Faculty of Nursing-IUG

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Faculty of Nursing-IUG

• Chapter (7)
• Assessment of respiratory system

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• Anatomy of Respiratory System
• The lung is a two cone-shaped, elastic structure
  suspended within the thoracic cavity.
• Lung are paired, they are not complete symmetric,
  the right lung contain three lobe, whereas the
  left lung contain only two lobes.
• The apex of each lung extended slightly above the
  clavicle, where the base is at the level of
  diaphragm
• The thoracic cavity contains the nasopharynx,
  larynx, trachea, bronchi, bronchioles, alveoli.
• The thoracic cavity is lined by a thin, double-
  layered serous membrane collectively called the
  pleural membrane

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• Assessment of respiratory system
• Subjective data the nurse must ask the client
  about-
• Coughing (productive, non productive)
• Sputum (type amount)
• Allergies, dyspnea or SOB (at rest or on
  exertion).
• Chest pain, history of asthma, bronchitis,
  emphysema, tuberculosis.
• Cyanosis, pallor.
• Exposure to environmental inhalants (chemicals,
  fumes).
• History of smoking (amount and length of time)

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• Technique for Respiratory Exam
• Before beginning, if possible
• Quiet environment
• Proper positioning (patient sitting for posterior
  thorax exam, supine for anterior thorax exam)
• Expose skin for auscultation
• Patient comfort, warm hands and diaphragm of
  stethoscope, be considerate of women (drape sheet
  to cover chest)
• After that the nurse should apply the four
  techniques Inspection, Palpation, Percussion and
  Auscultation

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• Initial Respiratory Survey (Inspection)
• Observe the patients breathing pattern
• Rate (normal vs. increased/decreased)
• Depth (shallow vs. deep)
• Effort (any sign of accessory muscle use, inspect
  neck)
• Assess the patients color
• Cyanosis
• Normal Respiratory Rates
• Infant 30-60
• Toddler 24-40
• Preschooler 22-34
• School-age child 18-30
• Adolescent 12-16
• Adult 16-20

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• Inspection and assessment of respiration patterns
• Assess the skin and overall symmetry and
  integrity of the thorax.
• Assess thoracic configuration.
• Client must be uncovered to the waist, and in
  sitting position without support.
• Observation of skin may give you knowledge about
  nutritional status of the client.
• Anterior- posterior diameter of thorax in normal
  person less than the transverse diameter (12).
• Assess for abnormality of configuration, e.g.
  pigeon chest, funnel chest, spinal deformities.
• Assess ribs and inter spaces on respiration may
  give information about obstruction in air flow
  e.g. bulging of inter spaces on expiration may be
  from obstruction to air out flow tumor,
  aneurysm, cardiac enlargement

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• Assess pattern of respiration
• Normally men and children breathe
  diaphragmatically and Women breathe
  thoracically or costally.
• Tachypnea respiratory rate over than 20/m for
  adult.
• Bradypnea respiratory rate less than 10/m.
• Palpation palpate areas of chest especially
  areas of abnormalities.
• If clients complains all chest areas must
  palpated carefully for tenderness, bulges, or any
  movements

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• Assess thoracic expansion
• Anterior put your hands over anterior-lateral
  chest and thumbs extended along costal margin
  pointing to xiphoid process.
• Posterior thumbs placed at level of T 10 with
  palms placed on posterior-lateral chest.
• By two ways you feel amount of thoracic expansion
  during quiet and deep breathing, and symmetry of
  respiration between left and right hemi thoraces.
• Assessment of fremitus which is vibration
  perceptible on palpation"
• In subcutaneous emphysema you must palpate the
  tissue, audible cracking sounds are heard these
  sounds are termed Crepitation

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• Percussion of chest
• Done to determine relative amounts of air,
  liquid, or solid material in the underlying lung,
  and to determine positions and boundaries of
  organs.
• Percussion done for posterior and anterior and
  lateral aspects of chest with all directions, and
  with about 5cms intervals.
• Auscultation
• To obtains information about the function of
  respiratory system to detect any obstruction in
  the passages.
• Instruct the client to breathe through the mouth
  more deeply and slowly than in usual respiration
  and then to hold the breath for a few seconds at
  the end of inspiration to increase intrapleural
  pressure and reopen collapsed alveoli.
• Auscultate all areas of chest for at least one
  complete respiration 12 anterior locations and
  14 posterior locations
• Auscultate symmetrically Should listen to at
  least 6 locations anteriorly and posteriorly

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• Breathe sounds are analyzed according to pitch,
  intensity, quality, and relative duration of
  inspiratory and expiratory phases.
• Bronchial breathe sounds are normally heard over
  manubrium of sternum
• If heard over lung tissue indicate pathologic
  condition, these sounds high-pitched loud sounds
  with decrease inspiratory and lengthened increase
  expiratory phases.
• Absent or decreased breath sounds can occur in
• Foreign body.
• Bronchial obstruction.
• Shallow breathing.
• Emphysema

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• Breath Sounds
• Normal breath sounds are distinguished by their
  location over a specific area of the lung and are
  identified as tracheal, vesicular,
  bronchovesicular, and bronchial (tubular) breath
  sounds as the next
• 1. Tracheal
• Very loud, high pitched sound
• Inspiratory Expiratory sound duration
• Heard over trachea in the neck
• 2. Bronchial
• Loud, high pitched sound
• Expiratory sounds gt Inspiratory sounds
• Heard over manubrium of sternum
• If heard in any other location suggestive of
  consolidation

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• 3. Bronchovesicular
• Intermediate intensity, intermediate pitch
• Inspiratory Expiratory sound duration
• Heard best 1st and 2nd ICS anteriorly, and
  between scapula posteriorly
• If heard in any other location suggestive of
  consolidation
• 4. Vesicular
• Soft, low pitched sound
• Inspiratory gt Expiratory sounds
• Major normal breath sound, heard over most of
  lungs

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• Adventitious Breath Sounds
• An abnormal condition that affects the bronchial
  tree and alveoli may produce adventitious
  (abnrmal addtional) sounds. Adventitious sounds
  are divided into two categories discrete,
  noncontinuous sounds (crackles) and continuous
  musical sounds (wheezes) as the next
• 1. Crackles (Rales)
• Discontinuous, intermittent, nonmusical, brief
  sounds. Heard more commonly with inspiration
• Classified as fine or coarse
• Its may associated with Prolonged recumbency
• Crackles caused by air moving through secretions
  and collapsed alveoli and associated with the
  following conditions pulmonary edema, early CHF,
  and pnumonia

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• 2. Wheeze
• Continuous, high pitched, musical sound, longer
  than crackles
• Whistle quality, heard during expiration,
  however, can be heard on inspiration
• Produced when air flows through narrowed airways
• Associated conditions asthma, chronic
  bronchitis, and COPD
• 3. Rhonchi
• Similar to wheezes (subtype of wheeze)
• Low pitched, snoring quality, continuous, musical
  sounds
• Implies obstruction of larger airways by
  secretions
• Associated condition acute bronchitis

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• 4. Stridor
• Inspiratory musical wheeze
• Loudest over trachea
• Suggests obstructed trachea or larynx
• Medical emergency requiring immediate attention
• Associated condition
• inhaled foreign body
• 5. Pleural Friction Rub
• Pleural friction rubs are specific examples of
  crackles. Discontinuous or continuous brushing
  sounds
• It is a loud dry, cracking or grating sound
  indicating of pleural irritation, heard over
  lateral and anterior lung in sitting position
  that heard during both inspiratory and expiratory
  phases
• Occurs when pleural surfaces are inflamed and rub
  against each other
• Associated conditions as pleural effusion,
  Pneumonothorax

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• Medical conditions associated with decreased or
  absent of breath sounds
• Asthma
• COPD
• Pleural Effusion fluid accumulating within the
  pleural space
• Pneumothorax caused by accumulation of air or
  gas in the pleural space.
• ARDS( adult respiratory distress syndrome)
• Atelectasis is defined as a state in which the
  lung, in whole or in part, is collapsed or
  without air entery
• Five Main Symptoms of Respiratory Disease
• Cough Sputum
  Pain
• Breathlessness Wheeze