ASSESSMENT OF RESPIRATORY SYSTEM.pdf

ASSESSMENT OF THE RESPIRATORY SYSTEM JOSTINE  Introduction The respiratory system is composed of the upper and lower respiratory tracts. Together, the two tracts are responsible for ventilation (movement of air in and out of the airways). The upper airway, warms and f...

ASSESSMENT OF THE RESPIRATORY SYSTEM JOSTINE  Introduction The respiratory system is composed of the upper and lower respiratory tracts. Together, the two tracts are responsible for ventilation (movement of air in and out of the airways). The upper airway, warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange.  Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration. Upper airway structures consist of the nose, sinuses and nasal passages, pharynx, tonsils and adenoids, larynx, and trachea. The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange.  Subjective data ØThe nurse should collect subjective data from the client and determine the presence of the following signs and symptoms that are suggestive of respiratory problems. Use judgment in determining whether all or part of the history and physical examination will be completed based on the patient’s problems and degree of respiratory distress HISTORY TAKING  History of present illness Current state of health, functioning of body systems, degree of the symptoms Document all the cues that indicate the possibility of underlying respiratory problem. Chief complaint- Chief complaint- what brings them to hospital Use OLDCART to assess the symptoms  Past Health History Determine the frequency of upper respiratory problems (e.g., colds, sore throats, sinus problems, allergies) and whether seasonal changes have an effect on these problems. Allergies- ask about possible precipitating factors or triggers Document characteristics and severity of the allergic reaction  Inquire about a past history of lower respiratory problems, such as asthma, COPD, pneumonia, and tuberculosis (TB). Ask about history of other problems e.g. Cardiac disorders or HIV History of smoking Medications. Take a thorough medication Hx Encourage the patient to bring the medication bottles to each visit  Surgery or Other Treatments Determine if the patient has been hospitalized for a respiratory problem. Note the dates, therapy (including surgery), and current status of the problem. Determine if the patient has ever been intubated because of a respiratory problem. Ask about the use and the response to respiratory treatments such as a nebulizer, humidifier etc.  Nutritional history Ask about unintentional wt loss If food intake is altered by anorexia, fatigue or feeling full quickly (from lung hyperinflation). Anorexia, weight loss, and chronic malnutrition are common in patients with COPD, lung cancer, TB, and chronic severe infection (bronchiectasis).  Nutritional Hx cont… Also note fluid intake- Dehydration can cause mucus to thicken and obstruct the airway. Excessive weight interferes with normal ventilation and may cause sleep apnea Rapid weight gain from fluid retention may decrease pulmonary gas exchange  Common signs and symptoms Ø The clinical manifestations are related to the duration and severity of the disease. These major signs and symptoms of respiratory disease are: Ø Dyspnea- This is a symptom common to many pulmonary and cardiac disorders, particularly when there is decreased lung compliance or increased airway resistance.  It may also be associated with neurologic or neuromuscular disorders such as Guillain- Barre syndrome. Occurs mostly in acute respiratory disorders. The right ventricle of the heart will be affected ultimately by lung disease because it must pump blood through the lungs against greater resistance.  Cough- results from irritation of the mucous membranes anywhere in the respiratory tract which may arise from an infectious process or from an airborne irritant, such as smoke, smog, dust, or a gas. May be painful, productive or non- productive. Helps clear the airway. If present ask about the quality & ability to clear secretions, acute or chronic & pattern of cough.  Sputum production- If the patient has a productive cough, evaluate the following characteristics of sputum: amount, color, consistency, and odor. Quantify the amount of sputum in teaspoons, tablespoons, or cups per day. The normal color is clear or slightly whitish. If a patient is a cigarette smoker, the sputum is usually clear to gray with occasional specks of brown.  Note any recent increases or decreases in the amount. A profuse amount of purulent sputum or a change in color of the sputum probably indicates a bacterial infection. A gradual increase of sputum over time may indicate the presence of chronic bronchitis. Thin, mucoid sputum frequently results from viral bronchitis.  Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath point to the presence of a lung abscess, or an infection caused by anaerobic organisms.  Wheezing- is a high pitched, musical sound heard mainly on expiration. It is often the major finding in a patient with broncho- constriction. Clubbing of the fingers- is a sign of lung disease found in patients with chronic hypoxic conditions, chronic lung infections, and malignancies of the lung.  Hemoptysis- is a symptom of both pulmonary and cardiac disorders. The most common causes are: Pulmonary infection, pulmonary emboli and infarction. Cyanosis- is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood.  Chest pain/ discomfort may be associated with pulmonary or cardiac disease. Chest pain associated with pulmonary conditions may be sharp, stabbing, and intermittent, or it may be dull, aching, and persistent.  The pain usually is felt on the side where the pathologic process is located, but it may be referred to the neck, back, or abdomen. Chest pain may occur with pneumonia, pulmonary embolism with lung infarction, and pleurisy. It also may be a late symptom of bronchogenic carcinoma.  Objective data Equipment required Examination gown. Gloves. Stethoscope. Skin marker. Ruler/ tape measure. Watch with second hand  Inspection Ø Thorax- Inspection of the thorax provides information about the musculoskeletal structure, the patient’s nutritional status, and the respiratory system. Ø observe the skin over the thorax for color and turgor. Ø Note asymmetry, if present. Ø When findings are recorded or reported, anatomic landmarks are used e.g. crepitations over the right lung.  Chest configuration Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1: 2. However, there are four main deformities of the chest associated with respiratory disease that alter this relationship: i) Barrel Chest. Barrel chest occurs as a result of overinflation of the lungs causing an increase in the anteroposterior diameter of the thorax e.g. in a patient with emphysema. Barrel chest ii) Funnel Chest (Pectus excavatum)- occurs when there is a depression in the lower portion of the sternum e.g. in rickets patients. This may compress the heart and great vessels, resulting in murmurs..  iii) Pigeon Chest-. A pigeon chest occurs as a result of displacement of the sternum resulting in an increase in the anteroposterior diameter. This may occur with rickets or severe kyphoscoliosis Carinatum iv) Kyphoscoliosis- is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax. It may occur with osteoporosis and other skeletal disorders that affect the thorax.  Breathing patterns and respiratory rates The normal adult who is resting comfortably takes 12 to 18 breaths per minute. Except for occasional sighs, respirations are regular in depth and rhythm. This normal pattern is described as eupnea. Apnoea refers to lack of spontaneous breathing for more than 10seconds. Apnoea is an indicator of brain stem injury.  Patterns normal respirations are regular and even in rhythm Hypoventilation- Shallow, irregular breathing. Cheyne-stokes respirations refers to a disturbance in respiratory rhythm in which there is gradual deepening and then diminishing respiratory effort (crescendo and decrescendo) and rate, associated with episodes of apnoea 15 -30 seconds  Hyperpnea- An increase in depth of respiration. Abnormal breathing patterns include: Bradypnea (decreased breath rate) is associated with increased intracranial pressure, brain injury, and drug overdose. Tachypnea (increased breathing rate) is commonly seen in patients with pneumonia, pulmonary edema, metabolic acidosis, septicemia, severe pain.  Hyperventilation- An increase in both rate and depth. Hyperventilation that is marked by an increase in rate and depth, associated with severe acidosis of diabetic or renal origin, is called Kussmaul’s respiration. Apnea describes varying periods of cessation of breathing. If sustained, apnea is life- threatening.  NB: Certain patterns of respiration are characteristic of specific disease states e.g. Cheyne-Stokes respiration is usually associated with heart failure and damage to the respiratory center (drug-induced, tumor, trauma). Depth – The normal depth of inspiration is nonexaggerated and effortless. Kaussmaul’s respirations are characterized by extreme increase in depth and rate of respirations. These respirations are both active and regular and are typically seen in patients in DKA.  Symmetry – The thorax should rise and fall in unison in the respiratory cycle. Abnormal findings include unilateral expansion of either side for example when the lung is absent or collapsed in instances such as pneumonectomy, pneumothorax, pulmonary fibrosis, atelectasis, and flail chest.  Thoracic Palpation The nurse palpates the thorax for tenderness, masses, lesions. Tactile fremitus- The detection of the resulting vibration on the chest wall by touch is called tactile fremitus. A patient with consolidation of a lobe of the lung from pneumonia will have increased tactile fremitus over that lobe.  Tracheal Position To assess the position of the trachea, place the finger pad of the index finger on the patient’s trachea in the suprasternal notch and palpate for the trachea. Normal findings;- The trachea is midline in the suprasternal notch. Abnormal findings include;-  Tracheal deviation to the affected side (lung) is suggestive of atelectasis. Tracheal deviation away from the affected lung is common in patients with tension pneumothorax and pleural effusion.  Masses – No masses should be present. Abnormal findings are palpated when there are tumors or cysts present. Thoracic tenderness – No tenderness should be expressed on palpation. Tenderness experienced when there is for instance, rib fractures. Crepitus – Should be absent. Presence of crepitus is abnormal This occurs when air escapes the lungs and is trapped in the subcutaneous tissue (emphysema).  Thoracic percussion Percussion sets the chest wall and underlying structures in motion, producing audible and tactile vibrations. Percussions are used to determine whether underlying tissues are filled with air, fluid, or solid mass. They are also used to estimate the size and location of certain structures within the thorax (e.g, diaphragm, heart, liver). Dullness over the lung occurs when air-filled lung tissue is replaced by fluid or solid tissue. THORACIC AUSCULTATION  It is useful in assessing the flow of air through the bronchial tree and in evaluating the presence of fluid or solid obstruction in the lung structures. The nurse auscultates for normal breath sounds, adventitious sounds, and voice sounds.  PROCEDURE To auscultate the lungs: Ask the patient to sit in an upright position. If he can’t sit, have him lie on his side. Begin by auscultating the patient’s trachea. Continue down over the bronchi between the clavicles and mid sternum. When you reach the mainstem bronchus, the sound will be loud, high-pitched, and longer on expiration than on in inspiration.  Auscultate the anterior thorax, assessing for changes in normal breath sounds. Listen for a full inspiratory-expiratory phase at each location. Be alert for crackles, rhonchi, wheezes, and friction rubs, and Document their location.  Also note any dyspnea, coughing, or chest pain or discomfort that the patient may report. Auscultate the patient’s posterior thorax in a systematic right-to-left pattern. Note any abnormal sounds.  ADVENTIOUS BREATH SOUNDS Breath sounds that are not normal can be classified as either abnormal or adventious breath sounds. They are superimposed sounds on the normal breath sounds. There are 6 adventitious breath sounds. Fine crackles (rales) – These are heard on inspiration. Common finding in CCF, COPD, pneumonia  Coarse crackles (coarse rales) – These are heard on inspiration. Common finding in pulmonary edema and pneumonia Rhonchi - These are heard on expiration. Common finding in asthma and brochospasms  Pleural friction rub – These are heard on both inspiration and expiration. Also described as a grating sound. Common finding in pleurisy, TB and pleural effusion Stridor - These are heard on inspiration. Also described as a crowing sound. Common finding in airway obstruction, croup and large airway tumor.  Wheezes: continuous musical sounds that are associated with bronchial wall oscillation and changes in airway diameter. Wheezes are commonly heard in patients with asthma, chronic bronchitis, and bronchiectasis.  VOICE SOUNDS The assessment of voice sounds will reveal whether the lungs are filled with air, with fluid or are solid. This auscultation need be performed only if an abnormality is detected during the general auscultation, percussion or palpation. There are three techniques by which voice sounds can be assessed; Broncophony Egophony Whispered pectoriloquy  PROCEDURE To perform bronchophony, Position the patient for posterior, lateral or anterior chest auscultation. The area to be auscultated will be that in which an abnormality was found during percussion or palpation or in which adventitious breath sounds were hear.  Place the stethoscope in the appropriate location on the patient’s chest. Instruct the patient to say the words “99” or “1,2,3” every time the stethoscope is place on the chest or when told to do so. Auscultate the transmission of the patient’s spoken word.  To perform egophony Repeat steps 1 and 2 from the bronchophony procedure. Instruct the patient to say the sound “ee” every time the stethoscope is placed on the chest or when told to do so. Auscultate the transmission of the patient’s spoken word.  To perform whispered pectoriloquy Repeat steps 1 and 2 from the bronchophony procedure. Instruct the patient to whisper the words “99” or “1,2,3” every time the stethoscope is placed on the chest or when told to do so. Auscultate the transmission of the patient’s spoken word.  FINDINGS Normal findings when performing the tests (bronchophony, egophony and whispered pectoriloquy) are; unclear transmission or muffled sounds. Abnormal findings include; there is increased and clear transmission of voice sounds with increased intensity. This is then referred to as positive voice sounds.  Any type of lung consolidation process such as pneumonia, will produce positive voice sounds. Remember the principle that sound is transmitted reasonably well by a fluid medium. Voice sounds are absent or even more decreased in lung conditions where the lung is more air filled than usual. Examples include; emphysema, asthma and pneumothorax will produce absent voice sounds.  DIAGNOSTIC EVALUATION Pulmonary function tests- (PFTs) are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilator function, and the mechanics of breathing, diffusion, and gas exchange.  Indications PFTs are useful: In following the course of a patient with an established respiratory disease and assessing the response to therapy. as screening tests in potentially hazardous industries, such as coal mining and those that involve exposure to asbestos and other noxious fumes, dusts, or gases. for screening patients scheduled for thoracic and upper abdominal surgery, and symptomatic patients with a history suggesting high risk. PFTs include: Forced vital capacity Forced expiratory volume (qualified by subscript indicating the time intervals in seconds). Maximal voluntary ventilation PFT results are interpreted on the basis of the degree of deviation from normal, taking into consideration the patient’s height, weight, age, and gender.  ARTERIAL BLOOD GAS STUDIES It is an invasive method of measuring blood pH and levels of arterial oxygen and carbon dioxide when managing patients with respiratory problems to adjust oxygen therapy as needed. The arterial oxygen tension (PaO2) indicates the degree of oxygenation of the blood, while the arterial carbon dioxide tension (PaCO2) indicates the adequacy of alveolar ventilation.  Arterial blood gas studies aid in: assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Assessing whether the lung has been damaged after chest trauma.  Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SpO2 or SaO2). It is used in all settings where oxygen saturation monitoring is needed. Values less than 85% indicate that the tissues are not receiving enough oxygen, and the patient needs further evaluation. Cultures Throat cultures may be performed to identify organisms responsible for pharyngitis. Throat culture may also assist in identifying organisms responsible for infection of the lower respiratory tract. Nasal swabs also may be performed for the same purpose.  Sputum studies- Sputum cultures are used in diagnosis, for drug sensitivity testing, and to guide treatment. Sputum is obtained for analysis to: Identify pathogenic organisms and to determine whether malignant cells are present. Monitor patients receiving antibiotics, corticosteroids, and immunosuppressive medications for prolonged periods because these agents are associated with opportunistic infections.  Collection is done through expectoration (review procedure for sputum specimen collection), endotracheal aspiration, bronchoscopic removal, bronchial brushing, transtracheal aspiration, and gastric aspiration- usually for tuberculosis organisms. NB: instruct the patient on techniques of sputum collection.  Abnormal findings on sputum inspection include Mucoid – associated/ common in asthma, coryza Yellow or green – bacterial infection( staph, strep or pseudomonas) Blood tinged – PTB, lung cancer Pink, frothy – pulmonary edema Tenacious form of mucoid sputum – asthmatics after an attack Black sputum – fungal element of aspergillus Rusty, small in quantity, very viscid – lobar pneumonia  IMAGING STUDIES Chest X-Ray- may reveal an extensive pathologic process in the lungs in the absence of symptoms. Chest x-rays are usually taken after full inspiration because the lungs are best visualized when they are well aerated.  Computed Tomography (CT) scan is 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. CT scans can distinguish fine tissue density. They may be used to define pulmonary nodules and small tumors adjacent to pleural surfaces that are not visible on routine chest x-ray.  Magnetic Resonance Imaging MRIs are similar to CT scans except that magnetic fields and radiofrequency signals are used instead of a narrow-beam x-ray. MRIs yield a much more detailed diagnostic image than CT scans. MRI is used to characterize pulmonary nodules, stage bronchogenic carcinoma and evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension.  Fluoroscopic Studies- Fluoroscopy is used to assist with invasive procedures, such as a chest needle biopsy, performed to identify lesions. It also may be used to study the movement of the chest wall, heart, and diaphragm, to detect diaphragm paralysis, and to locate lung masses.  Pulmonary Angiography is most commonly used to investigate thromboembolic disease of the lungs, such as pulmonary emboli and congenital abnormalities of the pulmonary vascular tree. It involves the rapid injection of a radiopaque agent into the vasculature of the lungs for radiographic study of the pulmonary vessels.  ENDOSCOPIC PROCEDURES Bronchoscopy is the direct inspection and examination of the larynx, trachea, and bronchi through a bronchoscope. Indications for diagnostic bronchoscopy This is used to: (1) examine tissues or collect secretions (2) determine the location and extent of the pathologic process and to obtain a tissue sample for diagnosis. (3) to determine if a tumor can be resected surgically (4) to diagnose bleeding sites (source of hemoptysis).  Indications for Therapeutic bronchoscopy: This is used to: (1) remove foreign bodies from the tracheobronchial tree (2) remove secretions obstructing the tracheobronchial tree when the patient cannot clear them (3) treat postoperative atelectasis. (4) destroy and excise lesions.  Nursing interventions Before the procedure: Ensure a signed consent form is obtained from the patient. Withhold food and fluids for 6 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia.  Explains the procedure to the patient to reduce fear and decrease anxiety and administer 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.  Instruct the patient to remove dentures and other oral prostheses. Sedatives or opioids are administered intravenously as prescribed to provide moderate sedation.  After the procedure Ensure the patient takes nothing by mouth until the cough reflex returns. Once the patient demonstrates a cough reflex, provide ice chips and eventually fluids. Assesse for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine given during the procedure. Monitor the patient’s respiratory status and observes for hypoxia, hypotension, tachycardia, dysrhythmias, hemoptysis, and dyspnea.  The patient is not discharged from the recovery area until adequate cough reflex and respiratory status are present. Instruct the patient and family caregivers to report any shortness of breath or bleeding immediately.  Pleural Biopsy is accomplished by needle biopsy of the pleura. Pleural biopsy is performed when there is pleural exudate of undetermined origin and when there is a need to culture or stain the tissue to identify tuberculosis or fungi.  Nursing interventions Nursing care involves monitoring the patient for shortness of breath, bleeding, and infection. In preparation for discharge, the patient and/or family is instructed to report pain, shortness of breath, visible bleeding, or redness of the biopsy site or pus to the health care provider immediately. Patients who have undergone biopsy are often anxious because of the need for the biopsy and the potential findings; the nurse must consider this in providing post biopsy care and teaching.