Health assessment and diagnostic assessment of respiratory system

1. HEALTH
ASSESSMENT AND
DIAGNOSTIC
ASSESSMENT OF
RESPIRATORY
SYSTEM
MATHEW VARGHESE V
RN RM MSN FHNP CCEPC CSTPN

2. ANATOMIC AND PHYSIOLOGIC
OVERVIEW

3. PHYSIOLOGY OF RESPIRATORY SYSTEM

4. PHYSIOLOGY OF RESPIRATORY
SYSTEM

5. LUNG VOLUMES
TERM SYMBOL DESCRIPTION NORMAL
VALUE
SIGNIFICAN
CE
Lung
Volumes:
Tidal volume VT or TV
The volume of air inhaled
and
exhaled with each breath
500 mL or
5–10
mL/kg
The tidal
volume
may not
vary, even
with severe
disease.
Inspiratory
reserve
volume
IRV The maximum volume of
air that can be inhaled
after a normal inhalation
3000 ml

6. LUNG VOLUMES
TERM SYMBOL DESCRIPTION NORMAL
VALUE
SIGNIFICANCE
Expiratory
reserve volume
ERV The maximum volume of air
that can be exhaled forcibly
after a normal exhalation
1100 ml Expiratory
reserve volume is
decreased
with restrictive
conditions,
such as obesity,
ascites,
pregnancy.
Residual
volume
RV The volume of air remaining in
the lungs after a maximum
exhalation
1200 ml Residual volume
may be
increased
with obstructive
disease.

7. LUNG CAPACITIES
TERM SYMBOL DESCRIPTION NORMAL
VALUE
SIGNIFICANCE
Vital capacity VC The maximum volume of
air exhaled from the
point of maximum
inspiration
VC = TV + IRV + ERV
VC= 500+3000+1100
=4600
4600 ml A decrease in
vital capacity
may be
found in
neuromuscular
disease,
generalized
fatigue,
atelectasis,
pulmonary
edema, and
COPD.

8. LUNG CAPACITIES
TERM SYMBOL DESCRIPTION NORMAL
VALUE
SIGNIFICANCE
Total lung
capacity
TLC The volume of air in the
lungs after a
maximum inspiration
TLC = TV + IRV + ERV +
RV
*Values for healthy men;
women are 20%–25%
less
5800 ml Total lung
capacity may
be decreased
with restrictive
disease
(atelectasis,
pneumonia)
and increased
in
COPD.

9. HEALTH HISTORY
 The health history focuses on the physical and
functional problems of the patient and the effect of
these problems on his or her life
 To identifying the chief reason why the patient
is seeking health care, the nurse tries to
determine:
 when the health problem or symptom started?
 How long it lasted, if it was relieve at any time.?

10. THE NURSE COLLECTS INFORMATION ABOUT:
Precipitating factors
Duration
Severity
Associated factors or symptoms
Assesses for risk factors and
genetic factors that may contribute
to the patient’s lung condition.

11. CONTD…..
 The nurse assesses the impact of signs and symptoms
on the patient’s ability to perform activities of daily living
and to participate in usual work and family activities.
 Psychosocial factors that may affect the patient are
explored.
 These factors include anxiety, role changes, family
relationships, financial problems, employment status, and
the strategies the patient uses to cope with them.

12. HISTORY TAKING
 PAST MEDICAL HISTORY:
 Clients past medical plays a significant role to
identify and diagnosis of respiratory illnesses.
 PRESENT MEDICAL HISTORY:
 Present status of any disease is important to
enquire because co relation of present condition
with the symptoms will help to diagnose the
disease.

13. HISTORY TAKING
 PERSSONAL HABITS
 Personal habits like Smoking, Alcohol intake and
use of Tobacco has adverse effects on respiratory
health of the client.
 ALLERGIES:
 To know the status of any allergies is important to
know as it may be the reason of existing respiratory
problem.

14. HISTORY TAKING
 OCCUPATION:
 There are various occupations, who gave adverse
impact on respiratory health for example cotton
industry, coal mines, sugar cane industry etc.
 FAMILY HISTORY:
 Family history of any allergies and communicable
diseases may effect the health of the health of the
individual. Assessment to be done for age related
changes is very important aspect in assessment of
respiratory system of the geriatric client.

15. SIGN AND SYMPTOMS OF RESPIRATORY
DISORDERS
 COUGH

16. DYSPNOEA
 Dyspnoea (difficult or laboured breathing, shortness of
breath) is symptom common to many pulmonary and
cardiac disorders, particularly when there is decreased
lung compliance or increased airway resistance.
 The right ventricle of the heart will be affected ultimately
by lung disease because it must pump blood through the
lungs against greater resistance.
 It may also be associated with neurologic or
neuromuscular disorders such as myasthenia gravis,
Guillain-Barre syndrome, or muscular dystrophy.

17. SPUTUM PRODUCTION
 A patient who coughs long enough almost invariably
produces sputum. Violent coughing causes bronchial
spasm, obstruction, and further irritation of the bronchi
and may result in syncope (fainting). A severe,
repeated, or uncontrolled cough that is non-productive
is exhausting and potentially harmful.
 Sputum production is the reaction of the lungs to
any constantly recurring irritant. It also may be
associated with a nasal discharge.


18. CHEST PAIN
 Chest pain or discomfort may be associated
with pulmonary or cardiac disease. Chest pain
associated with pulmonary conditions may be
sharp, stabbing, and intermittent, or it may be dull,
aching, and persistent. The pain usually is felt on
the side where the pathologic process is located,
but it may be referred elsewhere—for example, to
the neck, back, or abdomen

19. HAEMOPTYSIS
 Haemoptysis (expectoration of blood from the
respiratory tract) is a symptom of both pulmonary
and cardiac disorders. The onset of haemoptysis is
usually sudden, and it may be intermittent or
continuous. Signs, which vary from blood-stained
sputum to a large, sudden haemorrhage, always
merit investigation.

20. HAEMOPTYSIS

21. HAEMOPTYSIS
 The most common causes are:
 Pulmonary infection
 Carcinoma of the lung
 Abnormalities of the heart or blood
vessels
 Pulmonary artery or vein abnormalities
 Pulmonary emboli and infarction

22. CYANOSIS
 Cyanosis, a bluish colouring of the skin, is a very
late indicator of hypoxia.

23. WHEEZING
 Wheezing is often the major finding in a patient with
bronchoconstrictionor airway narrowing. It is heard
with or without a stethoscope, depending on its
location. Wheezing is a high pitched, musical sound
heard mainly on expiration.


24. CLUBBING OF THE FINGERS

25. CLUBBING OF THE FINGERS
 Clubbing of the fingers is a sign of lung disease
found in patients with chronic hypoxic conditions,
chronic lung infections, and malignancies of the
lung. This finding may be manifested initially as
sponginess of the nail bed and loss of the nail bed
angle.

26. OTHER PRESENTING SYMPTOMS
 Apnea:-It is the cessation of breathing. During
apnoea, there is no movement of
the muscles of inhalation, and the volume of
the lungs initially remains unchanged
 Hoarseness: - Hoarseness is an abnormal
change in the voice caused by a variety of
conditions. The voice may have changes in pitch
and volume, ranging from a deep, harsh voice to
a weak, raspy voice.

27. OTHER PRESENTING SYMPTOMS
 Stridor:-Stridor is a high-pitched, wheezing
sound caused by disrupted airflow. Stridor may
also be called musical breathing or extra thoracic
airway obstruction.
 Snoring :-Snoring is the vibration of respiratory
structures and the resulting sound due to
obstructed air movement during breathing while
sleeping
 Fever
 Night sweating
 Weight loss

28. PHYSICAL ASSESSMENT OF THE UPPER
RESPIRATORY STRUCTURES
 Nose and Sinuses
 The nurse inspects the external nose for lesions,
asymmetry, or inflammation and then asks the
patient to tilt the head backward.
 Gently pushing the tip of the nose upward, the
nurse examine the internal structures of the nose,
inspecting the mucosa for colour, swelling,
exudates, or bleeding.
 The nasal mucosa is normally redder than the oral
mucosa, but it may appear swollen and hyperaemic
if the patient has a common cold. In allergic rhinitis,
however, the mucosa appears pale and swollen.

29. NOSE AND SINUSES
 Next the nurse inspects the septum for deviation,
perforation, or bleeding. Most people have a slight
degree of septal deviation, but actual displacement
of the cartilage into either the right or left side of the
nose may produce nasal obstruction. Such
deviation usually causes no symptoms.
 While the head is still tilted back, the nurse inspects
the inferior and middle turbinates. In chronic rhinitis,
nasal polyps may develop between the inferior and
middle turbinates; they are distinguished by their
grey appearance. Unlike the turbinates, they are
gelatinous and freely movable.

30. NOSE AND SINUSES
 Next the nurse may palpate the frontal and
maxillary sinuses for tenderness.
 Using the thumbs, the nurse applies gentle
pressure in an upward fashion at the supraorbital
ridges (frontal sinuses) and in the cheek area
adjacent to the nose (maxillary sinuses).
Tenderness in either area suggests inflammation.
 The frontal and maxillary sinuses can be inspected
by trans illumination (passing a strong light through
a bony area, such as the sinuses, to inspect the
cavity. If the light fails to penetrate, the cavity is
likely to contain fluid or pus.

31. PHARYNX AND MOUTH
 After the nasal inspection, the nurse may assess
the mouth and pharynx, instructing the patient to
open the mouth wide and take a deep breath.
Usually this will flatten the posterior tongue and
briefly allow a full view of the anterior and posterior
pillars, tonsils, uvula, and posterior pharynx. The
nurse inspects these structures for colour,
symmetry, and evidence of exudates, ulceration, or
enlargement. If a tongue blade is needed to
depress the tongue to visualize the pharynx, it is
pressed firmly beyond the midpoint of the tongue to
avoid a gagging response

32. TRACHEA
 Next the position and mobility of the trachea are
usually noted by direct palpation. This is performed
by placing the thumb and index finger of one hand
on either side of the trachea just above the sternal
notch. The trachea is highly sensitive, and palpating
too firmly may trigger a coughing or gagging
response. The trachea is normally in the midline as
it enters the thoracic inlet behind the sternum, but it
may be deviated by masses in the neck or
mediastinum. Pleural or pulmonary disorders, such
as a pneumothorax, may also displace the trachea.

33. PHYSICAL ASSESSMENT OF THE LOWER
RESPIRATORY STRUCTURES AND
BREATHING
 THORAX
 Inspection of the thorax provides information about the
musculoskeletal structure, the patient’s nutritional
status, and the respiratory system. The nurse observes
the skin over the thorax for colour and turgor and for
evidence of loss of subcutaneous tissue. It is important
to note asymmetry, if present. When findings are
recorded or reported, anatomic landmarks are used as
points of reference.

34. CHEST CONFIGURATION
 Normally, the ratio of the antero-posterior diameter to the
lateral diameter is 1:2. However, there are four main
deformities of the chest associated with respiratory
disease that alter this relationship:
 Barrel chest
 Funnel chest (pectus excavatum)
 Pigeon chest(pectus carinatum)
 Kyphoscoliosis.

35. BARREL CHEST:
 Barrel chest occurs as a result of over inflation of
the lungs. There is an increase in the antero
posterior diameter of the thorax. In a patient with
emphysema, the ribs are more widely spaced and
the intercostal spaces tend to bulge on expiration.
The appearance of the patient with advanced
emphysema is thus quite characteristic and often
allows the observer to detect its presence easily,
even from a distance.

36. FUNNEL CHEST (PECTUS EXCAVATUM):
 Funnel chest occurs when there is a depression in
the lower portion of the sternum. This may
compress the heart and great vessels, resulting in
murmurs. Funnel chest may occur with rickets or
Marfan’s syndrome.

37. PIGEON CHEST (PECTUS CARINATUM):
 A pigeon chest occurs as a result of displacement
of the sternum. There is an increase in the
anteroposterior diameter. This may occur with
rickets, Marfan’s syndrome, or severe
Kyphoscoliosis.

38. KYPHOSCOLIOSIS
 A Kyphoscoliosis is characterized by elevation of
the scapula and a corresponding S-shaped spine.
This deformity limits lung expansion within the
thorax. It may occur with osteoporosis and other
skeletal disorders that affect the thorax.

40. RESPIRATORY ASSESSMENT
 Observing the rate and depth of respiration is a
simple but important aspect of assessment.
There are five aspects to see while assessing
respiratory pattern:

41. RATE:
 The rate is the number of full respiration in a
minute. The normal adult who is resting comfortably
takes 12 to 18 breaths per minute.
 The respiratory rate varies according to a number
of factors:
 Age of the person:
 At birth 30 to 40 per minute
 First year 26 to 30 per minute
 Second year 20 to 26 per minute
 Adolescence 18 to 20 per minute
 Adults 18 to 20 per minute
 Old age 10 to 24 per minute

42. RATE:
 Sex: Females tend to have slightly rapid respirations
than male.
 Emotions: Sudden stressful conditions such as fear,
rage, or anxiety etc., may influence the respiratory rate
as the body prepares for flight or fight.
 Changes in atmosphere pressure: In high attitudes,
the content of oxygen is very low, so that not enough
oxygen is absorbed by blood. Increased demand of the
oxygen by the tissues must be met by an increased
respiratory rate.
 Exercise: Exertion of any sort increases the metabolic
rate and stimulates respiration. During exercise the rate
and depth of respiration are increased. Rest and sleep
keep the respiratory rate normal.

43. RATE:
 Changes in the external temperature: Exposure
of cold increases the oxygen need. In order to keep
the body warm, It shivers. The individual takes
deep breaths. If the temperature of the body is
raised by the application of heat, or due to fever,
the metabolic rate is increased and the respiratory
rate is also increased. Respiration increases by
about 4 breaths per minute for every one degree
rise in temperature above normal.
 Ingestion of food and digestion: The intake of
food, its digestion and assimilation increases the
metabolism and the need for oxygen, hence the
respiratory rate is increased.

44. RATE:
 Disease conditions:
 Endocrine disease, particularly thyroid diseases
raises the metabolic rate. Thus the respiratory rate
is also increased.
 Anything that reduces the functioning lung area
increases the respiratory rate. The collapse of a
lung or part of it, inflammation of the pleura, fluid in
the abdominal cavity that gives pressure on the
diaphragm reduce the lung expansion and force the
person to breath rapidly in order to get an adequate
oxygen supply.

45. RATE:
 Conditions that increases the carbon dioxide
content of the blood increase the depth and rate of
respiration e.g. asphyxia.
 Anything that reduces the blood volume or oxygen
carrying elements of the blood increases the
respiratory rate e.g., haemorrhage, anaemia,
carbon monoxide poisoning.
 Brain pathology affects the respiratory rate and is
most likely to slow down e.g., brain tumours, brain
injuries.

46. RATE:
 Drugs: Stimulant drugs such as caffeine, coramine,
atropine, spirits of ammonia, carbon dioxide etc.,
stimulates the respiratory centre and the reflex
centres, thus the respiration is increased.
 Respiratory depressants such as narcotics,
sedatives, opium etc., decrease the respiratory rate

47. DEPTH:
 A normal average man at rest inspires and exhales about 500
cc. of air with each respiration. If more than this quantity of air
passes in and out of the lungs, the respiration is said to be
deep. If the quantity of air is considerably less, the respiration
is said to be shallow.
 Any diseases that reduces the vital capacity of the lungs,
which interferes with the exchange of gases by the blood or
that increases the need for oxygen beyond the body’s
capacity to supply it, causes hyperpnoea (deep breathing),
polypnoea, (rapid breathing), dyspnoea (difficult, laboured,
painful breathing).
 When a person is dyspnoeic, he assumes a sitting
position to get relief from dyspnoea. In sitting position, the
abdominal organs and the diaphragm are pulled downwards
by the force of gravity. The vertical diameter of the chest cavity
is increased. This allows more freedom for the movement of
the lungs. Air rushes into the lungs.

48. RHYTHM:
 Except for occasional sighs, respirations at regular
in depth and rhythm. This normal pattern is
described as Eupnoea.
 Apnoea describes varying periods of cessation of
breathing. If sustained, apnoea is life-threatening.
 Bradypnea, also called slow breathing, is
associated with increased intracranial pressure,
brain injury, and drug overdose.
 Tachypnea, or rapid breathing, is commonly seen
in patients with pneumonia, pulmonary oedema,
metabolic acidosis, septicaemia, severe pain, and
rib fracture.

49. RHYTHM:
 Shallow, irregular breathing is referred to as
Hypoventilation.
 An increase in depth of respirations is called
Hyperpnoea.
 An increase in both rate and depth that results in a
lowered arterialPCO2 level are referred to as
Hyperventilation. With rapid breathing, inspiration
and expiration are nearly equal in duration.
 Hyperventilation that is marked by an increase in
rate and depth, associated with severe acidosis of
diabetic or renal origin, is called Kussmaul’s
respiration.

50. RHYTHM:
 Cheyne-Stokes respiration is characterized by
alternating episodes of apnoea (cessation of breathing)
and periods of deep breathing. Deep respirations
become increasingly shallow, followed by apnoea that
may last approximately 20 seconds. The cycle repeats
after each apnoeic period. The duration of the period of
apnoea may vary and may progressively lengthen;
therefore, it is timed and reported. Cheyne-Stokes
respiration is usually associated with heart failure and
damage to the respiratory centre (drug-induced, tumour,
trauma).
 Biot’s respirations, or cluster breathing, are cycles of
breaths that vary in depth and have varying periods of
apnoea. Biot’s respirations are seen with some central
nervous system disorders.

51. RHYTHM:

52. BREATH SOUNDS
 Respiratory sounds, breath sounds, or lung
sounds refer to the specific sounds generated by
the movement of air through the respiratory system.
These may be easily audible or identified
through auscultation of the respiratory
system through the lung fields with
a stethoscope as well as from the spectral
chacteristics of lung sounds. These include normal
breath sounds and adventitious or "added" sounds
such as rales, wheezes, pleural friction
rubs, stertor and stridor.

53. BREATH SOUNDS
 Rhonchi occur when air tries to pass
through bronchial tubes that contain fluid or mucus.
 Crackles occur if the small air sacs in the lungs fill
with fluid and there’s any air movement in the sacs,
such as when you’re breathing. The air sacs fill with
fluid when a person has pneumonia or heart failure.
 Wheezing occurs when the bronchial tubes
become inflamed and narrowed.
 Stridor occurs when the upper airway narrows

54. MUSCLE INVOLVED:
The muscles of respiration are those muscles that
contribute to inhalation and exhalation, by aiding in
the expansion and contraction of the thoracic cavity
The diaphragm and, to a lesser extent, the intercostal
muscles drive respiration during quiet breathing
Additional 'accessory muscles of respiration' are
typically only used under conditions of high
metabolic demand (e.g. exercise) or respiratory
dysfunction (e.g. an asthma attack).

55. MUSCLE INVOLVED:
 "Accessory muscles" refers to muscles that assist,
but do not play a primary role, in breathing. There is
some controversy concerning which muscles may
be considered accessory muscles of inhalation.
However the sternocleidomastoid and the scalene
muscles (anterior, middle and posterior scalene)
are typically considered accessory muscles of
breathing. Both assist in elevating the rib cage. The
involvement of these muscles seems to depend on
the degree of respiratory effort.

56. MUSCLE INVOLVED:
 During quiet breathing, there is little or no muscle
contraction involved in exhalation; this process is
simply driven by the elastic recoil of the thoracic wall.
When forceful exhalation is required, or when the
elasticity of the lungs is reduced (as in emphysema),
active exhalation can be achieved by contraction of
the abdominal wall muscles (rectus
abdominis, transverse abdominis, external oblique
muscle and internal oblique muscle). These press the
abdominal organs cranially (upward) into the
diaphragm, reducing the volume of the thoracic cavity.

57. MUSCLE INVOLVED:
 The internal intercostal muscles have fibres
that are angled obliquely downward and
backward from rib to rib. These muscles can
therefore assist in lowering the rib cage,
adding force to exhalation.

58. PALPATION

59. PALPATION
 Palpation is the next stage of the examination. With
the patient disrobed, place the entire palm of each
hand first on the superior portion of both
hemithoraces and then, gently though firmly, move
the hand inferiorly to just below the twelfth rib.
Repeat the process moving laterally and
subsequently anteriorly; search for rib deformities,
nodules, and areas of tenderness

60. PALPATION
 Palpation is also important in the assessment of
ventilation. One can sensitively assess the
symmetry, synchrony, and volume of each breath.
This is done by examining the patient posteriorly,
placing the examiner's thumbs together at the
midline at the level of the tenth rib with hands
grasping the lateral rib cage; both visual and tactile
observations are made both during tidal volume
breathing and during deep forceful inhalation. With
the latter, thumbs typically separate by
approximately 2 to 3 cm.

61. PALPATION
 A part of the palpatory portion of the chest
examination is to assess the position of the trachea.
This is accomplished best with the examiner
stationed behind the patient, palpating the anterior
inferior neck just above the jugular notch by gently
pressing the fingertips between the lateral tracheal
wall and the medial portion of the
sternocleidomastoid muscle. Comparing one side to
the other, an assessment is made of the position of
the trachea: midline or deviation away from the
centrist position.

62. TACTILEFREMITUS
 :A tremulous vibration of the chest wall during spea
king that is palpable on physical examination. Tactil
e fremitus may bedecreased or absent when vibrati
ons from the larynx to the chest surface are impede
d by chronic obstructive pulmonarydisease, obstruc
tion, pleural effusion, or pneumothorax. Respiratory
expansion, indicating whether lung expansion is
equal. The position of the apex beat to check if
there has been deviation of the heart.

63. TACTILEFREMITUS

64. PERCUSSION
 The purpose of percussion is to determine if the
area under the percussed finger is air filled
(sounding resonant like a drum), fluid filled (a dull
sound) or solid (a flat sound). To make this
interpretation it is important not only to listen for the
sound produced but also to feel the intensity and
frequency of vibrations produced by this maneuver.

65. PERCUSSION

66. PERCUSSION
 Specifically, percussion is performed with the
middle finger striking the middle phalanx of the
other middle finger of the other hand. The sides of
the chest are compared. This is performed
symmetrically on all lung fields, on the anterior and
posterior chest walls.
 Percussion sets the chest wall and underlying
structures in motion, producing audible and tactile
vibrations. The nurse uses percussion to determine
whether underlying tissues are filled with air, fluid,
or solid material.

67. PERCUSSION
 Percussion also is used to estimate the size and
location of certain structures within the thorax (eg,
diaphragm, heart, liver). Percussion usually begins
with the posterior thorax.
 Ideally, the patient is in a sitting position with the
head flexed forward and the arms crossed on the
lap. This position separates the scapulae widely
and exposes more lung area for assessment.
 The nurse percusses across each shoulder top,
locating the 5-cm width of resonance overlying the
lung apices.

68. PERCUSSION
 Then the nurse proceeds down the posterior thorax,
percussing symmetric areas at 5- to 6-cm (2- to 2.5-
inch) intervals.
 The middle finger is positioned parallel to the ribs in
the intercostal space; the finger is placed firmly
against the chest wall before striking it with the
middle finger of the opposite hand.
 Bony structures (scapulae or ribs) are not
percussed. Percussion over the anterior chest is
performed with the patient in an upright position
with shoulders arched backward and arms at the
side.

69. PERCUSSION
 The nurse begins in the supraclavicular area and
proceeds downward, from one intercostal space to
the next. In the female patient, it may be necessary
to displace the breasts for an adequate
examination.
 Dullness noted to the left of the sternum between
the third and fifth intercostal spaces is a normal
finding because it is the location of the heart.
 Similarly, there is a normal span of liver dullness in
the right thorax from the fifth intercostal space to
the right costal margin at the midclavicular line.

70. PERCUSSION
 The anterior and lateral thorax is examined with the
patient in a supine position. If the patient cannot sit
up, percussion of the posterior thorax is performed
with the patient positioned on the side. Dullness
over the lung occurs when air-filled lung tissue is
replaced by fluid or solid tissue

71. AUSCULTATION
 NORMAL BREATH SOUNDS
 Normal breath sounds are distinguished by their
location over a specific area of the lung and are
identified as vesicular, bronchovesicular, and
bronchial (tubular) breath sounds.

72. ADVENTITIOUS SOUNDS
 ADVENTITIOUS SOUNDS
 An abnormal condition that affects the bronchial
tree and alveoli may produce adventitious
(additional) sounds. Adventitious sounds are
divided into two categories: discrete, non
continuous sounds (crackles) and continuous
musical sounds (wheezes)

73. BREATH
SOUND
DESCRIPTION ETIOLOGY
Crackles
Crackles in general
Coarse crackles
Fine crackles
Soft, high-pitched, discontinuous
popping sounds that occur during
inspiration.
Discontinuous popping sounds heard in
early inspiration; harsh, moist sound
originating in the large bronchi
Discontinuous popping sounds heard in
late inspiration; sounds like hair rubbing
together; originates in the alveoli
Secondary to fluid in the airways or
alveoli or to opening of collapsed
alveoli
Associated with obstructive
pulmonary disease
Associated with interstitial
pneumonia, restrictive pulmonary
disease (eg, fibrosis). Fine crackles in
early inspiration are associated with
bronchitis or pneumonia.

74. Wheezes
Sonorous wheezes
(rhonchi)
Sibilant wheezes
Deep, low-pitched rumbling sounds
heard primarily during expiration;
caused by air moving through
narrowed tracheobronchial
passages
Continuous, musical, high-pitched,
whistle like sounds heard during
inspiration and expiration caused by
air passing through narrowed or
partially obstructed airways; may clear
with coughing
Secretions or tumor
Bronchospasm, asthma, and
Build up of secretions
Stridor It is a high-pitched musical breath
sound resulting from turbulent air flow
in the larynx or lower in the bronchial
tree. It is not to be confused
with stertor
Causes are typically obstructive,
including foreign
bodies, croup, epiglottitis, tumours,
infection and anaphylaxis.

75. COVID 19
 Clinical suspicion — in symptomatic patients, the
possibility of COVID-19 should be considered
primarily in those with new-onset fever and/or
respiratory tract symptoms (eg, cough dyspnea). It
should also be considered in patients with severe
lower respiratory tract illness without any clear
cause. Other consistent symptoms include smell or
taste disturbances, myalgias, and diarrhea. As
SARS-CoV-2 is prevalent worldwide, clinicians
should have a low threshold for suspicion of
COVID-19, and the likelihood is further increased if
the patient:

76. NAME OF TEST PURPOSE AND DESCRIPTION RELATED NURSING
CARE
Chest x-ray Chest x-rays are used to identify
abnormalities in chest structure and lung
tissue, for diagnosis of diseases and
injuries of the lungs, and to monitor
treatment.
No special preparation is
needed
Computed
tomography (CT)
CT of the thorax may be performed
when x-rays do not show some areas
well, such as the pleura and
mediastinum. It is also done to
differentiate pathologic conditions (such
as tumors, abscesses, and aortic
aneurysms), to identify pleural effusion
and enlarged lymph nodes, and to
monitor treatment. Images are shown in
cross section
No special preparation is
needed.
Magnetic resonance
imaging (MRI)
An MRI of the thorax is used to
diagnose alterations in lung tissue more
difficult to visualize by CT scan and to
identify abnormal masses and fluid
accumulation.
Assess for any metallic
implants (such as pacemaker,
pacemaker wires, or implant).
Test will not be performed if
present.
IMAGING STUDIES

77. Positron emission tomography
(PET)
This relatively noninvasive test, when used to examine
the lungs, is performed to identify lung nodules (cancers).
The client is given a radioactive substance and cross-
sectional images are displayed on a computer. Radiation
from PET is only 25% of that from a CT scan.
No alcohol, coffee, or tobacco is allowed
for 24 hours prior to the test. Encourage
increased fluid intake to help eliminate the
radioactive material.
Pulmonary angiography This test is done to identify pulmonary emboli, tumors,
aneurysms, vascular changes associated with
emphysema, and pulmonary circulation. A catheter is
inserted into the brachial or femoral artery, threaded into
the pulmonary artery, and dye is injected through vein .
ECG leads are applied to the chest for cardiac
monitoring. Images of the lungs are taken.
Monitor injection site and pulses distal
to the site after the test.
Pulmonary ventilation/perfusion
scan
This test is performed with two nuclear scans to measure
breathing (ventilation) and circulation (perfusion) in all
parts of the lungs. A perfusion scan is performed by
injecting radioactive albumin into a vein and scanning the
lungs. A ventilation scan is performed by scanning the
lungs as the client inhales radioactive gas. A decreased
uptake of radioisotope during the perfusion scan
indicates a blood flow problem, such as from a
pulmonary embolus or pneumonitis. A decreased uptake
of gas during the ventilation scan may indicate airway
obstruction, pneumonia, or COPD.
No special preparation is needed.

78. Bronchoscopy A bronchoscopy is the direct visualization of the
larynx, trachea, and bronchi through a
bronchoscope to identify lesions, remove foreign
bodies and secretions, obtain tissue for biopsy,
and improve tracheobronchial drainage
■ During the test, a catheter brush or biopsy
forceps can be passed to obtain secretions or
tissue for examination for cancer.
Bronchoscopy is an invasive
procedure requiring conscious
sedation or anesthesia.
■ Provide mouth care just prior to
bronchoscopy. Mouth care reduces oral
microorganisms and the risk of
introducing them into the lungs.
■ Bring resuscitation and suction
equipment to the bedside .
Laryngospasm and respiratory distress
may occur following the procedure.
■ Following the procedure, closely
monitor vital signs and respiratory
status. Possible complications of
bronchoscopy include laryngospasm,
bronchospasm.
■ Instruct to avoid eating or drinking for
approximately 2 hours or until fully
awake with intact cough and gag
reflexes.
■ Monitor colour and character of
respiratory secretions.
■ Collect post bronchoscopy sputum
specimens for cytologic examination as
ordered.

79. PULMONARY FUNCTION TESTS

80. PULMONARY FUNCTION TESTS
 Pulmonary function tests (PFTs) are routinely
used in patients with chronic respiratory
disorders. They are performed to assess
respiratory function and to determine the extent of
dysfunction.
 Such tests include measurements of lung volumes,
ventilator function, and the mechanics of breathing,
diffusion, and gas exchange.
 PFTs are useful in following the course of a patient
with an established respiratory disease and
assessing the response to therapy.

81. PULMONARY FUNCTION TESTS
 They are useful as screening tests in potentially
hazardous industries, such as coal mining and
those that involve exposure to asbestos and other
noxious fumes, dusts, or gases.
 These assessment methods allow for detailed
evaluation of expiratory flow limitations and airway
inflammation.
 PFT results are interpreted on the basis of the
degree of deviation from normal, taking into
consideration the patient’s height, weight, age, and
gender.

82. PULMONARY FUNCTION TESTS
 Because there is a wide range of normal values,
PFTs may not detect early localized changes.
 The patient with respiratory symptoms (dyspnoea,
wheezing, cough, sputum production) usually
undergoes a complete diagnostic evaluation, even
though the results of PFTs are “normal.”

83. ARTERIAL BLOOD GAS STUDIES
 Measurements of blood pH and of arterial oxygen
and carbon dioxide tensions are obtained when
managing patients with respiratory problems and in
adjusting oxygen therapy as needed.
 The arterial oxygen tension (PaO2) indicates the
degree of oxygenation of the blood, and the arterial
carbon dioxide tension (PaCO2) indicates the
adequacy of alveolar ventilation.

84. ARTERIAL BLOOD GAS STUDIES
 Arterial blood gas studies aid in assessing the
ability of the lungs to provide adequate oxygen and
remove carbon dioxide and the ability of the
kidneys to reabsorb or excrete bicarbonate ions to
maintain normal body ph.
 Serial blood gas analysis also is a sensitive
indicator of whether the lung has been damaged
after chest trauma.
 Arterial blood gas levels are obtained through an
arterial puncture at the radial, brachial, or femoral
artery or through an indwelling arterial catheter

85. THE COMPONENTS OF ABG:
 pH
 PaCO2
 PaO2
 HCO3
 O2sat
 BE

86. DESIRED RANGES OF ABG:
 pH - 7.35 - 7.45
 PaCO2 - 35-45 mmHg
 PaO2 - 80-100 mmHg
 HCO3 - 21-27
 O2sat - 95-100%
 Base Excess - +/-2 mEq/L

87. RESPIRATORY ACIDOSIS
 ph, CO2, Ventilation
 Causes
 CNS depression
 Pleural disease
 COPD/ARDS
 Musculoskeletal disorders

88. RESPIRATORY ALKALOSIS
 pH, CO2, Ventilation
 Causes
 Intra cerebral hemorrhage
 Salicylate and Progesterone drug usage
 Anxiety lung compliance
 Cirrhosis of the liver
 Sepsis

89. METABOLIC ACIDOSIS
 pH, HCO3

 Causes:
 Diarrhea
 Pancreatic Fistula
 Methanol
 Uremia
 DKA
 Uremia

90. METABOLIC ALKALOSIS
 pH, HCO3

 Causes
 Vomiting
 Diuretics
 Chronic diarrhea
 Hypokalemia
 Renal Failure

91. PULSE OXIMETRY
 Pulse oximetry is a non-invasive method of continuously
monitoring the oxygen saturation of haemoglobin (SpO2 or
SaO2).
 Although pulse oximetry does not replace arterial blood gas
measurement, it is an effective tool to monitor for subtle or
sudden changes in oxygen saturation.
 A probe or sensor is attached to the fingertip forehead,
earlobe, or bridge of the nose.
 The sensor detects changes in oxygen saturation levels by
monitoring light signals generated by the oximeter and
reflected by blood pulsing through the tissue at the probe.
 Normal SpO2 values are 95% to 100%. Values less than 85%
indicate that the tissues are not receiving enough oxygen, and
the patient needs further evaluation.

92. PULSE OXIMETRY

93. CULTURES
 Throat cultures may be performed to identify
organisms responsible for pharyngitis. Throat
culture may also assist in identify in organisms
responsible for infection of the lower respiratory
tract. Nasal swabs also may be performed for the
same purpose.

94. SPUTUM STUDIES
 Sputum is obtained for analysis to identify
pathogenic organisms and to determine whether
malignant cells are present. It also may be used to
assess for hypersensitivity states (in which there is
an increase in eosinophils). Periodic sputum
examinations may be necessary for patients
receiving antibiotics, corticosteroids, and
immunosuppressive medications for prolonged
periods because these agents are associated with
opportunistic infections. In general, sputum cultures
are used in diagnosis, for drug sensitivity testing,
and to guide treatment.

95. THORACENTESIS
 A thin layer of pleural fluid normally remains in the
pleural space. An accumulation of pleural fluid may
occur with some disorders. A sample of this fluid
can be obtained by thoracentesis (aspiration of
pleural fluid for diagnostic or therapeutic purposes).
It is important to position the patient correctly. A
needle biopsy of the pleura may be performed at
the same time. Studies of pleural fluid include
Gram’s stain culture and sensitivity, acid-fast
staining and culture, differential cell count, cytology,
pH, specific gravity, total protein, and lactic
dehydrogenase.

96. THORACENTESIS

97. BIOPSY
 Biopsy, the excision of a small amount of tissue,
may be performed to permit examination of cells
from the pharynx, larynx, and nasal passages.
Local, topical, or general anaesthesia may be
administered, depending on the site and the
procedure.
 Lung biopsy may be done
 transbronchially,
 percutaneously or via transthoracic needle
aspiration (TTNA),
 by video-assisted thoracic surgery (VATS),
 as an open lung biopsy

98. OTHER TESTS
 Pleural Biopsy
 Lung Biopsy Procedure
 Lymph Node Biopsy

99. NAAT AND RTPCR FOR COVID 19
 Initial testing and specimen collection — Nucleic
acid amplification testing (NAAT), most commonly
with a reverse-transcription polymerase chain
reaction (RT-PCR) assay, to detect SARS-CoV-2
RNA from the upper respiratory tract is the
preferred initial diagnostic test for COVID-19 . In
some settings, antigen testing may be the initial test
used, but the sensitivity of antigen tests is lower
than that of NAATs, and negative antigen tests
should usually be confirmed with NAAT.

100. TYPES OF NAATS
 The diagnosis of COVID-19 is made primarily by direct
detection of severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) RNA by nucleic acid
amplification tests (NAATs), most commonly reverse-
transcription polymerase chain reaction (RT-PCR) from
the upper respiratory tract . Various RT-PCR assays are
used around the world; different assays amplify and
detect different regions of the SARS-CoV-2 genome.
Some target two or more genes, including the
nucleocapsid (N), envelope (E), and spike (S) genes,
and regions in the first open reading frame, including the
RNA-dependent RNA polymerase (RdRp) gene . Other,
less common types of NAAT include isothermal
amplification, CRISPR-based assays, and next-
generation sequencing .

101. ANTIGEN TESTING AS AN ALTERNATIVE TO
NAAT
 Tests that detect SARS-CoV-2 antigen can be
performed rapidly and at the point of care and thus
may be more accessible with a faster time to results
than some NAATs. However, data on antigen test
performance for SARS-CoV-2 are limited, and they
are typically less sensitive than NAATs . Clinicians
should be aware of the possibility of false-negative
results with antigen tests; a negative antigen test
does not rule out SARS-CoV-2 infection. Negative
antigen test results should be confirmed using a
sensitive NAAT if the clinical suspicion is high .

102. RESEARCH STUDIES REGARDING THE
IMPORTANCE OF RESPIRATORY SYSTEM
ASSESSMENT
 Title: Effectiveness of a learning support
program for respiratory physical assessment: A
quasi-experimental study
 Authors: Rika Mitoma, Toyoaki Yamauchi,
 Design: This study used a quasi-experimental
design of two groups with pre-test, post-test
measurements of training and follow-up test 8
weeks practice in their work place after the training.

103.  Methods: 57 currently working visiting nurses
were assigned to 1 of 2 groups: a control group in
which nurses would not receive any special support
after respiratory physical assessment training and
an experimental group in which nurses would
receive support to utilize the knowledge and skills
they had learned during the training.

104.  Results: The average practical examination score
was significantly higher after the training. In the
experimental group, the average score 8 weeks
after training was not significantly higher than that
obtained just after training. Further, after 8 weeks,
the experimental group’s average score was not
significantly higher than that of the control group.
Practice evaluation scores obtained by an
investigation of daily clinical practice were not
significantly higher seventh weeks compared to
third weeks after training for either the experimental
or control groups.

105.  Seventh weeks after training, the average practice
evaluation score of the experimental group was
significantly higher than that of control groups. The
mean learning support program satisfaction score
was higher among the experimental group than the
control group.The results suggested that support
from others was effective in maintaining motivation
for learning and making use in the regular practice
of the knowledge and skills acquired in the
respiratory physical assessment training.

106. CONCLUSION
 We nurses are the backbone of health care team.
By knowing the assessment and diagnostic
measures of respiratory system we can improve the
quality of nursing care we provide and thus will
strive towards the early recovery of patients
especially during the covid 19 pandemic situation.
As a nurse, we have the opportunity to heal the
heart, mind, soul and body of our patients, their
families and ourselves. They may forget your name
but they will never forget how you made them feel.

107. REFERENCES:
 Chungh S N ,Chungh A.”Textbook of Medical Surgical
Nursing”2013.part 1.Avichal Publishing company New
Delhi .page no 368-383
 Hinkle L J,Cheever K H.Brunner and suddarths
Textbook of medical surgical nursing 13 th edition
wolters Kluwer publicayions Philadelphia page num 463-
489
 https://courses.kcumb.edu/physio/adaptations/vq.htm
 https://lifeinthefastlane.com/ccc/oxygen-haemoglobin-
dissociation-curve/
 http://www.cts.usc.edu/lpg-thoracoscopy-
thethoracoscopyprocedure.html
 Google images.com
