NSG 313 The Respiratory System Fall 2024 PDF

The Respiratory System N S G 31 3 FA L L 2 0 24 Respiratory System Anatomy of Chest Wall Ribs and Intercostal Spaces Anterior, Right Lateral and Posterior Anterior and Posterior View Right Side Left Side  12 locations in the front...

The Respiratory System N S G 31 3 FA L L 2 0 24 Respiratory System Anatomy of Chest Wall Ribs and Intercostal Spaces Anterior, Right Lateral and Posterior Anterior and Posterior View Right Side Left Side  12 locations in the front 14 locations in the back Where to auscultate Use diaphragm of scope Tell the patient to breathe deeply through an open mouth Listen to one full breath in each location Be mindful of elderly patients who may be weaker and fatigue easily Never listen through clothing Vertical Anterior Chest Lines Axillary lines Posterior Chest Lines Trachea and Major Bronchi Lungs The apex of each lung extends slightly above the clavicle The base of each lung is at the level of the diaphragm Lungs are not symmetrical Right lung has three lobes, and the left lung has two lobes Most lung tissue in the upper lungs is located on the anterior surface of the chest wall The lower lobes of both lungs are located toward the posterior surface of the chest wall The right middle lobe must be assessed from the anterior and anterolateral surfaces alone Airways Largest airway is the trachea which branches into the left and right bronchi The bronchi branch into smaller airways ending in the narrowest airways, the bronchioles Thousands of alveoli (small air sacs) are at the end of each bronchiole Within the alveolar walls are tiny airways called capillaries Breathing Largely an automatic act – controlled by the respiratory center in the brainstem mediated by the muscles of respiration Diaphragm – primary muscle of respiration Inspiration – the muscles expand the thorax – especially the intercostal muscles (incentive spirometer) and lungs are expanded. ACTIVE Diaphragm Primary muscle of inspiration Separates thoracic cavity from the abdominal cavity contracts→ ↑ volume creating negative pressure that draws air into the lungs Diaphragmatic expansion Lungs are expanded Expiratory phase Inspiratory effort stops and expiratory phase begins Diaphragm relaxes and passively rises Chest and abdomen return to their resting positions Normal breathing is quiet and effortless – barely audible Abdominal muscles assist in expiration During exercise – more work is required to breathe – accessory muscles join the effort Sternocleidomastoids – most important of these muscles, assist with respiration during exercise. Changes in Chest and Thorax due to age Life expectancy for women is 80 and men 75 – decreased due to COVID-19 Chest wall becomes stiffer and harder to move- respiratory muscles weaken Lungs lose some of their elastic recoil Osteoporotic vertebral collapse produces kyphosis – which increases the Anteroposterior (AP) diameter of the chest – aka barrel chest – has little effect on function. Patients with COPD. Major Functions of the Respiratory System Inhaling and exhaling – gas exchange Exchange of oxygen and carbon dioxide between the lungs and bloodstream Exchange of oxygen and carbon dioxide between the bloodstream and tissues Creating vibration of the vocal cords to produce sound Helping with the sense of smell Concerning Pulmondary Symptoms Shortness of breath – dyspnea – the uncomfortable awareness of breathing that is inappropriate for the level of exertion Wheezing Cough Blood-streaked sputum (hemoptysis) or purulent sputum Chest pain Dyspnea Questions – Air Hunger Onset - with exercise or at rest? Certain time of day? Seasonal allergies? Location – is the difficulty in your throat or neck or your chest? Duration – does it come on gradually? Suddenly? Characteristic symptoms – can you talk in full sentences? End stage COPD patients can barely speak a full sentence. Associated manifestations – wheezing, cough? Chest pain, nausea? Relieving factors – does anything make it better? Rest? Sitting up? Exacerbating factors – lying down make it worse Treatment – depends on cause – pulmonary? Cardiac? Inhaler? Dyspnea Asthma – acute episodes followed by symptom free Pneumonia – timing varies – usually dyspneic on exertion Spontaneous pneumothorax – sudden onset Pulmonary embolism – sudden onset, with tachypnea- on exertion. Vague symptoms, very hard to diagnose. COPD – slowly progressive dyspnea – end stage difficulty talking, eating Left sided heart failure – may progress slowly with fluid build up, or acutely if progresses to pulmonary edema  Difficulty taking a breath that feels deep enough smothering sensation with the inability to Ruling out get air anxiety as a cause for Hyperventilating – paresthesia around the dyspnea lips, hands and feet Episodic dyspnea during rest and exercise An upsetting event is not always evident  Wheezes Musical respiratory sounds may be audible without a stethoscope – middle of asthma attack Caused by partial obstruction of the lower airways Airways may be narrowed by bronchoconstriction, edema, secretions or a foreign body Your patient was admitted with pneumonia and has oxygen on at 2Lvia/nc. She has a history of asthma. She is now This Photo by Unknown Author is licensed under CC BY-SA-NC complaining of difficulty breathing and on auscultation you hear wheezes throughout the lung fields. Her pulse ox on O2 at 2L has dropped from 94% to 89%. Would increasing her O2 to 4 L help her respiratory distress? NO – obstruction does not allow oxygen in, patient needs bronchodilator. Cough Reflex response to stimuli that irritate receptors in the larynx, trachea or large bronchi Stimuli could be mucus, pus, blood ,dust, foreign bodies and even extremely hot or cold air Cause could be inflammation of the respiratory mucosa or tension in the air passages from a tumor or enlarged lymph nodes Acute cough lasts less than 3 weeks A chronic cough lasts over 8 weeks May also be a symptom of left sided heart failure ACE Inhibitors produce a persistent dry cough Cough - Bates Table 13-2 p. 358 Acute inflammation – acute bronchitis, pneumonias, pertussis – whooping cough Chronic inflammation – postnasal drip, chronic bronchitis, bronchiectasis, TB, lung abscess, GERD, asthma Pulmonary embolism – dark, bright red, mixed with blood - PND Lung cancer - commonly with dyspnea, weight loss and history of tobacco use Cardiac disorders – left sided HF Sputum sample to r/o is sometimes helpful Hemoptysis (blood in sputum) – cancer of lung, pulmonary edema. TB, bronchitis, pneumonia, PE Cough- OLDCART When did you first notice your cough? Have you been ill? COVID? Any new meds? Does cough come from throat or deep in chest? Does it happen only in the morning, throughout the day? Does it come and go? Do you feel the urge to cough when you inhale? Exhale? Does it make breathing difficult? Does it wake you up from a sound sleep? Is it productive? If yes, color, consistency, smell, amount SOB associated with cough? Wheezing? Chest pain from coughing? What makes it better or worse (what antihypertensive can cause a cough?) Have you tried any medications (ACE inhibitors/lisinopril can cause cough), vaporizers, dehumidifiers? Past History Prior lung problems or infections? Chest surgery or biopsies or trauma to your chest? Allergies? TB skin testing? Flu and COVID vaccines? Over 65 – pneumovax vaccine Traveled outside of US within the last 6 months? Lifestyle and Habits Do you smoke? If so, how much and for how long? If you quit, when? Do you vape? Do you chew tobacco? Are you exposed to 2nd hand smoke? Environmental conditions at home or work? Asbestos? Meds? Drugs? Do you use oxygen or other treatment for breathing?  Physical Assessment RESPIRATORY SYSTEM This Photo by Unknown Author is licensed under CC BY-SA-NC Initial inspection and survey of respiratory system Observe and document the rate, rhythm, depth and effort of breathing Healthy adult breathes regularly and quietly 12-20 breaths/minute Observe the facial expression, it should be relaxed and calm (hypoxia can produce anxiety and restlessness) Observe level of consciousness (LOC) Color of skin, mucous membranes and nails (cyanosis signals hypoxia); nail clubbing clubbing (Inspecting) Deformities of Thorax Normal adult – thorax is wider than it is deep Funnel chest – Pectus Excavatum –depression in lower part or sternum Pigeon chest – Pectus Carinatum – increases AP diameter – sternum displaced anteriorly Barrel chest – increased AP diameter – normal in infancy and often accompanies aging and chronic COPD AP Diameter : Lateral Diameter Inspection continued Inspect the neck for contraction of the accessory muscles during inspiration – especially the sternocleidomastoid scalene muscles or supraclavicular retraction. Is the trachea midline? Displaced trachea could be possible pneumothorax. Observe the shape of the chest – anteroposterior (AP) diameter should be less than the lateral diameter The AP of the chest : the lateral diameter of the chest should be 1:2 AP diameter may increase with aging and COPD Retraction of Intercostal Spaces and Accessory Muscle Use End Stage COPD patient having Asthma Attack Tripod Position Individuals with severe asthma or COPD may prefer to sit leaning forward with lips pursed during exhalation and arms supported on their knees or table Note supraclavicular and substernal retractions Tracheal Deviation Tracheal Deviation Pneumothorax pushing on Trachea This Photo by Unknown Author is licensed under CC BY-NC Respiratory Rate And Rhythm Normal respirations are 12-20/ per minute – but it depends on the patient Observe rhythm, depth and effort of breathing Apnea – no breathing Bradypnea – less than 12/min Tachypnea – more than 20/min Hyperpnea or hyperventilation – Kussmauls (over breathing due to DKA) Cheyne-Stokes – period of Apnea with period of slow breathing, sign of end of life. Palpation Focus on areas of tenderness and abnormalities in overlying skin, muscles and ribs- looking for muscle mass, bony defects, nodules or masses – ask patient about tenderness Palpate for lung expansion – either anteriorly or posteriorly – rib cage should expand smoothly and symmetrically under your hands as your thumbs move apart Palpate for crepitus – also called subcutaneous emphysema – a crackling sensation that occurs when air passes through fluid or exudate; air escapes from the lung into the subcutaneous tissue Subcutaneous Emphysema Right Chest - Crepitus Symmetric Chest Expansion Place your thumbs at the level of the 10th rib with your fingers loosely grasping and parallel to the lateral rib cage Raise a loose fold of skin on each side between your thumb and spine Ask the patient to inhale deeply What are you looking for? (Chest Expansion) Unilateral decrease or delay in chest expansion is seen in: ◦ Pleural effusion ◦ Lobar pneumonia ◦ Pleural pain associated with splinting ◦ Unilateral bronchial obstruction ◦ Chronic fibrosis of the underlying lung or pleura Tactile Fremitus Palpation of chest wall to detect changes in the intensity of vibrations created with certain spoken words in a constant tone and voice indicating underlying lung pathology Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking Percussion Helps establish whether the underlying tissues are air- filled, fluid filled, or solid It penetrates 5-7 inches into the chest so deep-seated lesions will not be detected Not an assessment technique utilized by undergraduate nursing students ◦ Auscultation Listen to the sounds generated by breathing Listening for adventitious (extra) sounds Auscultate in a systematic manner Compare one side to the other Listen to one full respiration at each spot – take a deep breath in and breathe out Do not listen through gown or clothes – hair on chest can produce crackling noises Listen anteriorly, laterally, posteriorly What sounds do you hear where? Vesicular Bronchovesicular Bronchial Tracheal Where to auscultate Use diaphragm of scope Tell the patient to breathe deeply through an open mouth Listen to one full breath in each location Be mindful of elderly patients who may be weaker and fatigue easily Never listen through clothing Breath sounds video https://www.youtube.com/watch?v=JUoZCrq25gc Adventitious Lung Sounds Crackles – a series of tiny explosions when small distal airways, deflated on expiration, pop open during inspiration ◦ Fine/Rales – change according to body position, heard best at end of inspiration ◦ Coarse – change or disappear when coughing, happen in airways. Wheezes – bronchial airways are narrowed almost to the point of closure, with sputum formation. ◦ Typical of asthma/COPD but can occur in a number of pulmonary diseases ◦ Silent chest of severe asthma requires immediate intervention – no air moving at all, possible intubation. ◦ High pitched and continuous whistling, worse on expiration Rhonchi – a variant of wheezes- may clear with coughing so secretions may be involved. Air bubbling past foreign body. - continuous, low pitched, bubbling sounds, on inspiration and expiration Stridor – narrowing of the upper respiratory tract- airway obstruction – immediate intervention warranted. Larger parts of airway, loud and high- pitches whistling. Pleural friction rub – arises from inflammation and roughening of the visceral pleura as it slides against the parietal pleura. Symmetrical, leather cracking sound outside the lungs, DOES NOT CHANGE WITH COUGH. Special techniques Pulse oximeter – continuous or spot checks Peak flow assessment – meter assesses the maximum volume of air expelled from lungs during a vigorous exhalation. A decrease in peak flow volume occurs in diseases that reduce outflow of air Regular monitoring of peak flow can evaluate the effectiveness of treatment for chronic asthma Pulse Oximeter Immunizations Influenza – annual – 6 months or older Pneumococcal – Streptococcus is most common cause of bacteremia, pneumonia, meningitis and middle ear infections in young children Pertussis Vaccine – Bordetella pertussis COVID -19 - follow latest CDC guidelines Documentation Patient denies cough or shortness of breath. Denies past or current respiratory illness or disease. Symmetrical anterior and posterior thorax. Anteroposterior –transverse ratio is 1:2. Respiratory rate is 16 breaths/minute, unlabored, regular and no audible wheezing. No retractions, accessory muscle use or nasal flaring. Chest rise and fall are equal bilaterally. No crepitus, masses or tenderness on palpation of anterior and posterior chest. Lung sound are clear bilaterally in all lobes anteriorly and posteriorly. No adventitious sounds. SpO2 saturation 99% on room air.