs and potential findings of the biopsy LYMPH NODE BIOPSY ▪ may be performed to detect spread of pulmonary disease to the lymph nodes and to establish a diagnosis or prognosis in such diseases as Hodgkin lymphoma, sarcoidosis, fungal disease, tuberculosis, and carcinoma. MEDIASTINOSCOPY is the endoscopic examination of the mediastinum for exploration and biopsy of mediastinal lymph nodes that drain the lungs Biopsy is usually performed through a suprasternal incision carried out to detect mediastinal involvement of pulmonary malignancy and to obtain tissue for diagnostic studies of other conditions (eg, sarcoidosis) LYMPH NODE BIOPSY NURSING INTERVENTIONS (after the procedure) ▪ Provide adequate oxygenation ▪ Monitor for bleeding ▪ Provide pain relief ▪ Upon discharge, instruct patient & caregiver about monitoring the changes in respiratory status  END Thank you for listening!