RESPI-HANDOUT-COMPLETE-anaphy-lower-respi-conditions.pdf

RESPI MODULE 1: RESPIRATORY SYSTEM ANATOMY/STRUCTURES UPPER Functions: ANATOMY AND PHYSIOLOGY STRUCTURES RESPIRATORY Conduction of air to AND FUNCTIONS...

RESPI MODULE 1: RESPIRATORY SYSTEM ANATOMY/STRUCTURES UPPER Functions: ANATOMY AND PHYSIOLOGY STRUCTURES RESPIRATORY Conduction of air to AND FUNCTIONS (NOSE, PHARYNX, lower respiratory LARYNX) tract Filters. It protects LRT(lower respiratory tract) from foreign bodies e.g. dust. Warms- regardless of the temperature outside of the body. Air is warmed to body temperature before it reaches the lungs. Humidifies- moistens BODY PORTION FORM FROM air to about 70-80% Germ level humidity.  Ectoderm- skin hair, nails, sebaceousgland, LOWER FUNCTIONS: sense organs, mouth, nose, tooth, enamel RESPIRATORY Ciliary body and mammary glands TRACT Production of mucus  Mesoderm- connective tissue, bones, (TRANCHAE, Conduction cartilages, muscles, ligaments, tendons, MAINSTEM BRONCHI, dentin of teeth reproductive system, SEGMENTAL heart, BRONCHI, Circulatory system, lymph SUBSEGMENTAL  Endoderm-pleurae, peritoneal cavity, lower BRONCHI bladder and urethra lining, GIT, respiratory tract, RESPIRATORY Actual exchange of parathyroid gases (utilization of oxygen and VITAL FUNCTIONS OF RESPIRATORY SYSTEM elimination of carbon 1. Gas exchange (elimination of carbon dioxideand G dioxide) utilization of oxygen Macrophage 2. Regulation of acid-base balance Production of surfactant STRUCTURES AND FUNCTIONS OF THE RESPIRATORY SYSTEM - Respiratory System developed from the fluid environment during the intrauterine life. - The first breath took place during thefirst cry immediately after birth. Regina Mae Tamano G NOSE Olfactory – sense of smell, adjunct to taste Gives shape to the face 2 nostrils (alae nasae or nares) flaring may signify difficulty of breathing PARTS OF THE NOSE: A. Columnar epithelial cells- production of mucus to humidify. B. Turbinates – rich in blood supply, if injured nose bleeding will occur(epistaxis). PHARYNX  Funnel shape. The pharynx, commonly called the throat, is a passageway that extends from the base of the skull to the level of the sixth cervical vertebra. It serves both the respiratory and digestive systems by receiving air from the a. SEPTUM- division between vestibule nasal cavity and air, food, and water from the (abnormal deviated septum, perforated oral cavity. septum). 3 PARTS b. Nasolacrimal glands –tears production NASOPHARYNX Is the upper part of the SINUSES: throat(pharynx) that 1 FRONTAL SINUS lies behind the nose. 2 ETHMOIDAL It’s a box-like 2 SPHENOIDAL 2 MAXILLARY chamber about 1 ½ FUNCTIONS: inches on each edge. It Help in humidifying the air lies just above the soft Lighten the skull part of the roof of the Phonation – resonating chamber in mouth (soft palate) speech and just in back of the nasal passages. It contains adenoid tissue, which fights Regina Mae Tamano  infections and the cavity diverges opening to the anteriorly into the Eustachian tubes, larynx and which lead to the ears. posteriorly into the It provides a major esophagus. drainage path for lymphatic fluids and LARYNX (VOICE BOX) Located at the level of the 4th or 6th cervical spin generally drains into 3 the throat, nose or CARTILAGES ears. EPIGLOTTIS Closes when you OROPHARYNX swallow thus aspiration The part of the throat of food and water is at the back of the prevented to go to the mouth behind the oral lungs during drinking cavity. It includes the and eating. back third of the Thyroid – adam’s apple tongue, the soft palate, the side and back walls CRICOID Where you create of the throat and the tracheotomy or tonsils. cricoid stab or tracheostomy TONSILS tube insertion, narrow (OROPHARYNGEAL) Palatine or facial in children tonsils – sides of the mouth Lingual tonsils – base of the tongue WELDEYER’S RING- composed of four tonsils – pharyngeal, tubal, palatine, lingual TRACHEA (WIND PIPE) Made of 15-20 C- shape cartilages L-11.2 cm, W- 2 to 2.2 cm. Carina – the bifurcation of the trachea Landmark for ET insertion LARYNGOPHARY The laryngopharynx: NX or the position is inferior to HYPOPHARYNX the epiglottis and is bordered by the pharyngoepiglottic fold superiorly and the upper esophageal sphincter inferiorly. It refers to the portion of the pharynx where the Regina Mae Tamano   Composed the lung tissue, spongy  24 thousand at birth  8 years and older, it increases to 3 million  Surface area- 750 to 860 sq.ft or the size of tennis court. Above 70 square meters or some – 40 times the surface area of the entire body or TBSA.  10% of oxygen supply consume by the lungs  Has NO PAIN RECEPTOR, no sensation usually pain is referred to other area.  Left lung – 8 segments, 2 lobes (Upper and Lower lobe)  Right lung – 10 segments, 3 lobes (superior, middle and inferior MAINSTEM Cartilaginous lobe) BRONCHI 2 mainstem bronchi  Known as the gas exchanger 1.Left- narrow and PARIENTAL  Covers the longer,45-55 degree angle, PLEURA thoraciccavity more horizontal, not VISCERAL  Covers the outer accident prone. PLEURA surfaces of the lungs 2.Right-wider and and adheres to them shorter,20-30 degree angle, much as the skin of more vertical, accident an prone. apple. SEGMENTAL Cartilaginous BRONCHI Serve to conduct air, do not absorb gas ACCESSORIES: MUSCLES SUBSEGMENTA The smallest DIAPHRAGM Primary or main L BRONCHI cartilaginous portion of the conducting muscle of respiration. structure. Nerve supply – phrenic nerve. RESIRATORY ZONES INTERCOSTAL a.Internal - Forced expiration and TERMINAL BRONCHOILE and ALVEOLAR coughing muscles DUCTS and sacs - decreases the diameter - Gas exchange starts here, made of of the chest wall muscular tube, can collapse. b. External - inspiration - increases the diameter of the chest wall ECTORALIS Both increase the work of MAJOR breathing. AND MINOR RECTUS Forced expiration and ABDOMINIS coughing At the end of the smallest bronchioles are small, hollow sacs called alveoli. As blood flows through the capillaries, oxygen moves from the air, and carbon dioxide and water pass out of the blood. This process is called GAS EXCHANGE. SCALENE  Stabilized the upper ALVEOLI chest wall  Elevates the 1st and Regina Mae Tamano  2nd ribs during inspiration, increases the size of the thorax. STERNOCLEIDO  Stabilizes upper MASTOID chest wall. Assist in elevating the rib cage  Elevates sternum PARASTERNAL Inspiratory muscle, increases work of 2.STERNUM breathing - Manubrium TRAPEZIUS Inspiratory muscles - Body - Xiphoid SUMMARY Muscles responsible for supraclavicular retraction - Sternocleidomastoid - Scalene - Trapezius Inspiratory Muscles - Parasternal - Trapezius - Pectoralis - IC-external Expiratory Muscles 3.SCAPULAE – 2 - IC-internal 4.CLAVICLES – 2 - Rectus Abdominis 5.VERTEBRA - T1-T10 – true and false ribs ACCESSORIES: BONES - T11-T12- floating rib 1. RIBS - 12 pairs - 7 pairs – true libs (attached directly to sternum) 3 pairs – false ribs 8th,9th, and 10th ribs (attached to one another by costalcartilages but not directly to the sternum.) 3 pairs – floating ribs 11th and 12th ribs(not attached to other ribs and sternum -Allow full expansion of the chest -Protect the kidneys COMMON CONCEPTS Regina Mae Tamano  3. Cilia -hair like projections – columnar epithelial cells – propels particles foreign body(FB) to Oropharynx – coughed or swallowed 4. Goblet Cells, lysosomes and other elements to fight invading bacteria 5. Cough reflex- protective mechanism rapidly expels air and particles from airway. 6. Sneeze reflex – cleans nasal passageway 7. Hering-Bruer reflex – prevents over inflation of the alveoli 8. Alveolar Macrophages – phagocytize and detoxify. 9. Reflex Bronchoconstriction – sudden narrowing of the tracheobronchial tree (TBT) preventing foreign bodies and noxious substances to enter the system OXYGENATION  Respiratory Physiology: most cells in the diversoxygen body obtain their energy from chemical thebody can reactions involving oxygen and elimination of carbon dioxide. The exchange of respiratory gases occurs between environmental air and the blood. There are 3 steps in the process of oxygenation: VENTILATION, PERFUSION, and MUSCLES of respiration must be intact and the central nervous system able to regulate the respiratory cycle. DIFFUSION OR DALTON’S LAW VENTILATION  Diffusion is the movement of molecules from an  Ventilation is the process of moving gases into area of higher concentration. Diffusion of and out of the lungs. Ventilation requires respiratory gases occurs at the alveolar capillary coordination of the muscular and elastic membrane, and the rate of diffusion can be properties of the lung and thorax, and intact affected by the thickness of the membrane. innervation. The major inspiratory muscle of  Increased thickness of the membrane impedes respiration is the diaphragm. It is innervated by diffusion because gases take longer transfer the phrenic nerve – the spinal cord at the fourth across. Patients with pulmonary edema, cervical vertebra. pulmonary infiltrates or a pulmonary effusion have an increased thickness of the alveolar capillary membrane resulting in slowed diffusion, slowed exchange of respiratory gases and impaired delivery of oxygen to tissues.  The surface area of the membrane can be altered as a result of a chronic disease (emphysema), an acute disease (e.g. Pneumothorax) or a surgical Regina Mae Tamano  process (e.g. lobectomy). When fewer alveoli are functioning, the surface area is decreased. G FACTORS DETERMINE LUNG COMPLIANCE: 1. ELASTICITY OF THE LUNG TISSUE – represents the mechanical properties of the lungs. to be expanded or distended by I pressure surrounding or inflating the lungs andto collapse as soon as the latter pressure disappear. 2. SURFACE TENSION – force exerted by water molecules on the surface of the lung tissue as those water molecules pull together. This occurs at the interface between the alveolar membrane and the airway. Increase surface  Breathing- is the effort required to expand and tension increase cohesion within the alveoli contract the lungs. The work of breathing is closed. determined by the degree of compliance of the lunngs, airway resistance, presence of active AIRWAY Is the pressure expiration and use of accessory muscle of RESISTANCE difference between respiration the environment  Compliance – is the ability of the lungs to distend and the alveoli in or to expand in response to increased intra alveolar relation to the rate pressure. Compliance is decreased in diseases of flow of inspired such as pulmonary edema, intertitial and pleural gas. Increased by fibrosis, congenital or traumatic structural an airway abnormalities such as Kyphosis or fractured ribs, obstruction small premature babies. airway disease  Decreased Compliance – increased airway (such as asthma), resistance, active expiration or use of accesssory and tracheal edema. muscles increases the work of breathing, resulting When resistance is in icnreased energy expenditure. To meet this increased the expenditure, the body increased its metabolic rate amount of air and need for oxygen, as well as the elimination of traveling through carbon dioxide. This sequences is a vicious cycle the anatomical for the client with impaired ventilation, causing airways is further deterioration of respiratory status and decreased. EXPIRATION Is normally a ability to oxygenate adequately. passive process that depends on the elastic recoil properties and requires little or no muscle work. Regina Mae Tamano ELASTIC RECOIL Produced by elastic LUNG VOLUMES Normal lung fibers in the lung volumes are tissue and by measured through surface tension in pulmonary the fluid film lining function testing. the alveoli. Spirometry Advanced COPD measures the lose the elastic volume of air recoil of the lung entering or leaving and thorax- work of the lungs. breathing is Variations in lung increased. volumes may be PRESSURES Gases are moved associated with into and out of the health states such lungs through as pregnancy, pressure changes. exercise, obesity or Intrapleural obstructive and pressure is negative restrictive or less than condition of the atmospheric lung. The amount pressure. Which is of surfactant, 760 mmHg at sea degree of level. For air to flow compliance, into the lungs, strength of intrapleural respiratory pressure must muscles can affect become more pressures and negative, setting up volumes within a pressure gradient the lungs. between the PERFUSION The primary atmosphere and function of alveoli. pulmonary SURFACE TENSION Any factor that circulation is to reduces the airway move blood to and caliber (mucosal from the alveolar edema, capillary inflammation, membrane so gas secretion, exchange can bronchospasm, less occur. Pulmonary surfactant) will circulation is a raise the resistance reservoir for blood to airflow and so the lung can decrease the increase its blood ventilation of the volume without corresponding increasing in alveoli similarly pulmonary artery any area in which or venous the local pressures. The compliance has pulmonary decreased (i.e. that circulation also acts potion of the lung as filter, removing has become more small thrombi stiff) will before they can receive less reach vital organs. ventilation than the surrounding more expandable portion of the lungs. Regina Mae Tamano PULMONARY Pulmonary vessels are thinner CIRCULATION circulation begins than those in the at the pulmonary systemic circulation artery, which and contains less receives poorly smooth muscles, oxygenated mixed because of the low venous blood from pressure and the right ventricle. resistance. The lung Blood flow through accepts the total this system cardiac output from depends on the the right ventricle pumping ability of and except in cases the right ventricle, of alveolar hypoxia, which has an does not direct output of blood flow from approximately 4 to one 6 liters/minute. region to another. The flow EXCHANGE OF Respiratory gases continuous from RESPIRATORY GASES are exchanges in the pulmonary the alveoli and the artery through the capillaries of the pulmonary body tissues. arterioles to the Oxygen is pulmonary transferred from capillaries where the lungs to the blood comes in blood, and carbon contact with the dioxide is alveola capillary transferred from membrane and the the blood to the exchange of alveoli to be respiratory gases exhaled as a waste occurs. The oxygen product. At the rich blood then tissue level, oxygen circulates through is transferred from the pulmonary tissues to the blood venules and to return to the pulmonary veins alveoli and exhaled. returning to the left This transfer is atrium. dependent on the DISTRIBUTION Pressure within the process of pulmonary diffusion. circulatory system are low in  During inspiration, the upper respiratory comparison to tract warms and humidifies atmospheric air those in the increasing PH20 to 47 mmHg > Partial systemic pressures of other gases decline because total circulation system. pressure must remain at 760 mmHg. The normal pulmonary systolic  Before entering the alveoli, inspired air mixes arterial pressure is with gas that wasn’t exhaled on the previous between 20 and 30 expiration. Because this gas contains more mmHg, the CO2 and less O2 than inspired air, partial diastolic pressure is pressures change again. less than 12 mmHg. And the mean  The air that finally enters the alveoli for pressure is less diffusion across the respiratory membrane than 5 than goes to further partial pressures changes. 20mmHg. The walls of pulmonary However, it remains high in PO2 and low inPCO2. Regina Mae Tamano  The differential in partial pressures of O2 and Co2 cases the two gases to cross the respiratory membrane toward the lower side of their respective pressure gradients. O2 diffuses into the blood, and CO2 diffuses outward, equalizing gas pressures on both sides of the respiratory membrane. OXYGEN CONTENT  The total amount of O2 in the blood equals to the amount of O2 bound to Hgb+02 dissolved in plasma.  SaO2 (Oxygen Saturation) – impt. Index to O2 content  Hgb. & PaO2 (partial pressure of oxygen in arterial blood) – affect values of O2 content  Arterial O2- 20ml/dl of blood  Mixed O2 – 15ml/dl of blood OXYGEN DELIVERY (DO2)  The amount of 02 transported to tissue is determined by 02 content and cardiac volume.  In normal adult- 1000 ml. of 02 travels/ min through arteries to tissue and 775ml.returns to the right side of the heart and lungs. CARBON DIOXIDE TRANSPORT  Carbon dioxide diffuses into red blood cells and is rapidly hydrated into carbonic acid (H2CO2) because of the presence of carbonic anhydrase.  The carbonic acid then dissociates into hydrogen (H+) and bicarbonate (HCO3) ions. HCO3 diffuses into plasma. In addition, some of the CO2 in red blood cells react with amino acid groups forming carbamino compounds. This reaction can occur rapidly without the presence of an enzyme. Reduced hemoglobin (deoxyhemoglobin) can combine with CO2 more easily the deoxyhemoglobin. Therefore, venous blood transport the majority of CO2 Regina Mae Tamano  maximum amount of oxygen that could possibly bind to H. because Hb carries most of the blood oxygen, a normal SaO2 level is 95% to 100%. Normal Hb level for women is 14 to 18 g/dl for men and 11.5 to 15.5 g/dl. The oxygen supply may be adequate or inadequate, depending on tissue demand for oxygen. Normally tissues use about 250cc of oxygen/min SvO2 (venous oxygen saturation) is the amount of oxygen that returns to the heart from the tissues, normal SvO2 levels range from 60% to 80%  Some conditions that raise SvO2 levels and lower the demand for oxygen include increased cardiac output, elevated SaO2 levels, vasoconstriction, septic shock, hypothermia, anesthesia, sedation, and chemical paralysis.  Conditions that lower SvO2 demand for oxygen include decreased cardiac output, reduced SaO2 levels, vasodilation, cardiogenic shock, hyperthermia or fever, shivering, seizures, positive end-expiratory  pressure and high airway pressure. SUMMARY OF GAS EXCHANGE AND TRANSPORT  During diffusion, molecules of oxygen and carbon dioxide move between the alveoli and the capillaries. Partial pressure – the pressure exerted by one gas in mixture of gases – dictates the direction of movement, which is always from an area of greater concentration to one of lesser concentration. In the process, oxygen crosses the alveolar and capillary membranes into the circulatory system, where it dissolves in the plasma and passes through the red blood cell membranes. Here it attaches to hemoglobin. Which in turn furnishes body tissues with oxygen. Carbon dioxide moves in an opposite direction- from the tissues, across the alveolar capillaries, and out through the respiratory system.  The circulatory system transports the oxygenated blood from the pulmonary veins to the left side of the heart and then to the rest of the body. The pulmonoppositeary arteries transport the deoxygenated blood to the right side of the heart and then into the arterioles and alveoli for exchange in the lungs. OXYGEN SATURATION Cardiac output refers to the volume of blood pumped from the heat each minute a normal cardiac output of 4 to 8 liters per minute is maintained by a normal heart rate and stroke volume. SaO2, expressed as a percentage, represents the actual amount of oxygen bound to Hb. Divided by the Regina Mae Tamano  - Such as anemias, increases in the body’s metabolic demands such as pregnancy or fever and infection and alteration that affect that patient’s chest wall movement or the central nervous system.  DECREASED INSPIRED OXYGEN CONCENTRATION LUNG RESISTANCE -When the Force that must be overcome for effective concentration of ventilation inspired oxygen 3 KINDS: declines, the 1. ELASTIC- chest wall rigidity oxygen carrying 2. NON-ELASTIC – factors that capacity of blood interferes with ventilation as obesity, decreased. pregnancy, diseases Decreases in the 3. AIRWAY – problem with airflow as mucus, fraction of edema inspired oxygen concentration (FiO2) can be cause by an upper or lower airway FACTORS AFFECTING OXYGENATION obstruction PHYSIOLOGIC  ANY CONDITION limiting delivery of FACTORS THAT AFFECTS inspired oxygen to CARDIOPULMONA alveoli, decreased R environmental Y FUNCTION oxygen (occurs at - These general high altitudes) or classifications of decreased the cardiac inspiration as the disorder include result of an disturbances in incorrect oxygen conduction, concentration impaired valvular setting or function, respiratory myocardial therapy hypoxia, equipment. cardiomyopathic  HYPOVOLEMIA conditions and -Hypovolemia is a peripheral tissue reduced hypoxia, circulatory blood respiratory volume resulting disorders include from extra cellular hyperventilation, fluid loss that hypoventilation occurs in and hypoxia. condition such as  ALTERATION THAT shock and severe AFFECT THE dehydration. If the OXYGEN fluid loss is CARRYING significant, the CAPABITY OF BLOOD body tries to adopt by increasing the Regina Mae Tamano  heart rate and DEVELOPMEN These are the peripheral TAL FACTORS developmental stages of vasoconstriction to the patient/clients, and increase volume of the normal aging process blood returned to can affect tissue the heart of oxygenation. increase the  PREMATUR cardiac output EINFANTS  INCREASE - Are at risk for D hyaline membrane METABOLI diseases or IRDS ( C infant respiratory - Pregnancy, wound distress healing, and syndrome) which exercises and is thought to be fever caused by a  CONDITIONS surfactant AFFECTING CHEST deficiency. The WALL MOVEMENT surfactant - Any condition that synthesizing reduces chest wall ability of the lungs movement can develops late in result in decreased pregnancy about ventilation. If the the 7th month and diaphragm cannot may therefore, be fully descend with lacking in preterm breathing, the infants. volume of inspired  INFANTS air decreases and AND less oxygen is TODDLERS delivered to the - Are at risk for alveoli and upper respiratory subsequently to tract infection as tissues. aresult of frequent 1.pregnancy exposure to other 2.obesity children and 3.musculoskeletal exposure to abnormalities second hand smoke. In addition, during teething process, some infants develop nasal congestion which encourages bacterial growth and increases the potential for respiratory tract infection.  SCHOOL AGE CHILDREN AND ADOLESCENTS - School age children and adolescent are exposed to respiratory infections and Regina Mae Tamano  respiratory risk distensible. The factors such as trachea and large second-hand bronchi become smoke and enlarges from cigarette smoking. calcification of the A healthy child airways, and usually does not alveoli enlarge, have adverse decreasing the pulmonary effects surface area from respiratory available for gas infections. A exchange. person who starts smoking in adolescence and continuous to smoke into middle age, however, has an increased risk for cardiopulmonary disease and lung cancer.  YOUNG AND MIDDLE AGE ADULTS - Young and middle age adults are at BEHAVIORAL Behavior or lifestyle may risk to multiple FACTORS: directly or indirectly affect cardiopulmonary (BEHAVIOR OR the body’s ability to meet risk factors: an LIFESTYLE) oxygen requirements. unhealthy diet, Lifestyle factors that lack of exercises, influence respiratory stress, drugs and functioning includes smoking. nutrition, exercise,  OLDER ADULTS – the cigarette smoking, cardiac and substance abuse and respiratory system stress. undergo changes throughout the aging  NUTRITION process. In the arterial - Nutrition affects system, atherosclerotic cardiopulmonary plaques develop and functions in the systematic blood several ways. pressure may rise. Severe obesity - Chest wall decreases oxygen compliance is demands to meet decreased in the metabolic needs. older patient due The malnourished to osteoporosis patient may and calcification experience of the costal respiratory muscle cartilages. The wasting, resulting respiratory in decreased muscles weaken muscle strength and the pulmonary and respiratory vascular excursion. circulation Coughing becomes less efficiency is reduced secondary Regina Mae Tamano  to respiratory greater oxygen muscle weakness, extraction by putting the patient working muscles. at risk for Fully conditioned retention of people can pulmonary increase oxygen secretions. Diet consumption by high in fat 10% because of increase increased cardiac cholesterol and output and thermogenesis in increased the coronary efficiency of the arteries. Patient myocardial who are obese and muscles. or malnourished  CIGARETT are at risk for E anemia. Diets SMOKING high in Cigarette smoking carbohydrates is associated wit a may play a role in number of increasing the diseases including carbon dioxide heart disease, load for patients chronic with carbon obstructive lung dioxide retention. disease and lung As carbohydrates cancer. Cigarette are metabolized, smoking can an increased load worsen peripheral of carbon dioxide vascular and is created and coronary artery excreted via disease. Inhaled lungs. nicotine cause vasoconstriction of  EXERCISE peripheral and - Exercise increases coronary blood the body’s vessels, increasing metabolic activity blood pressure an oxygen and decreasing demands. The rate blood flow to and depth of peripheral vessels. respiration The risk of lung increase. Enabling cancer is 10 times the person to greater for a inhale more person who smoke oxygen and expire than for a excess carbon nonsmoker. dioxide. Exposure to side - Physical exercise stream smoke program has many increases the risk benefits. People of lung cancer in who exercise 3 to the nonsmoker. 4 times a week for  SUBSTANCE ABUSE 20 to 40 minutes -excessive use of alcohol increased blood and other drugs can flow, lower pulse impair tissue oxygenation rate, blood in two ways. First the pressure, person who chronically decreased abuses substances often cholesterol, and has a poor nutritional Regina Mae Tamano intake. ENVIRONMEN  The environment can With the resultant TAL FACTORS also influence decrease in intake of iron oxygenation. The rich foods, hemoglobin incidence of production declines. pulmonary diseases is Second excessive use of higher is smoggy, alcohol and certain other urban areas that in drugs can depress the rural areas. In respiratory center, addition, the patient’s reducing the rate and work place may depth of respiration and increase the risk for the amount of inhaled pulmonary disease. oxygen. Substances abuse Occupational by either smoking or pollutants include inhaling, such s crack asbestos, talcum cocaine or inhaling fumes powder, dust and from paint or glue cans airborne fibers. cause direct injury to SUMMARY lungtissue that can lead to FACTORS AFFECTING OXYGENATION: permanent lung damage 1. PHYSIOLOGICAL an impaired oxygenation. 2. DEVELOPMENTAL  ANXIETY/STRESS 3. BEHAVIORAL - A 4. ENVIRONMENTAL continuous state of severe anxiety increases the PHYSICAL ASSESSMENT body’s metabolic ASSESSMENT GOAL: rate and the oxygen demand. 1. Detect early changes in patient’s The body responds pulmonary function to anxiety and 2. Ensure prompt care and treatment other stresses by an increased rate WHEN TO ASSESS: and depth of - Hospital admissions respiratory. Most - at regular intervals during illness people can adapt, - routine health evaluation or screening but some, - done daily for ambulatory patients particularly those - more frequently for patients who are acutely with chronic ill/more susceptible to disease(pediatric and illnesses or acute geriatric clients, those who activities are life-threatening limited by medications, surgery or debilitating illnesses such as condition) myocardial - assessment can be deliberate or infarction cannot organized – e.g. newly admitted patients tolerate the or informal e.g. during patient’s bath oxygen demands meals associated with anxiety. INSPECTION 1. Evaluating the thorax & lungs Begin your assessment by gathering the necessary equipment. You’ll need a stethoscope, a marker pen and a tape measureor ruler. You’ll also need an area that’s well lightened (preferably with natural light). Typically, your assessment will proceed in this order: inspection, palpation, percussion, and auscultation. You’ll finish by assessing respiratory excursion separately. Regina Mae Tamano  2.Inspecting the thorax cardiac enlargement and sparse sputum help the patient to a sitting position, production then observe his respirations and general Ruddy skin with blue overtones: seen in appearance. Note his respiratory rate and patients with pure chronic bronchitis. any unusual breathing pattern. Patients usually heavyset, with ankle Remember that men and children use edema and distended neck veins. thediaphragm to breathe, whereas women use the thoracic muscles. In both male and female patients, be alert for any accessory muscle use. Watch for use of the EYES sternocleidomastoid,scalene, or Engorged veins, swollen optic disc or trapezius muscles to breathe, or for papilloedema: means that patient is supraclavicular retractions, if they’re retaining carbon dioxide. LIPS present, the impeded. Similarly, watch for prolonged exhalation Pursed lips: seen in patients with COPD. Standing directly in front of the patient, Breathing out through pursed lips helps check his skin for discoloration, the patient get rid of more CO2. scars, lumps, dimples, lesions, and Circumoral cyanosis (a bluish or dusky ring circling the mouth): means ulceration. Then asses his chest for presence of hypoxemia. symmetry of thoracic and NOSE respiratory muscles. Nose flaring: means respiratory distress, Mentally position the ribs, trachea, and especially in infants. May be lungs within the patient’s anterior accompanied by respiratory grunt. thorax. Next, inspect the posterior Nasal polyps may interfere with thorax, noting respirations any skin or other abnormalities. Mentally Red, swollen nose: means allergies position the scapulae, ribs and vertebrae INSPECTING THE NOSE, MOUTH within the posterior thorax. AND THROAT NOSE: equipment: penlight, nasoscope with light, ophthalmoscope or otoscope Inspection/Observation with light or nasal speculum To properly inspect a patient with a  Procedure: observe the size, shape, respiratory disorder, look at everything placement, and general condition of the including his behavior. Examine your patient’s nose patient from head to toe and  Abnormal findings: Flaring document nostrils, which suggest your initial findings. Mental State respiratory difficulty.  Procedure: test for nasal obstruction by Delirium, confusions or hallucinations: may holding a small mirror under the patient’s mean hypercapnia or severe hypoxemia nostril. Observe the condensation circles (with elderly patient, don’t attribute that appear as the patient breathes. disorientation to age)  Abnormal Findings: Fearfulness: seen in patients with acute respiratory distress, usually restless, with an Condensation circles of varying anxious expression. sizes, indicating a partial nasal COLOR obstruction or an absent Flushing: the patient is retaining carbon condensation circle, indicating dioxide total nasal obstruction Cyanosis of the buccal mucosa and lips:  Procedure: ask the patient to tilt his head indicates hypoxemia, although anemia if back; gently push up the tip of his nose. present, may affect with recognition. Using a penlight, observe the mucous Peripheral cyanosis indicates vascular membranes, septum, and inferior changes, (if patient has dark ski, check turbinate. soles of his feet and palms of his hands  Abnormal findings: gray, pale, red or swollen mucous membranes for  Discharge or purulent drainage duskiness)  Foreign objects Pink skin: seen in patients with pure  Deviated septum (septum that emphysema – patient usually thin, with inclines toward one side or the Regina Mae Tamano  other, giving it an S shape) time.  Perforated septum (indicated if  Abnormal findings: cleft palate light shines through the and/or ovula perforation into opposite  Enlarge, inflamed tonsils. nostril) Note:during childhood, tonsils  Nasal Polyps (pale, shiny balls normally is larger, with a with stalks) attached to glandular (not smooth) turbinate. appearance.  Procedure: using a nasal speculum,  Pus, exudates, or follicles on carefully expand the nostril and observe pharynx the inferior and middle turbinate. Note: Don’t use a nasal speculum when NECK examining a young or uncooperative  Retractions of muscles: indicates child; you may injure him. respiratory distress, esp.in  Abnormal findings: nasal polyps COPD.  Purulent drainage  Trachea position: should be centrally  Pallor and engorgement (may located. With tension pneumothorax or indicate allergic rhinitis) large pleural effusion, trachea shift MOUTH & THROAT: equipment: away from involved side. With penlight, tongue depressor atelectasis, trachea may shift toward  Procedure: observe color and condition affected side. of lips  Lack of turgor: indicates dehydration  Abnormal Findings: Lesions,  Vein engorgement: suggests high venous cyanosis, pallor. NOTE: Lips pressure. normally are slightly darker than surrounding skin. SIGNS AND ASSOCIATED  Procedure: ask the patient to open CONDITION: hismouth and say “Ahh”. Observe his  Postural disorder as forward mucous membranes. If the patient’s displacement of neck and Caucasian or Oriental, they should be shoulders;rickets-softening of the smooth and pink; of he’s black, they ribs causes depression of the lower should be a patchy pink. sternum  Lesions, bleeding, odor, SIGNS: upper thoracic kyphosis, protuberant ortenderness abdomen and functional heart murmur. May  Procedure: Observe gums and teeth. compress internal/vital organs along area of Nursing tips: if your patient age 2 or depression younger? Estimate the number of teeth he SCARS: indicate patient had previous chest should have by subtracting six from the surgery or injury number of months in his age.  Anterior- posterior diameter of  Abnormal Findings: puffy, tender chest:should be smaller than the or bleeding gums lateral diameter. Remember chest  Discolored, broken, maloccluded tends to become barrel – shaped teeth; delayed eruption of teeth with chronic lung disease.  Note: Teach the patient good  Sternum – should be located dental hygiene and refer him to a midlineanterior, giving rise to a dentist, if necessary. Also, keep visible projection known as the angle inmind that poor gum condition of Louis. may indicate malnutrition.  Procedure: Ask patient to stick out his tongue; observe for velvety-pink appearance CHEST DEFORMITIES  Abnormal Findings: smoothness, cracks, coating glossitis (tongue inflammation), lesions, lack of mobility.  Procedure: observe palate, uvula tonsils, and pharynx. Important: to avoid stimulating the patient’s gag reflex, depress only one side of his tongue at a Regina Mae Tamano  FUNNEL CHEST –  Wheezing PECTUS EXCAVATUM MANIFESTED IN CHRONIC  PHYSICAL CHARACTERISTICS: RESPIRATORY DISORDERS AS - Sinking or funnel-shaped EMPHYSEMA AND ASTHMA. depression of lower sternum diminished anteroposterior chest diameter.  SIGNS AND ASSOCIATED CONDITIONS: - Postural disorders, such as forward displacement of neck and shoulders. NOTE: The general over inflation, including the upper chest. The upper chest now moves in the so-called “pump handle” up and down movement, due to action of the accessory “strap” muscles of respiration. This is a” trick movement” rescue attempt to increase ventilation. The lower chest is over inflated and less mobile as to the normal so-called “bucket PIGEON CHEST – PECTUS handle” lateral and upward motion of the CARINATUM rib cage. This region of the chest normally  PHYSICAL CHARACTERISTICS: is the major area of rib movement to assists - Projection of sternum beyond breathing, and is the stabilizing region of abdomen’s frontal plane. Evident in diaphragm attachment necessary for that two variations: projection greatest at muscle to work properly. The diaphragm xiphoid process; projection greatest is at or near center of sternum  the dominant chest wall organ of respiration. BIFID STERNUM  PHYSICAL CHRACTERISTICS:  Complete or incomplete sternal separation  SIGNS & ASSOCIATED CONDITIONS:  Missing or supernumerary ribs; ectopia cordis (development of heart outside the thoracic cavity).  CHEST MOVEMENT BARREL CHEST  Inspiratory intercostal  PHYSICAL CHARACTERISTICS: retractions: occur in patients with  Enlarged antero-posterior and COPD, asthma or pulmonary transverse chest dimensions, fibrosis, Note: sudden violent chest appears barrel-shaped intercostal and neck retractions  Prominent accessory muscles; the can be caused by airway ribs tend to be more horizontal obstruction. E.g. aspiration of than sloped. No bulges. No foreign body. depression - Inspiratory intercostal bulges: mean  SIGNS & aneurysm, tumor or cardiac ASSOCIATED enlargement. CONDITIONS: - Use of accessory muscles during  Chronic respiratory disorders respiration; suggests respiratory  Increase shortness of breath distress. Seen in patients with COPD  Chronic cough and asthma. Regina Mae Tamano  Localized expiratory bulging; 9 MAJOR RESPIRATORY PATTERNS associated with flail chest. EUPNEA  How to recognize it: Normal respiration rate and rhythm. For adult 5-17 breaths per minute; teenagers 12 to 20 breaths per minute; children aged 2 to 12:20 to 30 breaths per minute;newborn:30- 50 breaths per minute. Occasional deep breaths at a rate of two to three per minute.  Normal respiratory rate and rhythm. Adults & teenagers, 12- 20 breaths per minute; for neonates, 30-50 breaths per minute. Occasionally, deep breaths at a rate of 2 to 3 per minute. TACHYPNEA  How to recognize it: Increased respiratory, as seen in RESPIRATORY PATTERNS fever, pneumonia, compensatory  Except for an occasional deep breath, respiratory alkalosis, respiratory breathing pattern should be rhythmical. insuffiency, lesions in the If the breathing isn’t rhythmical. Note brain’s for the depth, rate and pattern for several respiratory control center, and aspirin minutes. Then document your findings. poisoning.  Increased respiratory rate, as seen with fever. Respiratory rate increases about 4 breaths/minutefor every degree Fahrenheit above normal. BRADYPNEA  How to recognize it Slower but regular respirations. Can occur when the brain’s respiratory control center is affected by an opiate,a tumor, alcohol, a metabolic disorder, or respiratory decompensation. This pattern is normal during sleep. APNEA  How to recognize it: absence of breathing; may occur. Periodically, respiratory failure HYPERPNEA  How to recognize it: deeper respiration; rate normal Regina Mae Tamano CHEYNE-STROKES  How to recognize it: respiration gradually become faster and deeper than normal, then slower, over a 30 to 170 second period. Alternating with periods of apneafor 20 to 60 seconds. Cause: increased intracranial pressure, severe congestive heart failure, renal failure, meningitis, drug over dose. BIOT’S  How to recognize it: faster and deeper respirations than normal, with abrupt pauses between them. Each breath has same depth. May occur with spinal meningitis or other CNS conditions. KUSSMAUL’S RESPIRATION  How to recognize it: Faster and deeper respirations without pauses; in adults, over 20 breaths/mins. Breathing usually sounds labored, with deep breaths resembles sighs. May accompany or result from renal failure or metabolic acidosis. APNEUSTIC BREATHING  How to recognize it: prolonged gasping inspiration, followed by extremely short, inefficient SPINAL ABNORMALTIES expiration. May accompany or  If any of the following abnormalities are severe, result from lesions in the brain’s they can inhibit the patient’s respirations and respiratory center. decrease ventilations to the lungs. Some cases are obvious while others may need x-ray to determine the diagnosis. 1) KYPHOSIS – Abnormality in the convexity of the spine. 2) SCOLIOSIS – lateral deviation of the spine, which results in an S-shaped curve.On concave side of the chest, the patient’s ribs are close together. On convex side of the chest, his ribs are Regina Mae Tamano  further apart. ASSESSING THE FINGERS FORCLUBBING To quickly assess the fingers for clubbing, 3) LORDOSIS – is the abnormal increase in the have the patient place the first phalanges of forward curvature normal spin. Protuberant the forefingers together. Normally, the base of abdomen & functional heart murmur the nails are concave and create a small, diamond-shaped space when the first phalanges are opposed (as shown in the top illustration next slide). When clubbed fingers are opposed, the now convex bases of the nailscan touch without leaving a space. FINGERS AND TOES  Clubbing: associated with COPD, tuberculosis or chronic hypoxemia  Remember: clubbing is divided into early 4) SPONDYLISTHESIS – is an abnormal spinal clubbing – the angle between the nail and condition in which one -vertebra slips or is the nail bed is flattened to 180 degrees. displaced over another vertebra. The drawing In late clubbing, the angle where the nail shows spondylolisthesis as a result of a lumber meets the finger is inverted to 120 vertebra (L5) slipping over the sacrum (S1). degree.  Asterixis: to check, pull patient’s hand back toward his elbow. Flapping of the middle finger will occur in patients with CO2 narcosis or hepatic failure.  Nail bed cyanosis: suggests hypoxemia, particularly if it accompanie s central cyanosis 5) KYPHOSCOLIOSIS – a combination of kyphosis & scoliosis. The patient’s spine convex as seen in kyphosis and also S- shaped as seen in scoliosis.  LEGS - Thrombophlebitis: leads to 6) SPONDYLOLISTHESIS – is an abnormal spinal condition in which one - vertebra slips or is pulmonary embolism. Check patient’s displaced over another vertebra. calves for redness, swelling, warmth and spondylolisthesis as a result of a lumbar vertebra Homan’s sign. (L5) slipping over the sacrum (S1). Not  HOMAN’S SIGN: may mean presence of affecting respiratory function. deep vein thrombosis. To check, seat the patient on a chair and forcefully dorsiflex his foot, presence of pain in his calf EXTREMITIES muscle means positive Homan’s sign.  ANKLE EDEMA: indicates fluid  SKIN overloadin the patient’s tissues. Seen in  Warm / elevated temp. ; COPD or right –sided ventricular failure Suggestsinfection (cor pulmonale). To check for ankle  Diaphoresis or clamminess; edema; press your fingers into ankle means hypoxemia or decreased edema, holdand release. Note the blood pressure or decreased impression your perfusion. fingers leave on the skin. PEDIA ASSESSMENT  Multiple (more than 5) “café de au-lait”spots Regina Mae Tamano  may be associated with neurofibromatosis PALPATION (TACTILE FREMITUS, RESPIRATORY EXCURSION PEDIATRIC ANATOMY While you’re examining a child, note any structural abnormalities of his chest. Chest abnormalities in children and their significance include the following:  An unusually wide space between the nipples may indicate Turner’s syndrome. (The distance between the outside areolaredges should not be more than 1 quarter or ¼ of the patient’s chest circumference).  Rachitic beads (bumps at the coctochondrial junction of the ribs) may indicate rickets.  Pigeon chest maybe a sign of Marfan’s of Morquio’s syndrome or any chronic upper respiratory tract obstruction; funnel chest may indicate rickets or Marfan’s syndrome; barrel chest may indicate chronic respiratory disease, such as cystic fibrosis or asthma.  Localized bulges may suggest underlying pressures, such as cardiac enlargement or aneurysm.  Certain normal anatomical differences that distinguish a child’s respiratory tract make especially prone to respiratory prob lems such as airway obstruction. Example: A child’s mucous membranes are loosely attached to his airway. As a result, they’re easily irritated, which may cause edema and coughing.  His airway is smaller in diameter than an adult’s and contains a greater proportion of soft tissue, including the soft palate and tongue. All of these factors make airway obstruction more likely if excessive mucus formation or edema occurs for any reason,  An infant’s larynx is located two or three cervical vertebrae higher than an adult’s,increasing the risk of obstruction by aspiration. Keep in mind that even an apparently minor respiratory system problem may become life threatening. When your pediatric patient has such problem, treat him with special care. Regina Mae Tamano  PHYSICAL ASSESSMENT (PERCUSSION) How to Percuss Your Patient’s Chest The sound you hear when you percuss your patient’s chest can help to identify and locate any abnormalities in his lungs. Use guidelines to aids you in mastering this assessment skill. Percussing the Thorax and lung fields 1. Place your nondominant hand on