Respiratory assessment

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Respiratory assessment

  1. 1. Respiratory Assessment Skills Learning Plan 21Upper Respiratory SystemAnatomy of Respiratory SystemAlveoliSurfactant * Fatty protein that decreases surface tension of alveoli * Prevents collapse of alveoli * Increases lung compliance * Decreases work of breathingRespiratory Assessment Components * Breathing: the movement of air between the atmosphere and lung alveoli * Diffusion: there is an exchange of CO2 for O2 between the pulmonary capillaries and alveoli. * Transport: of O2 and CO2 via the blood stream to and from tissues.Inspection * Chest Variations
  2. 2. Changes with AgingInspection / Assessment * General appearance/subjective comments * C/o shortness of breath? * Use of accessory muscles? * Purse lip breathing? * Cyanosis –peripheral or circumoral (blue lips)? * Finger clubbing? * Restlessness? * Decreased Level of Consciousness? * Capillary refill time (CRT)Finger ClubbingInspection / Assessment * Check respiratory rate and rhythm * Depth and effort of breathing * Pulse oximetry
  3. 3. * Check skin color * Check skin temperature * Chest configuration * RetractionsRetractions * Intercostal * Substernal * SuprasternalInspection/Assessment * Lung sounds * Quality and frequency of cough * Sputum- color and consistency * Nasal flaring * Level of alertness
  4. 4. * Chest painRespiratory Assessment * Medical history * Past medical conditions * Family history of respiratory disorders * Personal History * Allergies * Smoking (ppd) or history of * Drug use * Recent travels * Diet and Weight * Occupational HistoryAuscultation: * Location of normal breath soundsAuscultation: * Listen to Breath Sounds
  5. 5. * Bronchial -loud, high-pitched and hollow * -like air blowing through a hollow tube * -heard over the throat * Bronchovesicular -heard over the main bronchi * -around sternum * Vesicular -heard over most of the peripheral lung tissueAuscultation of Breath Sounds * Client should be in sitting position if possible * Listen to both sides of the chest-front and back * Work from top of chest downward * Systematically compare breath sounds over right and left sidesAdventitious Breath Sounds * Crackles (Rales) –high pitched short crackling, popping sounds * Sound like rice crispies or crushing cellophane
  6. 6. * Usually caused by fluid in airways or alveoli * Sign of fluid overload * Gurgles (Rhonchi)-Wheeze (Sonorous) * low pitched continuous sounds caused by fluid or mucus in larger airways * Can be described as sonorous or coarseAdventitious Breath Sounds * Wheeze (Sibilant) – high-pitched musical squeaking sounds * Heard during inspiration or expiration * Due to narrowing of bronchioles * Do not clear with coughing * Pleural friction rub – rubbing/grating sound of sandpaper rubbing in chest * Inflammation of pleural lining
  7. 7. * Stridor – harsh/high pitched sound heard in the upper airway (larynx- trachea) – swelling associated with croup * Like a barky seal * Decreased or diminished breath sounds – unable to hear sounds where you normally should be able to hear themPalpation * Chest expansion * Tactile fremitus * Palpate abnormalities found on inspectionPercussion * Determine lung position and size * Detect the presence of air, liquids or solids within the lungs * Assess intensity, pitch, duration, and quality of sounds produced * Normal percussion tone is resonance * Flat tone over bony prominences
  8. 8. * Hyperresonance over emphysematous tissueDiagnostic Assessment * Lab tests * CBC, Hgb * Arterial blood gases (ABG’s) * X-ray * Non-invasive diagnostic exams * Pulse oximeter * Pulmonary function tests * Invasive diagnostic exams * ThoracoscopyRespiratory Terms * Eupnea- Normal respiratory rate- 12-20 bpm * Apnea- the absence of breathing * Bradypnea- decreased rate <12 bpm
  9. 9. * Tachypnea- rapid rate >20 bpm * Hyperventilation- increased rate and depth of respirationsRespiratory Terms * Kussmaul respirations- abnormally deep respirations- sign of diabetic ketoacidosis * Cheyne-Stokes- variable respirations * May be periods of apnea * Orthopnea- difficulty breathing lying down * Dyspnea- difficulty breathing, shortness of breathLifespan Changes * Respiratory rate is highest and most variable in newborn * Infant: 30-60 breaths per minute * Preschool: 25 per minute * Adolescent & Adult: 12-20 per minuteRespiratory System in Children * Newborns use abdominal muscles to breathe
  10. 10. * Heart rate in children varies with respirations---sinus arrhythmia. * Infants and preschoolers are at risk for airway obstruction because of their small airways. * Increased mucus membranes lining respiratory tractRespiratory System in Children * Immature immune system * Decreased action of cilia * Decreased cough reflex * Thinner chest walls * Chest retractions more common * Epiglottis more relaxedRespiratory Changes in Elderly * Decrease in elastic recoil in lungs * A-P diameter of thoracic cage increases * Decrease in depth of breathing
  11. 11. * Decrease in functional alveoli * Less forceful cough * Fewer and less functional cilia * Immune system less resilient * Elderly are more at risk for Pneumonia, COPD and Chronic BronchitisPhysiology of Respirations: * The stimulus to breathe in the normal person is rising levels of CO2Techniques for maintaining adequate respiratory function * Positioning- HOB up * Exercises- Pursed lip breathing * Incentive Spirometer * Deep breathing and coughing * Increasing liquids * Ambulation * Turn side-to-side
  12. 12. Chest Physiotherapy * Postural Drainage * Positioning to assist in removal of retained lung secretions * Chest Clapping * Create a vibration with the cupping of handsApplicable Nursing Diagnoses * Ineffective Airway Clearance- The state in which an individual experiences a threat to respiratory status related to inability to cough effectively * Ineffective or Absent cough * Inability to remove airway secretionsApplicable Nursing Diagnoses * Ineffective Breathing Pattern- The state in which a client experiences an actual or potential loss of adequate ventilation related to an altered breathing pattern * Changes in respiratory rate or pattern (from baseline)
  13. 13. * Changes in pulse (rate, rhythm, quality)Applicable Nursing Diagnoses * Impaired Gas Exchange-The state in which an individual experiences an actual (or potential) decrease in the passage of gases between the alveoli of the lungs and the vascular system * Dyspnea upon exertion * Decreased O2 saturation, cyanosisApplicable Nursing Diagnoses * Activity Intolerance- The state in which a person experiences a reduction in one’s physiologic capacity to endure activities to the degree desired or required * Activities tire the person out and increase respiratory rate and pulse rateTime to Practice! * Case Study

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