nursing assessment of respiratory system functioning in short .

1. Sachika Gaude
Nursing Tutor
Global Hospital School Of Nursing

2. To know physical and functional
problems of the patients.
To identify chief medical problem of
seeking help.
To know about risk factors .
Psycho social factors affecting
health.

3. Difficult or laboured breathing
Significance : acute causes more
dysnea .
Orthopnea: inability to breathe
except in an upright position .
Noisy breathing: narrowing of

4. How much exertion triggers shortness
of breath?
Is there an associated cough?
Is dyspnea related to other symptoms?
Sudden or gradual?
Time?
Position?
With rest or exercise?

5. Identify and correct its causes.
Place patient at rest with head
elevated.
Severe cases administer
oxygen.

6. Results from either irritants in the air
or through infectious process.
Significance :
Dry irritative cough: upper
respiratory tract infection of viral
origin.
Brassy cough :Tracheal lesion
Severe or changing cough : cancer
Chest pain with cough: chest wall
infection

7. Character of cough
Time

8. Patient who cough long enough
produces sputum.
Violent causes bronchial spasm ,
obstruction and irritation of
bronchi and result in syncope.

9. Purulent or change of colour : infection
Thin , mucoid sputum: viral bronchitis.
Gradual increase of sputum: bronchitis
Pink tinged mucoid: lung tumor
Profuse, frothy , pink material:
pulmonary edema
Foul smelling: lung abscess

10. If thick , adequate hydration
Inhalation of aerosolized solution
Smoking cessation

11.  Sharp, stabbing, intermittent
 Dull, aching and persistent.
 Felt at the place of pathology.

12.  Lung disease does not always produce
pain as lungs and visceral pleura lacks
nerves.
 Only parietal pleura has sensory
innervations.

13. Analgesics
Splinting
Positioning
Non steroidal anti inflammatory
drugs.

14.  Airway narrowing
 It is a high pitched , musical sound heard
mainly on expiration.
 Relief
 Oral or inhalant broncho dilators.

15. Sponginess of nail bed and loss of
nail bed angle.
Chronic hypoxic conditions.

16. Expectoration of blood from the
respiratory tract.
Sudden onset and intermittent.

17.  Nose / nasopharynx:
 considerable sniffing with blood
appearing in nose.
 Lung:
 Bright red, frothy and mixed with sputum.
 Alkaline ph
 Tickling sensation in throat.

18.  Bluish discolouration of skin.
 Occurs only when 5g/dl of deoxygenated hb
is present in body

20. Inspection
Palpation
Percussion
Auscultation

21.  Technique: observe for lesions, inflammation,
assymmetry .
 Tilt head back, and gently push tip of nose:
 Mucosa, colour, swelling, exudate, bleeding.

22. While the head is tilted back,the
nurse inspects inferior and middle
turbinates.
Palpate frontal and maxillary
sinuses.

23. Using the thumbs , the nurse applies
gentle pressure in an upward fashion
at suborbital ridges.

24. Mucosa : more reddish than oral
mucosa
Nasal septum : not deviated
Turbinates : gray appearance
 gelatinous and
freely movable.

25. Pass a light through the sinus .
If light fails to penetrate , cavity is
likely to be filled with fluid or pus.

26. Technique : instruct the patient to
open mouth wide and take a deep
breathe.
Assess anterior and posterior pillars ,
tonsils, uvula, and posterior pharynx.

27.  Direct palpation
 Technique :
 Place thumb and index fingerof one hand
on either side of trachea just above
sternal notch.
 Findings : midline behind sternum.

28. Note assymmetry
Skin for colour
Skin turgor

29. Normal : Antero-posterior: lateral
diameter= 1: 2
Abnormal :
i. Barrel chest
ii. Funnel chest
iii. Pigeon chest
iv. Kyphoscoliosis

30.  Cause : overinflation of lungs
 Increase in antero-posterior diameter.
 The ribs are more widely spaced
 Intercostal spaces tend to bulge on
expiration.

31. Depression in lower portion of the
sternum.
Compresses the heart and great
vessels leading to murmurs.

32. Cause: displacement of sternum.
Increase in antero-posterior
diameter.

33. Elevation of scapula
S-shaped spine
Limits lung expansion in thorax

34. Normal: 12-18 breaths per min
Bradypnea : slow breathing
Tachypnea: rapid breathing
Hyperpnea : increase in depth of
respiration.
Hyperventilation : an increase in
both rate and depth.

35. Hyperventilation marked by an
increase in rate and depth associated
with severe diabetic acidosis or of renal
origin is called kussmaul’s respiration.

36. It is characterized by alternating
episodes of apnea and periods od deep
breathing.
Associated with heart failure and
damage to respiratory centre.

37. Bulging during expiration:
obstruction of expiratory airflow.

38. Marked retraction on inspiration , if
asymmetrical : blockage of a branch
of the respiratory tree.

39. Asymmetric bulging of intercostal
spaces: hemothorax.

40. Respiratory excursion
Tactile fremitus

41. Nurse places thumb along the costal
margin , and tells patient to inhale
deeply.
Posteriorly, the nurse places the
thumbs adjacent to the spinal cord
at the level of 10th rib.

42. Normal symmetry
Decrease in chest excursion in case
of splinting due to trauma.

43. Sound generated by larynx travels
the bronchial tree to set the chest in
resonant motion.
The detection of resulting vibrations
on chest wall is called tactile
fremitus.

44. Patient is asked to repeat words like
ninety nine,”eee,eee”, or one two
three....
While the nurse’s hands move
down the patients thorax.
The vibrations are felt by the palms.

45. “Air does not conduct sound well,
but a solid substance do.”
If lungs is filled by fluids or tissues ,
there is increased fremitus.
If air is trapped within, there is
decreased fremitus.

46. Sets the chest walls and the underlying
structures in motion producing audible
and tactile vibrations.

47. Thoracic percussion begins with
posterior thorax.
Position: sitting , with head
flexed forward, and arms
crossed on the lap.
Nurse percusses from shoulder
tops to down.

48. Position: sitting , with shoulder
arched back, and hands on the side.
Nurse percusses from
supraclavicular area downwards.

49. Dullness is noted and checked.

50. Patient is instructed to inhale deeply and
hold.
Nurse percusses to mark the dullness
with a pen
The patient is than told to exhale and
hold that way.
Mark dullness with pen.
Normal findings: 5-7 cm.

54. Vesicular sounds :
Location : entire lung field except
over upper sternum and between
scapulae.
Intensity : soft
Pitch: low pitched
Duration: inspiratory lasts longer
than expiratory

55. Location : heard over trachea.
Intensity : loud
Pitch : high pitched
Duration : expiratory lasts
longer than inspiratory sound.

56. Location: between scapul;ae on
either sides of sternum
Intensity : intermediate
Pitch: intermediate
Duration: both are equal.

58. Location :in the neck
Intensity : very loud
Pitch: high pitched
Duration: inspiratory and
expiratory sounds.

59. Crackles : soft , high –pitched , dis
continous popping sounds that
occur during inspiration.

60. Sonorous wheezes: deep low
pitched rumbling sounds heard
primarily during expiration
Sibilant wheezes : continous ,
musical , high-pitched, whistle-like
sound

61. Hard crackling sounds.

62. BRUNNER AND SUDDHARTH’S
,TEXTBOOK OF MEDICAL SURGICAL
NURSING. Pg 382-392 .9th Edition .
 Pictures taken from GOOGLE source