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Physical Assessment of the Respiratory System
Day 2A
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History
• Physical problems• Function problems• Life style• Smoking• Family Hx• Occupation hx• Allergens / environment• Recreational exposure• Anxiety• S&S
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• The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
A. Low birth weightB. Large for gestational ageC. Preterm birth, but appropriate size for gestationD.Growth retardation in weight and length
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Inspection
• Normal chest– Slight retraction of
intercostal spaces– 2x as wide as deep– Anterior/posterior
diameter• 1:2
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Inspection
• Barrel chest– D/t over inflation of
lungs– anterior-posterior
diameter • 2:2
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Inspection
• Funnel chest– Depression of the
lower portion of the sternum
– Complications• Heart damage• Cardiac output
– Nrs management• Murmurs
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Inspection
• Pigeon chest– Sternum protrudes
outward– anterior-posterior
diameter•
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Inspection
• Scoliosis– Lateral curvature of
thoracic spine– Assessment
• Shoulders elevated?
– Complications• Lung & heart damage• Back problems• Body image
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Quiz?
• How many hours a day should a child wear a brace for treating scoliosis?
A. 8 hrB. 12 hrC. 23 hrD. 24 hr
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Inspection
• Kyphosis– AKA
• Hunchback
– Abnormal curvature of the thoracic spine
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Inspection
• Lordosis– AKA
• Sway-back
– Abnormal curvature of the lumbar spine
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Inspection
• Uniform expansion of the chest– Pneumonia– Pleural effusion– Pneumothorax
• Bulging intercostal spaces– Obstruction– Emphysema
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Inspection
• Marked retraction of intercostal spaces– Blockage
• Shoulder rise• Accessory muscles• Posture
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Inspection: Breathing patterns Rate• Eupnea– Normal– 12-20 / min
• Tachypnea– rate– Pnuemonia, pulm edema, acidosis, septicemia, pain
• Bradypnea– rate– ICP, drug OD
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Inspection: Breathing patterns
Depth• Hyperpnea– depth
• Hyperventilation– depth & rate
• Hypoventilation– depth & rate
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Inspection: Breathing patterns
Depth• Kussmaul's– rate & depth– Assoc. with sever acidosis
• Apneustic– Prolonged gasping I following by short
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Inspection: Breathing patterns
Rhythm• Apnea– Not breathing
• Cheyne-stokes– Varying depth f/b apnea– Death rattles– Death rales
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Inspection: Breathing patterns
Rhythm• Biot’s– rate & depth w/ abrupt pauses– Assoc w/ ICP
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Inspection:
• Trachea– ? Deviation
• Pleural effusion• Tension pneumothorax• Atelectasis
• Color• LOC• Emotional state
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Palpation
• TML– Tenderness (T)– Masses (M)– Lesions (L)
• Sinuses– Palpate below eyebrow &
Cheekbone• Crepitus
– Subcutaneous emphysema– Air leaks into the sub-q tissue
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Percussion
Rational• To determine if underlying
tissue is filled with air or solid material
Procedure• Pt sitting• Tap starting at shoulder• compare rt to lf
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Percussion: results
• Resonance – drum like– Normal
• Hyper-resonance– Too much air– Emphysema
• Flatness / dull– Fluid or solid– Pleural effusion– Pneumonia– Tumor
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Auscultation
Purpose• Asses air flow through
bronchial treeProcedure• Diaphragm of
stethoscope• Superior inferior• Compare rt to lf
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Auscultation: ResultsNormal• Vesicular
– Lung field– Soft and low
• Bronchial– Trachea & bronchi– Hollow
• Bronchovesicular– Mixed– Between scapulae– Side of sternum– 1st & 2nd intercostal space
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Auscultation: Results
Adventitious• Crackles– Rales– air bronchi with
secretions
• Fine crackles– Air suddenly
reinflated
• Course Crackles– Moist
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Auscultation: Results
• Wheezes– Sonorous wheezes
• Deep low pitched• Snoring• > E• Caused by air
narrowed passages• D/t secretions
– Sibilant Wheezes• High pitched• Whistle-like• I & E• Caused by air
narrowed passages• D/t constriction
– Asthma
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Auscultation: Results
• Pleural friction rub– D/t inflammation of
pleural membranes– Grating, creaking– I & E– Best heard
• Anterior, Lower, lateral area
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Auscultation: Results
• Stridor– Crowing – Partial obstruction of
the larynx or trachea
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Quiz?
• A child with difficulty breathing and a “barking” cough id displaying signs associated with which condition?
A. AsthmaB. CroupC. Cystic fibrosisD. Epiglottitis
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Quiz?
• When assessing the lung sounds of a child with asthma, which sound are you most likely to hear?
A. MurmursB. Sonorous WheezingC. Sibilant WheezingD. CracklesE. Pleural friction rub
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Early & late signs of hypoxia
• Anxiety• Bradycardia• Cyanosis• Depressed respirations• Diaphoresis• Disorientation• Dyspnea
• Restlessness• Headache• Agitation• Poor judgment• Retraction• Tachycardia• Tachypnea
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The nurse recognizes which of the following as an early sign of hypoxia?
A. Restlessness, yawning & tachycardiaB. Dyspnea, confusion & bradycardiaC. Bradycardia, hypotension dyspneaD. Dyspnea, restlessness, hypotension
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Dyspnea
• Definition– SOB–SOB, flat affect, BS x 4
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Dyspnea
• Significance– Common with cardiac & resp. disease– Sudden onset – healthy person • Pneumothorax
– Sudden onset ill, post-op or injury • Pulmonary emboli
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Dyspnea
• Orthopnea– Sit up to breath• COPD• CHF
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Dyspnea
• Right ventricle– If chronic airway resistance – pressure – Rt ventricle work – Rt. Vent damage
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Dyspnea
• Nrs Management– Find cause– Give O2
– HOB – Communication• KISS
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Cough
• Definition– To expel air from the lungs suddenly– Irritation of mucous membrane
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Cough
• Significance– Infection– Irritants– Protective mechanism– Dry, irritating• URT
– Cough + chest pain• Pleural or musculoskeletal
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Cough
• Nrs management– Assess– Describe – Directed – Pain control• Splinting
– Infection control– Suppressants / Anti-tussives
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Sputum Production
Definition• Matter discharged
from resp. track that contains mucus and pus, blood, fibrin, or bacteria
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Sputum Production
Significance• Purulent– Thick, yellow/green – Bacteria
• Rusty – Strep or staph
• Thin, mucous – Viral
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Sputum Production
• Pink-tinged– Lung CA– TB
• Pink tinged, profuse, frothy– Pulmonary edema
• Malodorous– Lung abscess
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Sputum Production
Nrs Management• Thick– Hydrate
• water• Nebulizer• Humidifier
• TCDB• No smoking• Oral care• Appetite
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Do You Know?????
What breath sound would you expect to hear on a patient with increased sputum production?
A. VesicularB. CracklesC. Sonorous wheezesD. Sibilant wheezes
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Obtaining a sputum specimen
• Explain– From lungs
• Sterile cup• Deep breath x 3 • Cough deeply• Expectorate • Best time for
specimen collection?– AM
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A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Whichaction should the nurse take first?
A. Ask client to cough sputum into containerB. Have the client take several deep breathsC. Provide a appropriate specimen containerD.Assist with oral hygiene
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Chest pain
Definition• Cardiac or pulmonary
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Chest pain
Significance• CA (late stage)• Pneumonia• Pulmonary embolism• Pleurisy
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Chest pain
• Pleurisy– Inflammation of pleura– Sharp with breath– breath sounds
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What?????
What breath sound would you expect to hear on a patient suffering from pleurisy?
A. CracklesB. Sonorous wheezesC. Sibilant wheezesD. Pleural Friction Rub
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Chest pain
Nrs Management• Assess• Analgesics OK, but…• Position for pain– Affected side– Splint
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Clubbed fingers
Definition• Sponginess of the nail
bed • Loss of the nail bed
angle• Finger tip is round and
bulbous
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Clubbed Finger
Significance• chronic hypoxiaNrs Management• Marker
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Mr. Caveman:
Mr. Caveman enters the ER unconscious following an Automobile accident. The paramedics report that his O2 sats are 86%. You note that Mr. Caveman has clubbed fingers. What does this tell you?
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Hemoptysis
Definition• Expectoration of blood
from the respiratory tract
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Hemoptysis
Significance• Pulm or cardiac• Common causes– Pulm infection– CA of lungs– Pulm. Emboli– Pulm. Infarction– TB
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Hemoptysis
• Hemoptysis– Definition?
• Coughed up blood
– From?• Pulm hemorrhage
– Description• Pink, red, mixed with
sputum
– Blood pH• Alkaline blood
• Hematemesis– Definition?
• Vomited blood
– From?• Stomach / GI
– Description• “Coffee ground”
– Blood ph• Acidic blood
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Hemoptysis
Nrs Management• Determine source• Serious
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Cyanosis
Definition• Bluish coloring of skin
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Cyanosis
Significance• Very late indicator of
hypoxia• Appears when O2 sats
< 85%• NOT a reliable sign of
hypoxia– Esp. with anemia
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Cyanosis
• O2 sat definition– % of hemoglobin
carrying oxygen compared to total # of hemoglobin
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Cyanosis
• NormalBreath 100 O2 molecules 98 cross into blood
Blood: 100 Hgb• O2 SATS– 98%– No cyanosis
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Cyanosis
• HypoxiaBreath 100 O2 molecules 75 cross into blood
Blood: 100 Hgb• O2 SATS– 75%– Cyanosis
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Cyanosis
• Anemic and hypoxicBreath 100 O2 molecules 75 cross into blood
Blood: 75 Hgb• O2 SATS– 100% – No Cyanosis
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Cyanosis
Nrs. Management• Know color of Pt. skin• Assess color of tongue &
lips• Fingernail polish• African-American• Vasoconstriction (cold
weather) peripheral cyanosis