NURS 2240: Review A&P of respiratory system

Transcription

1 NURS 2240: Review A&P of respiratory system Objetives: Identify landmarks used in assessment of respiratory system Complete a focused history in the lab using specific examples of respiratory problems Demonstrate physical assessment of the respiratory system using inspection, palpation, auscultation Differentiate normal from abnormal findings Describe developmental, psychosocial, cultural, & environmental findings in physical assessment of the respiratory system Describe signs & symptoms (S&S) of COPD (differentiate bronchitis & emphysema) Describe S&S of asthma Describe S&S of pneumonia Use critical thinking in selected simulations related to focused history & physical assessment of the respiratory system Structures of Respiratory System

2 Respiratory System Primary function: Exchange of gases in the body- O2 & CO2 Physiology of Respirations Mechanical Process: Pulmonary ventilation- inspiration & expiration- exchange of air between lungs & atmosphere Physiological Process: External- exchange between alveoli & blood Internal- exchange between systemic capillaries and tissue Cellular- exchange within the cell Oxygen Exchange

3 Respiratory Cycle Eupnea: Regular, even, rhythmic pattern of breathing Dyspnea: Change in pattern producing shortness of breath or difficulty breathing Orthopnea: difficulty breathing lying flat Paroxysmal nocturnal dyspnea: waking at night with sudden shortness of breath Health History History of respiratory disease e.g. COPD, asthma Presence of respiratory symptoms e.g. cough, sputum, shortness of breath Identification of risk factors e.g. smoking, family history Specific Respiratory Hx Includes: Is there a pattern? Is there a trigger? Current medications Client s management strategy/treatment plan Family supports Length of time since diagnosis Client s attitude toward illness and management Bony Landmarks - Provide exact location for assessment & documentation of findings Anterior Thorax, Lt Lateral view

4 Posterior Thorax Lines of the Anterior Thorax Lines of the Lateral Thorax Lines of the Posterior Thorax Lobes of the Lungs- Posterior View

5 Lobes of the Lungs- Lt. Lateral View Lobes of the Lungs- Rt. Lateral View

6 Physical Assessment Approach: *Vital signs*, O2 sat, consider pain, inspection, palpation, percussion & auscultation Position: Sitting Assessment tools: gown, drape, stethoscope If client can not lie down, then a semi-fowler s or fowler s or side lying position may have to be used. Use a systematic approach and proceed from apex to the base, comparing one side to the other Vital Signs: Elevated temperature: infection, pulmonary embolism Respirations: rate, depth & rhythm can be affected by cardiac, metabolic neurological, emotional disorders and medications (see text p ) Oxygen saturation: pulse oximetry, blood gases Rate: Tachypnea (increased rate): hypoxia, metabolic acidosis, anxiety, fear, pain, sepsis, fever, neurological control Bradypnea (decreased rate): sedation, hypercapnea, compromised neurological control & metabolic alkalosis Depth & Rhythm: Shallow respirations: habit; fatigue; metabolic alkalosis; ascites; restrictive lung disease; chest, abdominal or pleuritic pain; neurological disorders Increased depth: anxiety, neurological or metabolic disorders Abnormal Patterns: Hyperventilation: rapid, deep respirations; can be with fear or exertion; associated with metabolic acidosis (Kussmaul s respirations: with diabetic ketoacidosis or lactic acidosis); CO2 is blown off, causing alkalosis Cheyne Stokes: rapid deep inspirations followed by gradual ceasing & apnea (drug induced, heart or renal failure, brain damage or impending death) Biot s: irregular in rate & depth alternates with irregular periods of apnea seen in respiratory depression, damage to medullary respiratory centre or head injury (indicating increased ICP)

7 Explain procedure Inspection Observation of skin colour Inspect anterior & posterior thorax for: Symmetry Configuration Palpate Anterior Chest Respiratory rate Prolonged expiration phase (indicates airway narrowing e.g. asthma) Palpation of Posterior Thorax

8 Palpate for Fremitus Fremitus: vibration on chest wall when client speaks Strongest over trachea, diminishes over bronchi, nonexistent over alveoli in lungs Place hands while asking client to repeat 99 in clear loud voice Use palmar or ulnar surfaces, one or both hands Palpate for Fremitus Diminished Fremitus: Can be caused by thick chest wall or soft voice normal finding Fluid or air trapped outside the lung Excess air trapped in lungs Emphysema Pneumothorax (on affected side) Asthma Pleural effusion (on affected side) Increased Fremitus Fluid inside the lungs, called consolidation Infection (e.g. pneumonia) Tumour

9 Palpate for Tactile Fremitus Palpate for Chest Expansion

10 Palpate for Crepitus Crepitus is a coarse, crackling sensation palpable over the skin surface, crunchy feeling, caused by air leaking from the lung into subcutaneous tissue Percussion used to gather information about abnormal findings *Not commonly used in RN practice Auscultating Posterior Thorax Normal Breath Sounds: Bronchial: high-pitch; loud; inspiration < expiration (inspiration sounds shorter time than expiration) than ; heard over trachea & larynx; harsh, hollow tubular Bronchovesicular: moderate pitch & amplitude, inspiration = expiration, heard over main bronchi Vesicular: low-pitched, soft, inspiration > expiration, sounds like rustling of wind in trees, heard over most of lung fields p. 453 text

11 Auscultation of voice sounds findings in absence of respiratory problems Bronchophony: auscultating while client says 99, sound is muffled; abnormal if clearly heard Egophony: auscultating while client says E - sounds like eeee ; abnormal if sound changes to aaaaa Whispered pectoriloquy: auscultate while client whispers 1, 2, 3 - sounds should be indistinguishable; abnormal if distinguishable Auscultation of voice sounds findings if patient has respiratory problems Bronchophony, egophony & whispered pectoriloquy are found with increased consolidation or compression as with lobar pneumonia, atelectasis or tumour Assessed if patient has other findings such as increased breath sounds over the lung fields (advanced assessment techniques) Auscultate Anterior Chest Auscultate Posterior Chest

12 Normal & Abnormal Breath Sounds

13 Adventitious Sounds p. 469 text Crackles (rales): Discontinuous, high pitched sounds heard during inspiration, or loud low-pitched bubbling and gurgling sounds that start in early inspiration not cleared by coughing Air bubbling through secretions in alveoli or from collapsed alveoli popping open Sound is similar to that of rolling a strand of hair between your fingers near you ear or moistening your thumb and index finger and separating them near your ear (fine crackles), or Velcro opening (coarse crackles) Abnormal breath sounds are any sounds that are diminished or misplaced Rales/crackles result from air bubbling through moisture in alveoli or from collapsed alveoli popping open. You tend to hear crackles at the end of inspiration, in the terminal bronchioles and alveoli Rhonchi/Wheezes caused by the narrowing of an airway by spasm, inflammation, mucous secretions or a solid tumor. The pitch is determined by the relative tightness of the airway. They are most often heard during expiration. Rhonchi can be cleared with coughing at times so it is good to ask the client to cough before auscultating again. With infants it may be difficult to clear their chests and that is why they may need suctioning. Wheezes (rhonchi): Predominate in expiration; caused by narrowing of an airway by spasm, inflammation, mucous secretions or a solid tumor. Pitch determined by relative tightness of airway. May also be heard during inspiration. May be cleared with coughing at times, ask client to cough before auscultating again. Described as musical, multiple or single toned. p.470 text Stridor: Results from an upper airway obstruction, a partial obstruction or spasm of trachea or larynx. Usually acute respiratory distress! Grunting: Heard during expiration and results from air in the lungs- prevents alveolar collapse This is an emergency! Friction rub: Occurs when pleural layers of lung rub together; coarse, low-pitched & grating Friction rub results from the rubbing together of the parietal and visceral layers of an inflamed pleura which produces a high-pitched grating or squeaking sound. The rub may be heard during inspiration and expiration and is not affected by coughing Transmission of voice sounds through healthy lung tissue is normally muffled. Abnormal vocal sounds: Bronchophony: abnormal clarity of spoken word (through stethoscope), normally muffled, usually indicative of consolidated lung Egophony: eee sounds like aay, normally eee (Egophony sounds like a goat s voice. You would ask the client to say eee and if the eey sounds like an ay then they have egophony) Whispered pectoriloquy: 1,2,3 whispered should sound indistinct, not distinct (Whispered pectoriloquy would ask the client to whisper one, two, three and they should sound like puff, puff, puff if they are clear then they have pectoriloquy) These 3 often occur due to consolidated lung tissue, pulmonary edema or pulmonary hemorrhage

14 Assess for: Increased rate, wheezing Skin colour changes (Cyanosis, dusky, gray) Diaphoresis Nare flaring Accessory muscle use Anxiety Tripod positioning Grunting To minimize risk of progression to respiratory arrest The nurse is the key factor here! Common Abnormalities Pulmonary embolus: Abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia Pleural Effusion: Collection of fluid in pleural space; most often caused by heart failure, pneumonia, cancer, TB and pulmonary embolism Asthma: Reactive airway disease, resulting in inflammation & airway obstruction During an attack, client dyspneic with marked respiratory effort Nasal flaring, pursed-lip breathing, use of accessory muscles Cyanosis (late development) Auscultation reveals wheezing, particularly on expiration (absence of wheeze can be ominous no air movement) Coughing & chest tightness Classic Presentation Cough Dyspnea Wheezing

15 Clinical Manifestations Dehydration Pulse oximetry low Sats ABG s some degree of hypoxemia, increased CO2 in severe cases signals impending respiratory failure Status asthmaticus severe, life-threatening complication Common Abnormalities Bronchitis: Excessive mucous production with persistent cough Emphysema: Permanent enlargement of alveoli with destruction of alveolar wall Critical Concept: High flow (40-100%) oxygen can cause respiratory arrest High level of carbon dioxide and low oxygen level is responsible for the drive for breathing Clinical Manifestations of Bronchitis Productive cough, copious sputum with progression of disease Decreased exercise tolerance Shortness of breath, audible crackles/wheezes Prolonged expiration May have barrel chest Chronic hypoxemia & hypercapnia Pulmonary infections common Elevated hematocrit, polycythemia, abnormal blood gases Pulmonary hypertension, cor pulmonale common right sided ventricle enlargement with dependent edema Cyanosis ( blue bloaters ) Clubbing of fingers Clinical Manifestations of Emphysema Progressive dyspnea on exertion; eventually dyspnea at rest Client often thin Loss of lung normal elastic recoil, air trapping Known as pink puffers, reddish complexion & hyperventilation Prolonged expiration, use of accessory muscles Anteroposterior diameter of the chest is enlarged, chest has hyperresonant sounds on percussion Clinical Manifestations of Emphysema CXR shows hyperinflation, flattened diaphragm Auscultation: decreased breath sounds *Client often leans forward with arms braced on knees to support the shoulders & chest for breathing, classic tripod position

16 Asthma Asthma/COPD clinical differences Onset <40 Not caused by smoking Sputum rare Allergies often Spirometry normalizes Exacerbations then normalizes COPD Onset >40 Long term smoker Sputum frequent Allergies rare Spirometry never normalizes Disease progressively worsens Pulmonary Function Studies Pulmonary function studies FEV 1 /FVC < 70% Ratio of forced expiratory volume in 1 sec to forced vital capacity (evaluates air flow obstruction) Common Abnormalities Pneumonia: Infection of the lung tissue Pneumothorax: Complete or partial collapse of lung Cancer of the larynx/lung Clinical Manifestations of Pneumonia

17 Clinical Manifestations of Lung Cancer Insidious onset Cough, change in cough quality Starts as dry, persistent cough Frequently ignored Wheezing, dyspnea, fatigue, hoarseness Hemoptysis Repeated unresolved infections (e.g. pneumonia) Pain (late manifestation) Weakness, anorexia, wt. loss (non-specific) Clinical Manifestations of Larynx Cancer Hoarseness > 2weeks Cough or sore throat, prolonged Pain/burning in throat esp.with hot liquid or citrus juice Later S&S: dysphagia, dyspnea, unilateral nasal discharge/obstruction Wt. loss, cervical lymphadenopathy, pain radiating to ear with metastases Great Resources Jarvis & Bates videos on Thorax and Lung Assessment (COPD) (asthma) facetious