The RespiratoryThe Respiratory SystemSystem

Thorax and LungsThorax and Lungs

Rachel S. Natividad, RN, MSN, NPRachel S. Natividad, RN, MSN, NP

Lobes and LandmarksLobes and Landmarks

Performing the Assessment: Performing the Assessment: Subjective DataSubjective Data

ROS -Ask about dyspnea, cough, ROS -Ask about dyspnea, cough, chest pain (PQRST format)chest pain (PQRST format)

Short interview sessions if resp. Short interview sessions if resp. distress / tiring easilydistress / tiring easily

Assessment begins….Assessment begins….Inspection…Inspection………Always first!!!Always first!!!

The moment you see the The moment you see the patient.patient.

What position is most What position is most comfortable for him?comfortable for him?

Does he appear relaxed, Does he appear relaxed, anxious, uncomfortable?anxious, uncomfortable?

Is he having any trouble Is he having any trouble breathing?breathing? Tripod Position

Focused Assessment Focused Assessment

Inspection-cont.Inspection-cont. Color, Size and shape & symmetry of Color, Size and shape & symmetry of

chest, any lesions or scarschest, any lesions or scars

AnteriorAnterior Lateral Lateral PosteriorPosterior

Altered size/shape:Altered size/shape:Barrel ChestBarrel Chest

Increased Anteroposterior:Transverse DiameterIncreased Anteroposterior:Transverse Diameter

1:2

1:1

Barrel ChestBarrel Chest

Asymmetrical chestAsymmetrical chest

Fractured ribs/ flail Fractured ribs/ flail chest chest

PneumothoraxPneumothorax atelectasisatelectasis paralysis of the paralysis of the

diaphragmdiaphragm Spinal deformitySpinal deformity

Scoliosis

Intercostal Spaces and Intercostal Spaces and MusclesMuscles

Retractions

Focused Assessment Cont…Focused Assessment Cont…

Resp. rate (per min.) and depth (shallow, Resp. rate (per min.) and depth (shallow, even, deep)even, deep)

Normal pattern of respiration – regular Normal pattern of respiration – regular rhythmrhythm

Relating to other systems…Relating to other systems…

Skin: cyanosis, pallorSkin: cyanosis, pallor

Nails: ClubbingNails: Clubbing Spongy nail matrix and nail angle of Spongy nail matrix and nail angle of

greater than 160 degreesgreater than 160 degrees

Focused Assessment Cont.:Focused Assessment Cont.:PalpationPalpation

Check for tendernessCheck for tenderness(normally nontender)(normally nontender)

Crepitus – SQ air Crepitus – SQ air pocketspockets

Tactile fremitus – Tactile fremitus – increased with fluid increased with fluid accumulationaccumulation

AbnormalAbnormal if tumor, if tumor, fractured ribs, chestfractured ribs, chesttubes, wound site, fluidtubes, wound site, fluid

Focused Assessment:Focused Assessment:AuscultationAuscultation

Normal Breath SoundsNormal Breath Sounds

Adventitious/AbnormalAdventitious/AbnormalBreathBreath Sounds (T 11-2) p.132 Sounds (T 11-2) p.132

Continuous soundsContinuous sounds WheezesWheezes

SibilantSibilant Sonorous Sonorous

(Rhonchi)(Rhonchi)

Discontinuous soundsDiscontinuous sounds CracklesCrackles (Rales) (Rales)

FineFine CourseCourse *Atelectic crackles*Atelectic crackles StridorStridor Pleural friction rubPleural friction rub

Wheezes (Continuous)Wheezes (Continuous)Sibililant wheezeSibililant wheezeHeard 1Heard 1stst in expiration in expiration high-pitched musicalhigh-pitched musical sounds sounds

Partial blockage in airflowPartial blockage in airflow

Sonorous wheezeSonorous wheeze (rhonchi) (rhonchi)Heard primarily in expirationHeard primarily in expiration low pitched – low pitched – snoringsnoring, rattling , rattling

sound sound

Air passes through large Air passes through large airways filled with fluid/ airways filled with fluid/ secretions secretions

Interpreting what you Interpreting what you hear…hear…

Is the sound is continuous or Is the sound is continuous or discontinuous?discontinuous?

Is the sound occur during inhalation Is the sound occur during inhalation or exhalation, or both?or exhalation, or both?

CracklesCrackles (Discontinuous) (Discontinuous)

•FINE vs. COURSEFINE vs. COURSE

•Caused by collapsed or Caused by collapsed or fluid-filled alveoli popping fluid-filled alveoli popping openopen

• usually heard in usually heard in the lung bases the lung bases during during inhalationinhalation

•Atelectic crackles•Sridor•Pleural friction rub – pericarditis

Abnormal BreathAbnormal Breath Sounds Sounds

DiminishedDiminished breath breath soundssounds

AbsentAbsent breath sounds breath sounds

Assessment Guide: Gas ExchangeAssessment Guide: Gas Exchange RespiratoryRespiratory

• Rate: 18 resp/minRate: 18 resp/min• Depth: deep, even, shallowDepth: deep, even, shallow• Effort: labored, unlaboredEffort: labored, unlabored

Breath SoundsBreath Sounds

• Describe: clear, rhonchi, inspiratory/expiratory wheezes, Describe: clear, rhonchi, inspiratory/expiratory wheezes, cracklescrackles

• Location: all lobes, throughout lung fields, LLL, RUL/RML, Location: all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat.lower lobes bilat.

• Cough: present/not presentCough: present/not present

• Describe: productive, moist, nonproductiveDescribe: productive, moist, nonproductive

• Sputum: large amount, thick yellow; moderate pink frothy Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.sputum, sml. Amt. thin clear sputum.

Interventions in use:Interventions in use: Position, Turn, Cough, Deep breathePosition, Turn, Cough, Deep breathe

O2 Method: nc, venti mask, rebreathing maskO2 Method: nc, venti mask, rebreathing mask Flow rate: 2L/min; 3l/minFlow rate: 2L/min; 3l/min Humidity: yes/noHumidity: yes/no

Pulse Oximeter: continuous, spot monitoringPulse Oximeter: continuous, spot monitoring

Incentive Spirometer: in use, n/aIncentive Spirometer: in use, n/a Time used: 10 am, 11 am, 1 pm, 3 pmTime used: 10 am, 11 am, 1 pm, 3 pm Volume: 500 cc, 500 cc, 600 cc, 800 ccVolume: 500 cc, 500 cc, 600 cc, 800 cc

Oropharyngeal Suctioning: Describe- moderate amount thick tan Oropharyngeal Suctioning: Describe- moderate amount thick tan secretionssecretions

Med List: Albuterol inhaler, Prednisone, TheophyllineMed List: Albuterol inhaler, Prednisone, Theophylline