ST Assessment of Respiratory System 2024 - Tagged.pdf

ASSESSMENT OF THE RESPIRATORY SYSTEM NURS 1090 COURSE CONCEPTS ASSESSMENT THERMO-REGULATION TISSUE INTEGRITY METABOLISM ELIMINATION OXYGENATION  UNIT OUTCOMES Demonstrate basic techniques to assess the respiratory system. Identify basic oxygen delivery systems...

ASSESSMENT OF THE RESPIRATORY SYSTEM NURS 1090 COURSE CONCEPTS ASSESSMENT THERMO-REGULATION TISSUE INTEGRITY METABOLISM ELIMINATION OXYGENATION  UNIT OUTCOMES Demonstrate basic techniques to assess the respiratory system. Identify basic oxygen delivery systems used in the clinical setting. Identify physical assessment changes in the older adult.  GENERAL SURVEY Common Chief Complaints: shortness of breath, cough, sputum production, wheezing, chest pain Observe Overall Presentation Of The Patient: dyspnea, anxious facial expression, restlessness, hunched posture If Acute Respiratory Distress: do immediate focused assessment /initiate treatment  NURSING HISTORY History of respiratory disease: Colds, allergies, asthma, emphysema, bronchitis, Past pneumonia, tuberculosis TB test, pneumonia and/or medical influenza vaccine history: Allergies: environmental/seasonal History of smoking (pack years) Exposure to secondhand smoke  NURSING HISTORY Current OTC or RX’s for breathing medications: Lung cancer, Family cardiovascular disease, history: tuberculosis, asthma, etc Home environment Work Exposure to pollutants environment  PHYSICAL ASSESSMENT Includes: Inspection, Palpation, Percussion and Auscultation Examination area should be quiet to auscultate very soft sounds Maintain patient privacy Supplies: watch, stethoscope  Rate: per minute (12-20) Rhythm: regular or irregular Normal should be quiet, Respirations rhythmic, effortless – INSPECT Depth: shallow or deep Breathing Patterns Patterns of respiration Review descriptive terms Pearson, Volume 3 PHYSICAL ASSESSMENT: INSPECTION Restlessness Nasal Flaring Somnolence Pursed Lip Breathing Anxious Expression Cough Reduced Mental Clubbing Of Fingernails Alertness Cyanosis Dyspnea NASAL FLARING PURSED LIP BREATHING  INSPECTION Posture: scoliosis, kyphosis How can these problems affect breathing? Symmetry: Thorax normally expands and relaxes regularly with equality of movement bilaterally Use of accessory muscles neck, sternal, intercostal, abdominal Trachea should be midline  INSPECTION: COSTAL ANGLE Costal Angle angle between ribs and sternum should be less than 90 degrees in adult angle larger in expanded chest wall (COPD) INSPECTION ANTERIOR/POSTERIOR DIAMETER Diameter from front to back should be ½ the width of the chest Normal is a 1:2 anterior/posterior to lateral (transverse) ratio Barrel chest is 1:1  PALPATION Use Feel for lumps, palms bulges, depressions, and movable pads structures of Musculoskeletal fingers tenderness  PALPATION: RESPIRATORY EXCURSION THORACIC EXPANSION Evaluates chest wall symmetry and depth of breathing Place thumbs on the lower posterior chest wall at about the level of the 10th rib Thumbs adjacent to spine and fingers stretched laterally Ask patient to inhale deeply and note symmetry of thumb movement  PALPATION: RESPIRATORY EXCURSION THORACIC EXPANSION Should be symmetrical; Thumbs separate 3-5 cm. Note any asymmetric or decreased thoracic expansion What could cause asymmetry?? Palpation: Vocal (Tactile) Fremitus Faint, palpable vibrations caused by transmission of air when patient speaks Patient to repeat “99” Note symmetry of vibration Faint vibration is normal Increased or decreased vibrations are abnormal— What factors could contribute to this? PALPATION: VOCAL (TACTILE) FREMITUS Would you expect increased or decreased vibrations in this patient? Why? PERCUSSION To determine if lungs are filled with air, fluid, or solid material Percuss side to side, apex to base Compare sounds that are produced side to side ***Not usually performed in daily assessments; APN’s Percussion Technique hardluckasthma.blogspot.com  PERCUSSION: DOCUMENTATION RESONANT: NORMAL SOUND DULLNESS: HEARD OVER SCAPULA OR RIB IF DULLNESS HEARD OVER LUNG TISSUE: ASSOCIATED WITH FLUID, CONSOLIDATION OF LUNG TISSUE OR A MASS  AUSCULTATION Assesses movement of air through the tracheobronchial tree Detects mucus or obstructed airways The larger the airway the louder the breath sound Patient should be sitting, if possible Avoid auscultation through clothing AUSCULTATION Ask patient to take slow, deep breaths with mouth slightly open Keep diaphragm of stethoscope in tight contact with chest wall You may have to dampen chest or back hair to prevent crackling  AUSCULTATION Auscultate side-to-side, apex to base Listen front, back, and lateral Listen to the full respiratory cycle - inspiration and expiration To listen to the posterior sounds, have the patient lean forward and cross arms in front of chest  AUSCULTATION ANTERIOR SITES POSTERIOR SITES FOR AUSCULTATION Lateral Sites for Auscultation  DESCRIBE WHAT IS HEARD 1. Is the breath sound present? 2. Is it clear? 3. If it is not clear, is the extra noise on inspiration, expiration, or both? 4. What does it sound like? 5. Where is it located? Use thoracic landmarks 6. Note intensity, duration, and pitch AUSCULTATION: NORMAL BREATH SOUNDS Tracheal breath sounds Harsh, loud, and high pitched Listen over trachea Bronchial breath sounds Loud, high-pitched, hollow sounding Inspiration is shorter than expiration Place stethoscope beside the trachea, above the suprasternal notch Bronchovesicular breath sounds Softer than bronchial sounds Moderate pitched “blowing” sounds created by air moving through larger airways (bronchi) Inspiratory phase equal to the expiratory phase Listen anteriorly next to sternum (1st and 2nd intercostal spaces) Listen posteriorly between the scapula (to the right and left of T5 in the 5th , or 6th intercostal space) Vesicular breath sounds Softer, breezy, and more low pitched than the bronchovesicular sounds “gentle sighing sounds” created by air moving through smaller airways (bronchioles and alveoli) Inspiration is longer than expiration Listen anteriorly and posteriorly over the remainder of the peripheral lung fields 24nurse.tumbler.com  AUSCULTATION: DOCUMENTATION Asymmetry of breath sounds: May indicate lack of airflow in part of the lungs and require immediate attention If sounds are louder on one side than the other it may indicate early consolidation Distant or diminished sounds: very soft breath sounds may be caused by hyperinflated lungs from emphysema or COPD  AUSCULTATION ADVENTITIOUS SOUNDS Wheezes: High pitched whistling, musical sounds heard as air passes through narrow or obstructed airways air passages As a result of secretions, swelling, tumors Not usually altered by coughing https://www.youtube.com/watch?v=aMMlclpBNpg  AUSCULTATION: ADVENTITIOUS SOUNDS Rhonchi (gurgles) Coarse, low-pitched sounds heard during either inspiration or expiration resulting from secretions, swelling, tumors May clear with coughing May have a moaning or snoring quality https://www.youtube.com/watch?v=7ciexfqnyrq  AUSCULTATION: ADVENTITIOUS SOUNDS Crackles (rales): Fine, short, interrupted crackling sounds heard as air passes through fluid or re-expands collapsed small airway May sound like rubbing hair between your fingers (fine crackles) or moist or gurgling (coarse crackles) May not clear with coughing Often associated with pulmonary edema and congestive heart failure—Why?? Most commonly heard in bases of lower lung lobes Absent breath sounds  CRACKLES HTTPS://WWW.YOUTUBE.COM/WATCH?V=PYY5AVYHARI  OLDER ADULT: EXPECTED CHANGES WITH AGING: RESPIRATORY SYSTEM Diminished cough and laryngeal reflexes Decreased number of cilia Ineffective removal of dust and irritants from airways Increased risk for aspiration and infection Decreased number of alveoli with thinner alveolar walls Decreased gas exchange OLDER ADULT: EXPECTED CHANGES WITH AGING: RESPIRATORY SYSTEM Decreased muscle strength and endurance Decreased ability to breath deeply Chest excursion diminishes Diminished breath sounds Changes to shape of thorax Increased A/P chest diameter Kyphosis-how does this impact respiratory effort?  DOCUMENTATION Only describe breath sounds as clear if you hear symmetrical breath sounds without any adventitious sounds anteriorly, laterally, and posteriorly. Describe the sound and location.  SAMPLE DOCUMENTATION OF RESPIRATORY ASSESSMENT Respirations 20/minute with regular rhythm, unlabored. Lung sounds auscultated – anteriorly, posteriorly, and laterally- clear throughout. Lungs- equal expansion. Pulse ox 98%. No cough or shortness of breath noted. COMPETENCY EVALUATION SHEET: RESPIRATORY ASSESSMENT  OXYGEN DELIVERY SYSTEMS Indicated for patients who are unable to get enough oxygen from the air they breathe (Room Air) HCP order required Do not delegate initial administration of supplemental oxygen to UAP NASAL CANNULA Most common Delivers low concentrations of oxygen Measured in liters per minute 24% (1 L/min.) to 44% (6L/min.) Pearson, 2019 Nasal prongs Vitalitymedical.com  WALL OUTLET FLOWMETER Attach flowmeter to compressed air wall outlet Adjust ordered liters/minute of oxygen using floating ball Ball is adjusted to center of line Asevet.com Wtfarley.com VENTI MASK, NON-REBREATHER  INCENTIVE SPIROMETER Device that helps patients take slow, deep breaths. Helps to expand lungs to prevent complications such as pneumonia in patients who are not as active as usual due to illness or surgery.  INCENTIVE SPIROMETER Seal lips around mouthpiece Inhale slowly and deeply and hold for 2-3 seconds Remove mouthpiece and exhale normally Repeat 5-10 times every 1-2 hours or as ordered by hcp Cough productively as needed Lww.com after using spirometer