Transcript Respiratory Assessment

Respiratory Assessment
• Thoracic cage bony conical shape with
narrow at top
• Defined by sternum, 12 pairs ribs and 12
thoracic vertebrae
• Rib 1-7 attached to sternum via costal
cartilages
• Rib 8,9,10 attached to costal cartilage
• Rib 11,12 “floating” with free palpable tips
• Anterior thoracic Landmarks;
– Suprasternal notch, “U” shaped
– Sternum-”breastbone” has three parts:
• The body
• The xiphoid
• The Manubrium
– Manubriosternal Angle- “Angle of Louis”-is
articulation of the manubrium and the body
of the sternum; continuous with the 2ed rib;
marks site of the tracheal bifurcation into
the R & L bronchi
– Costal Angle- R & L costal margins form
angle where meet at xiphoid process
• Posterior thoracic Landmarks
– Vertebra Prominens
– Spinous Processes
– Interior Boarder of Scapula
– 12th Rib
• Anterior Chest
• Midsternal Line
• Midclavicular Line- bisects the center of
each clavicle at point halfway between the
palpated sternoclavicular and
acromioclavicular joint, near nipple line
• Posterior Chest
• vertebral Line- midspinal
• Scapular line- extends through inferior
angle of scapula
• Lateral Chest- Lift arms 90* & divide by 3
lines
• Anterior axillary- down from anterior
axillary fold to where the pectoralis major
muscle inserts
• Posterior anillary down from posterior
axillary fold to where latissimus dorsi
muscle inserts
• Midaxillary line-down from apex of axilla,
lies between and parallel to other two
• Thoracic cavity
– Mediastinum- middle section of thoracic
cavity contains esophagus, trachea, heart
and great vessels; and the Left & Right
pleural cavities
– Lung Borders- anterior
• Apex 9 highest point of lungs 3-4 cm
above inner 3rd of clavicles
• Base- lower border, rest on diaphragm
about 6th rib in midclavicular line
– Lungs Border- posterior
• C7-Apex of lung tissue
• Lungs- 2 pair
• Anterior
– Right lung shorter because of underlying
liver; has 3 lobes
• Anterior Right Upper Lobe (RUL)
• Right Middle Lobe (RML)
• Right Lower Lobe (RLL)
- Left Lung- narrower because heart bulges
to left; has 2 lobes
• Anterior Left Upper Lobe (LUL)
• Anterior Left Lower Lobe (LLL)
• Posterior
– Right Upper Lobe (RUL) and Left Upper
Lobe (LUL)- from apices at T1 down to T3
– Right Lower Lobe (RLL) and Left Lower
Lobe (LLL)- from the above border to T10
on expiration and to T12 on inspiration.
• Pleurae- thin slippery which forms an
envelope between lungs and chest wall.
• Visceral Pleura- lines outside of lungs down
into fissures
• Parietal Pleura- lining inside the chest
wall and diaphragm.
• Trachea- lies anterior to esophagus; is
10– 11 cm long in adult; starts at cricoid
cartilage bifurcates below sternal angle
into R and L bronchi; posterior
bifurcates at T4 or T5;
R bronchus shorter wider;
L bronchus vertical than L main
• Function of Trachea and bronchi- transport
gases between environment and lung
parenchyma.
– Bronchial tree- protect alveoli from small
particulate matter in the inhaled air
– Bronchi lined- goblet cells which secrete
mucus that entraps particles
– Bronchi line with cilia- which sweeps
particles upward swallowed or expelled
– Acinus- functional respiratory unit consist
of bronchioles, alveolar ducts, alveolar sac
and alveoli
•
•
Alveolar duct & Alveolar-gaseous
exchange takes place
Major function of Respiratory System1. Supply oxygen to body for energy
production
2. Remove CO 2 as waste product for
energy reaction
3. Maintaining homeostasis (acid-base
balance) of arterial blood
4. Maintaining heat exchange (less
important to humans)
• Control of Respirations
– Involuntary control mediated in respiratory
center in brain stem (pons & medulla)
– Change in carbon dioxide and oxygen
levels in blood
– Hypercapnia- Increase of carbon dioxidestimulus to breathe
– Hypoxemia ) decrease in oxygen in blood
can cause increase in respirations but less
effective
– Hypoventilation – slow, shallow breathing
causes carbon dioxide to build in blood
-With age less surface area available for gas
exchange
Increases older person risk for postoperative
pulmonary complications due to decreased
ability to cough
•
Assessment ( need to note normal from
abnormal)
A. Subjective Data: questions to ask-what
client tells you
1. Cough - cold in particular to children; how
frequent, when, time of day, contributing
factors; what kind of cough (hacking, dry,
with blood), what makes it worse or better
2. SOB- older adults on exercise
3. Chest pain with breathing
4. History of respiratory infections- chronic
allergies, history of asthma, TB.
Pulmonary disease in older adults
5. Environmental exposure- where did you
or do you work, do you smoke, do you
live or work near pollutants
6. Self care behavior- chest x-ray, TB
testing, etc.
7. Allergies in family- particularly in children
Objective
A. Inspection (what you see)
1. Shape and Configuration of chest wall.
a. Thorax symmetric, elliptical shape with
downward sloping ribs
b. Any signs tumors, lumps, bruising on
chest
– Check shape for:
» Scoliosis (“s” shape)
» Kyphosis (humpback)
» Barrel chest
Skin color and condition
»Person’s position
»Level of consciousness (LOC)
B. Palpation
a.Symmetric expansion- place hands of
posterolateral chest wall with thumbs at
level of T9 or T10; Slide hands medially to
pinch up a small fold of skin between
thumb; have person take a deep breath
your thumbs should move apart
symmetrically
b. Tactile Fremitus- palpable vibrations- with
palmar base ( the ball) of fingers or ulna edge
of one hand touch person’s chest and have
then repeat “ninety-nine” or “blue moon”
should feel vibration; varies among people
but symmetry most important
Affecting normal intensity of Tactile
Fremitus:
-Relative location of bronchi to
chest wall
- Thickness of chest wall
- Pitch and intensity
Check for:
Decreased fremitus
Increased fremitus
Rhonchal fremitus
Pleural friction fremitus
Crepitus
C Percuss
• Tapping on client’s skin with short sharp
strokes to assess underlying structure
•
Strokes yield palpable vibrations and
characteristics sounds that depict location,
size, density of underlying organ pg.163
• Two methods– Direct- striking hand direct contact with
body wall. Used in infant’s thorax and
adult sinus areas
– Indirect- use both hands. Striking hand
contacts stationary hand fixed on client’s
skin
Avoid striking client’s ribs & scapulae,
always a dull sound & yields no data
Lung Field
• Start at apices at top of both shoulders
• Percuss interspaces comparing side to
side going down lung region
–Hyperresonance- too much air
present
–Resonance-voice heard through
stethoscope; is muffled nondistinct
-Dull- abnormal density in lung
c. Diaphragmatic Excursion- mapping
out lower lung border at expiration &
inspiration; somewhat higher due to
liver
C. Auscultation-with the diaphragm of
stethoscope from apex to base, from side to
side.
a. Evaluate the presence and quality of normal
breath sounds.
b. With flat diaphragm of stethoscope listen at
least one full respiration in each location
c. Compare side to side and top to bottom ( Go
from left to right and then down or from right
to left and then down
d. analyze breath sounds
e. detect any abnormal sounds
f. examine sounds produced by spoken word
g. pulse oximeter-noninvasive method of
assessing arterial oxygen saturation (SpO2)
h Listening to own breathing
Stethoscope tubing bumping
Patient shivering
Patient has hairy chest
Rustling of paper gown
Music or talking in background
i. Normal breathing Sounds- for adults
a. Bronchial (tracheal) –loud, high pitched,
over trachea and larynx
b. Bronchovesicular-moderate, moderate
pitch, over major bronchi posterior
between scapular especially right anterior
upper sternum at 1st and 2ed intercostal
spaces
c. Vesicular- Soft, low pitch, rustling
sound of wind through trees; over
peripheral lung field
I. Decreased Sounds
•
Obstruction- by secretion, mucus
plug or foreign body
•
Loss of Elasticity- in lung fiber &
decreased force of inspired air
•
Something obstructs transmission
of sound between lung and
stethoscope
2. No breath sounds- no air moving;
ominous sign
i.
3. Increased breath sounds-bronchial
sounds are abnormal when heard
over abnormal location
Adventitious Sounds- sounds not
normally heard in the lungs; if present
are superimposed on breath sounds
1. Crackles- rales
2. Wheeze – rhonchi
3. Atelectatic crackles-short,
popping, crackling sounds like fine
crackles
j. Voice Sounds- Vocal Resonance ; soft
muffled indistinct, heard through
stethoscope
1. Bronchophony-repeat “99”soft,muffled, indistinct heard through
stethescope cannot distinguish.
2.Egophony- auscultate chest person
phonates long “ee-ee-ee-ee-” through
stethoscope
3. Whispered pectoriloquy- perslecton
whispers phrase “one-two-three”;
response faint, muffled and almost
inaudible
• Normal Adult Respiration Patterns
– Rate- 10 to 20 breaths/minute
– Depth- 500 ml to 800 mo
– Pattern- even
– Ratio to Respiration- fairly constant 4:1
– Depth- air moving in & out each respiration
– Sigh- occasional normal pattern; purposeful
to expand alveoli
• Respiration Patterns:
• Tachypnea- rapid shallow breathing;
increased to >24
– Bradypnea- Slow breathing decrease but
regular; < 10/minute
– Cheyne-Stokes- breathing periods last 30 to
45 seconds, with periods of apnea (20
seconds); alternating the cycle
– Hyperventilation- Increase both in rate and
depth
– Hypoventilation- irregular shallow pattern
– Biot’s Respiration- similar to Cheyne-Stokes
except pattern is irregular
– Orthopnea- difficulty breathing when supine
– Paroxysmal nocturnal dyspnea-is
awakening from sleep with SOB & needs to
be upright to achieve comfort
- Hyperventilation- rapid, deep breathing
causes carbon dioxide to be blown off
• Chest size changes– Inspiration- lung size increases; diaphragm
descends and flattens; negative pressure
air rushes in
– Expiration- chest size recoils; diaphragm
decreases in chest size and relaxes;
positive pressure air flows out
• Abnormal Tactile Fremitus
– Increased tactile Fremitus-increased density
of lung tissue, thereby making a better
conducting medium for vibration
– Decreased Tactile Fremitus- anything
obstructs transmission of vibration.
– Rhonchal Fremitus- vibration felt when
inhaled air passes through thick secretions in
larger bronchi
– Pleural Friction Fremitus- inflammation of the
parietal or visceral pleura causes a decrease
in normal lubricating fluid
• Adventitious Lung Sounds:
• Discontinuous Sounds- are discrete crackling
sounds
– Crackles-fine; formerly called rales, highpitched, short crackling, popping sounds
heard during inspiration cannot be cleared by
coughing
– Crackles-coarse; loud, low-pitched, bubbling
& gurgling sounds that start in early
inspiration and may be present in expiration;
sound like Velcro fastener opening
– Atelectatic crackles; sound like fine
crackles, but do not last and are not
pathologic
– Pleural friction rub- is coarse & low pitch has,
Sounds is inspiratory and expiratory
• Continuous Sounds are musical sounds
– Wheeze- high pitched- musical sound that
sound polyphonic; predominately in expiration
but may occur in inspiration & expiration
– Wheeze- low pitched- rhonchi; monophonic
single note; musical snoring; moaning sound;
more prominent on expiration; may be cleared
by coughing
– Stridor- high pitched- monophonic, crowing
sound, heard on inspiration
• Common Respiratory Conditions:
– Atelectasis-collapsed shrunken section of
alveoli or entire lung due to:
• Airway obstruction, Compression on
lung, Lack of surfactant
• Pt. exhibits-cough, increased pulse &
respiration, possible cyanosis
• None if bronchus obstructed; occasional
fine crackles is bronchus patent
– Lobar Pneumonia- Consolidation;
• alveoli consolidated with fluid, bacteria,
RBC’s & WBC’s
• Crackles, fine to medium
– Bronchitis-proliferation of mucous glands in
passageway
• Bronchial inflammation and copious
secretions
• Deflated alveoli beyond obstruction
• Crackle over deflated area; may have
wheeze
• Pt. exhibits hacking rasping productive
cough
– Emphysema-destruction of pulmonary
connective tissue
• Over distended alveoli with destruction of
• septa; permanent enlargement of air
sacs distal to terminal bronchioles
• Pt. exhibits barrel chest, uses accessory
muscles to aid respiration, SOB, tachypnea,
• Adventitious Sounds- usually none;
occasionally wheeze
– Asthma- allergic hypersensitivity to certain
inhaled allergens
• Bronchospasm
• Edema of bronchial mucosa
• Thick mucus
• Pt exhibit-SOB with audible wheeze,
retraction of intercostal spaces, use of
accessory muscles,cyanosis
– Pleural Effusion- excess fluid in the
intrapleural space with compression of
overlying lung tissue
• Effusion maybe; Transudative (watery
capillary fluid), Exudatative ( protein),
Empyemic (purulent matter)
Hemothorax (blood),Chylothorax (Milky
lymphatic fluid)
• Presence of fluid subdues lung sounds
• No adventitious sounds
• Pt. exhibits-increased respirations, dyspnea
dry cough, abdominal distention, cyanosis
– Heart Failure- pump failure increasing
pressure of cardiac overload causes
pulmonary congestion
• Bronchial mucosa may be swollen
• Dependent airways deflated
• Engorged capillaries
• Adventitious Sounds-crackles at lung
base
• SOB, increased respiratory rate, PND,
nocturia, ankle edema
– Tuberculosis (TB) Tuberculosis-inhale
tubercle bacilli into alveolar wall
• Initial complex is acute inflammatory
• Rust colored sputum
• Night sweats
• Low grade afternoon fever
• High incidence of Asian immigrant
– Initial complex is acute inflammatory
• Scar tissue forms, lesion calcifies
• Reactivation of previously healed lesion
• Extensive destruction as lesion erodes
into bronchus
• Adventitious sounds, crackles over
upper lobes, persist following full
expiration and cough
– Pneumocystis carinii Pneumonia
• Virulent form of pneumonia associated
with AIDS
• Cysts containing organism & macrophages form in alveolar space; alveolar
walls thicken
• Adventitious sounds-crackles may be
present but often absent
– Pulmonary Embolism-undissolved
material originating in legs or pelvis, detach
and travels and lodges to occlude
pulmonary vessels
• Sometimes occluded medium pulmonary
branches
• Client exhibits chest pain, worse on
inspiration, dyspnea, anxious,
apprehensive, Crackles and wheezes
• Adventitious Sounds- Crackles, Wheezes
– Acute Respiratory Distress Syndrome (ARDS)
• Acute pulmonary insult, damages alveolar
capillary membrane, increased permeability
of pulmonary capillaries, alveolar epithelium,
to pulmonary edema
• Adventitious Sounds- crackles, rhonchi
• Pt. exhibit-acute dyspnea, apprehension,
shallow rapid breathing, thin frothy
sputum,retraction of intercostal spaces
• Measurement of Pulmonary Function Status– Forced expiratory time-number of seconds it
takes for person to exhale from total lung
capacity to residual volume
– Pulse Oximeter- noninvasive method to
assess arterial oxygen saturation (Spo2)
Sensor attaches to client’s finger detector
measures amount of light absorbed by
oxyhemoglobin (HbO2) and unoxygenated
(reduced) hemoglobin (Hb); ratio of light
emitted to light absorbed con converts to %
of oxygen saturation; Healthy person no
lung disease or anemia has a Spo2 of 97%
to 98 %.
– 12 minute distance (12MD) walk, clinical
measure of functional status of clients with
COPD; used as outcome measure for
people in pulmonary rehabilitation
• Infants and children
• Inspect and then listen to lung sounds of
infants sleeping, can concentrate on
breath sounds
• May sit in parents lap and play with
stethoscope reduces fear
• Older children like to listen to their own
lungs
A. Inspection
• Infants has rounded thorax with equal
anteroposterior-to-transverse chest
diameter
• Infants and Children
• Respiratory system develops in utero
• Respiratory system doesn’t function till
birth
• At birth when cord cut blood gushes to
pulmonary circulation, the foramen oval
in heart closes, the ductus arteriosus
contracts and closes some hrs. later and
the pulmonary circulation functions
• In childhood-respiratory development
continues, increases in diameter and
length in size and number of alveoli
• Chest wall thin with little musculature; ribs &
xiphoid are prominent; thoracic cage soft &
flexible
• Newborn first respiratory assessment is part
of Apgar scoring system to measure
successful transition to extrauterine lifescored
at 1 minute and at 5 minutes after birth; 1
minute score of 7 to 10 very good condition,
needs only suction of nose and mouth
• Age 6 thorax ratio is 1:2 (anteroposterior-totransverse diameter) pg 464; Count
respiratory rate for 1 full minute; normal rate is
30 to 40 breaths/minute; may go to 60/minute;
get count when infant asleep
– Breathe through nose rather than mouth
– Intercostal muscles not well developed
– Abdominal bulges with each inspiration but
see little thoracic expansion
B. Other observations
Evidence of Infection, Cough, Wheezes,
Cyanosis, Chest Pain, Sputum, Bad
breath
C. Palpation
encircle infant’s thorax with both hands;
should be no lumps, masses or crepitus;
may feel costochondral junctions.
D. Percussion-limited, fingers of adult too large
in relation to tiny chest.; note hypperresonance occurs normally in infants
and young child due to thin chest wall
E. Auscultation-normally bronchovesicular
breath sounds in infants up to 5-6 year
old; breath sounds are louder and
harsher
-fine crackles commonly heard immediate
in newborns
-Cackles in upper lung field occur with
cystic fibrosis
-Expiratory wheezing occurs in lower
airway obstruction e.g., asthma,
bronchiolitis
-Stridor- high pitched inspiratory crowing
with upper arway obstruction, e.g.,
croup, foreign body aspiration, acute
epiglottitis
– Depth of respirations• Hyperpnea- too deep
• Hypopnea- too shallow
– -Retraction- sinking in of soft tissue relative
to the cartilaginous and bony thorax; in
severe airway obstruction- retraction
extreme.
– Nasal flaring- sign of respiratory distress
– Head bobbing- in sleeping or exhausted
infant sign of dyspnea
– Noisy breathing- “snoring” obstruction,
polyps or foreign body in nasal passages
– Grunting- sign of chest pain- acute
pneumonia/ pleural involvement
– Chest pain-older children maybe
pulmonary and or nonpulmonary
– Clubbing- proliferation of tissue about the
terminal phalanges, associated with
chronic hypoxia, chronic pulmonary
disease or primarily cardiac defect
– Cough- maybe associated with respiratory
disease; is protective mechanism
F. Tests– Pulse oximetry- similar to adults however
can position around foot, toe, earlobe
– Transcutaneous Oxygen Monitor –Tc Po2
measures O2 diffusion across skin
G. Oxygen Therapy
– Delivered by mask, nasal cannula, tent,
hood, face tent, or ventilator
– Oxygen mask- various sizes, delivers
higher O2 concentration than cannula; can
cause skin irritation
– Nasal Cannula-low-moderate O2
– concentration; can talk ad eat; must have
patent nasal passages
• Oxygen Tent-lower O2 concentrations;
can increase concentration while eating;
fit around bed to prevent leakage; cool &
wet environment; poor access to child
• Oxygen hood, face tent- high O2 concentration; free access to child’s chest; high
humidity; need to be removed for
feeding & care; humidified O2 not blown
directly on infants/child face
• Masks not well tolerated by child
• Pregnancy
– Thoracic cage wider; costal angle feels
wider; respirations deeper; although this
can be quantified only with pulmonary
function test
– Pregnancy induces small degree of
hyperventilation as tidal volume increases
steadily throughout pregnancy
– Diaphragm elevated and subcostal angle
increased due to enlarging uterus
– Lung disease maybe aggravated by
pregnancy
• Pregnancy
– As uterus increases elevates diaphragm
which decreases the vertical diameter of
thoracic cage but is compensated by
increase in horizontal diameter.
– As fetus grows there is increase in oxygen
demand on mother’s body; increasing tidal
volume( deep breathing)
• Aging Adults
– Costal cartilages calcifies, less mobile
thorax
– Respiratory muscles strength declines after
50 and continues to do so till 70
– Decrease in elastic properties of lungs,
becomes harder to inflate
– Decrease in Vital Capacity- maximum
amount of air that a person can expel from
lungs after first filling lungs to maximum
– Increase in Residual Volume- amount of air
remaining in lungs even after most forceful
expiration
– With age less surface area available for
gas exchange
-Chest cage increases anteroposterior
diameter; looks barrel shape and outward
curvature of thoracic spine; compensates
holding head extended and tilted back
-Chest expansion decreases though still
symmetric
-cartilages becomes calcified
-Older adults fatigue easily, make sure do not
hyperventilate and become dizzy
-Allow brief periods of rest
-If feeling faint, holding breath for few seconds
will restore equipibrium