Nursing Assessment Respiratory System & Diagnostic Study (PDF)

Nursing Science V ( Respiratory and Alementary System Disorders) Lesson 1.1 : Nursing Assessment Respiratory System & Diagnostic Studies 1  Learning Outcomes At the end of this lecture, students will be able to 1. explain nursing ass...

Nursing Science V ( Respiratory and Alementary System Disorders) Lesson 1.1 : Nursing Assessment Respiratory System & Diagnostic Studies 1  Learning Outcomes At the end of this lecture, students will be able to 1. explain nursing assessment of the lower respiratory system. 2. explain the abnormal breath sounds 3. list medical conditions associated with abnormal breath sounds 4. list five main symptoms of respiratory disease 2 3 4  Subjective data Interview: If patient have signs and symptoms of SOB, briefly ask specific questions during initial assessment: Coughing (productive, non productive) Sputum (type & amount) Allergies, dyspnea or SOB (at rest or on exertion). Chest pain, history of asthma, bronchitis, emphysema, tuberculosis. Cyanosis, pallor. Exposure to environmental inhalants (chemicals, fumes). History of smoking (amount and length of time) 5  Initial Respiratory Survey (Inspection) Observe the patient’s breathing pattern – Rate (normal vs. increased/decreased) – Depth (shallow vs. deep) – Effort (any sign of accessory muscle use, inspect neck) Assess the patient’s color – Cyanosis 6  (continued)Initial Respiratory Survey (Inspection) Normal Respiratory Rates – Infant 30-60 – Toddler 24-40 – Preschooler 22-34 – School-age child 18-30 – Adolescent 12-16 – Adult 16-20 7  Inspection and assessment of respiration patterns Assess for abnormality of configuration, e.g. pigeon chest, funnel chest, spinal deformities. Assess ribs and inter spaces on respiration – may give information about obstruction in air flow e.g. bulging of inter spaces on expiration may be from obstruction to air out flow “tumor, aneurysm, cardiac enlargement”  Assess pattern of respiration Tachypnea: respiratory rate over than 20/m for adult. Bradypnea: respiratory rate less than 10/m. Palpation: palpate areas of chest especially areas of abnormalities. If clients complains: all chest areas must palpated carefully for tenderness orbulges 9  Abnormal Breath Sounds 1. Crackles (Rales) Heard more commonly with inspiration Its may associated with Prolonged recumbency 10  (continued)Abnormal Breath Sounds 2. Wheeze Continuous, high pitched, musical sound, longer than crackles Whistle quality, heard during expiration, however, can be heard on inspiration 11  (continued)Abnormal Breath Sounds 3. Rhonchi Similar to wheezes (subtype of wheeze) Low pitched, snoring quality, continuous, musical sounds 12  (continued)Abnormal Breath Sounds 4. Stridor Inspiratory musical wheeze Loudest over trachea  (continued)Abnormal Breath Sounds 5.Pleural Friction Rub Pleural friction rubs are specific examples of c ra c k l e s. D i s co nt i n u o u s o r co nt i n u o u s brushing sounds 14  Arterial Blood Gas (ABG) There are five components in an ABG, and the first three listed here are the most important for being able to interpret the results: 1. pH 2. Partial pressure of carbon dioxide (PaCO₂) 3. Bicarbonate (HCO₃) 4. Partial pressure of oxygen (PaO₂) 5. Oxygen saturation (SaO₂) 6. pH expected range 15  Pulse oximetry (SpO₂) Pulse oximetry is another way to assess respiratory status. The expected range for SpO₂ is between 95 - 100%. 16  Bronchoscopy A bronchoscopy is a procedure in which a tube is inserted into the patient's airway that allows for visualization of the airway as well as collection of specimens. 17  Flexible Bronchoscopy A flexible bronchoscopy is a procedure to look inside the respiratory system (nose, throat, and lungs). Specialist use a bronchoscope. This is a soft tube with a light and camera on the end. Pictures of your respiratory system appear on a monitor during the procedure. 18 19  Indications of flexible bronchoscopy During a flexible bronchoscopy, a doctor can perform minor treatments, includingTrusted Source: 1. removing any blockages and cleaning out the airways 2. draining an abscess 3. removing fluid from the lungs 4. widening any narrowing airways 20 object. 21  Indications of Rigid Bronchoscopy 1. One of the main uses of rigid bronchoscopy is removing a foreign 2. Other therapeutic uses of rigid bronchoscopymanaging central airway obstructions from causes other than a foreign object, tumors, blood clots and mucus 3. performing a biopsy, which involves removing a tissue sample to examine under a microscope 22  Thoracentesis A thoracentesis is a procedure to remove fluid or air from the pleural cavity via insertion of a needle into a patient's posterior chest (thorax). 23 24  Basavanthappa, B.T. Volume 1 & 2 (2015) Medical Surgical Nursing ( 3rd Ed. ) New Delhi : Japyee Brothers. Berman,A., Symder,S.J & Frandsen, G., (2016) Kozier & Erb’s. Fundamentals of Nursing, Concepts, Process and Practice (10th ed.). China : Pearson Education Limited Hinkle,J.L.& Cheever,K.H. ( 2018 ) Burnner & Suddarth’s Textbook of Medical - Surgical Nursing ( 14th Ed.) China: Wolters Kluwer Baid, H., Creed,F.& Hargreave,J.(2016) https://oxfordmedicine.com/view/10.1093/med/9780198 701071.001.0001/med-9780198701071-chapter-4 25 End of Topic 26