Respiratory Assessment

Jan Bazner-Chandler CPNP, CNS, MSN, RN

Respiratory Bifurcation of trachea Change in chest wall shape

Upper Airway Characteristics

     Narrow tracheo-bronchial lumen until age 5 Tonsils, adenoids, epiglottis proportionately larger in children Tracheo-bronchial cartilaginous rings collapse easily Infants up to 4-6 weeks are obligate nose breathers Tongue is large in proportion to the mouth

Lower Airway Characteristics     Lack of firm bony structure to ribs/chest make child more prone to retractions when in respiratory distress Fewer alveoli in the neonate Poor quality of alveoli until age 8  Lack of surfactant that lines the alveoli in the premature infant Inhibits alveolar collapse at end of expiration

Focused Health History     Reason for the visit Include questions about the environment   What makes condition worse – triggers Allergies Past medical history: birth history, previous health problems, childhood illness, immunizations Family medial history: respiratory illness – genetic link

Focused Physical Assessment   Types of breathing: Less than 7 years abdominal breathing  Greater than 7 years abdominal breathing can indicate problems

Respiratory Rate    Inspiratory phase slightly longer or equal to expiratory phase Prolonged expiratory phase = asthma Prolonged inspiratory phase = upper airway obstruction  Croup  Foreign body

Color  Observe color of face, trunk, and nail beds  Cyanosis = inadequate oxygenation  Clubbing of nails = chronic hypoxemia

Respiratory Distress       

Grunting = impending respiratory failure

Severe retractions Diminished or absent breath sounds Apnea or gasping respirations Poor systemic perfusion / mottling Tachycardia to bradycardia Decrease oxygen saturations

Chest Muscle Retraction

Chest Retractions    Retractions suggest an obstruction to inspiration at any point in the respiratory tract.

As intrapleural pressure becomes increasingly negative, the musculature “pulls back” in an effort to overcome the blockage.

The degree and level of retraction depend on the extent and level of the obstruction.

Diagnostic Tests       Detects abnormalities of chest or lungs Chest x-ray Sweat chloride Test MRI Laryngoscope / bronchoscopy CT Scan

White Patchy Infiltrates

X-ray Hyperinflation of Lung Vh.org

Pleural Effusion

Pleural Effusion X-Ray vh.org

Foreign Body Aspiration A foreign body in one or the other of the bronchi causes unilateral retractions.

*usually the right due to broader bore and more vertical placement.

Sweat Test for Cystic Fibrosis Gold Standard test for Cystic Fibrosis

Oxygen Therapy: Nursing Interventions

 Proper concentration  Adequate humidity: make sure there is fluid in the bottle  Make sure prongs are in nose and that the nares are patent – suction out nares to increase oxygen flow  Monitor oxygen SATS: if alarm keeps on going off but the infant / child looks good, check the device  Monitor activity level or infant / child

Aerosol Therapy     Respiratory Therapist will do the treatment Communicate with therapist – eliminated needless paging for treatments Treatment should be done before the infant eats When you make your morning rounds assess if there is any infant / child that needs an immediate treatment

Home Teaching Inhaled Medications       Correct dosage Prescribed time Proper use of inhaler No OTC drugs Encourage fluids When to call physician

Aerosol Therapy Medication administered by oxygen or compressed air.

Outpatient Aerosol Treatment

Postural Drainage and Percussion      In the small child you can position on your lap Do first thing in the AM Do before meals or one hour after Do after the aerosol treatment since the treatment will help open the airways and loosen the mucous Suction the infant after treatment – teach parents to do bulb suction

Percussion and postural drainage

Mechanical Ventilation

Alterations in Respiratory Function

Severe Respiratory Distress • • • • • Nasal flaring and grunting Severe retractions Diminished breath sounds Hypotonia Decreased oxygen saturations

     

What to do if infant / child in respiratory distress!

Stimulate the infant / child - remember crying or activity will help mobilize secretions and expand lungs Have the older child sit up take deep breaths and cough Chest percussion to loosen secretions Give oxygen Assess if interventions work Call for help if you need it – pull the emergency cord – yell for help