The Goal of the Respiratory Assessment. Two Parts of the Respiratory Assessment

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1 The Respiratory System Respiratory Assessment of the Adult Patient Mary Douglas, MSN, RN Nurse Educator Minneapolis VA Health Care System Respiratory system: moves oxygen into the body and carbon dioxide out. The Upper Airway Everything above the cords nose, mouth, posterior pharynx The Lower Airway Below the cords from the trachea to the alveoli The Alveoli Terminal Air Sacks wrapped in capillaries Respiratory System Gas exchange occurs between the alveoli and capillaries. Oxygen diffuses into the blood for cellular metabolism Carbon dioxide waste from cellular metabolism diffuses out of the blood and is exhaled Breathe IN Breathe OUT The Goal of the Respiratory Assessment To identify problems in the normal function of the respiratory system Two Parts of the Respiratory Assessment Interview and Medical History Physical Examination To find ways to fix the problem or at least lessen the symptoms 1

2 Interview and Medical History Review of patient s present illness Review of patient s general respiratory status Ask about cough, wheezing, dyspnea Gather information regarding smoking history Review of patient s general health status Note: The interview is a great time to evaluate general appearance and respiratory distress Assessment of Cough Chronic vs Acute Acute: lasting less than 3 weeks usually due to resp. tract infection Chronic: more than 8 weeks may be caused by GERD, asthma, chronic bronchitis, COPD, cancer, tuberculosis Cough Timing Coughing at night may indicate GERD, asthma, cardiac Coughing in the morning seen with chronic bronchitis Smokers Cough After eating may in swallowing issue increase risk of aspiration Dry vs Productive Productive cough indicates infection or inflammation Dry cough can be associated with pulmonary fibrosis Sputum Production (EWWWWWWWW) How long have you been coughing up sputum? Acute VS chronic process What is the color of sputum? Pink tinged/frothy Purulent (thick, white, yellow, green) Clear to mucoid sputum Wheezing Acute vs Chronic acute wheezing seen in asthma, CHF/Pulmonary edema chronic wheezing seen in COPD, GERD Dyspnea A/K/A SOB Characteristics: acute vs. chronic Orthopnea or paroxysmal nocturnal dyspnea? Are there associated factors? Time of day, season, environmental, exertion Have patient rate dyspnea on a scale of 0 10 Helps identify severity of dyspnea Smoking History pack years cessation materials/aids don t get preachy! 2

3 General Appearance General Appearance Signs of Acute Respiratory Illness Inability to speak in full sentences Retractions Nasal flaring Tri pod ing Signs of Chronic Respiratory Illness Cyanosis Clubbed fingers or toes Cachexia Barrel chest Physical Examination Inspection Palpation (touching) Percussion (tapping) Auscultation (listening with a stethoscope) Inspection Facts and Instincts Objective information Age Height Weight Level of Consciousness Vital Signs Physical Inspection Subjective information General appearance Respiratory distress Level of Consciousness Vital Signs Alert Oriented to time, place and person Sleepy Arousable Unconscious Depressed level of consciousness may be a sign of poor cerebral oxygenation Depressed level of consciousness may be a sign of acute hypercarbia (increased CO 2 level) Temperature Heart Rate Respiratory Rate Blood Pressure Oxygen Saturation 3

4 Heart Rate Respiratory Rate Tachycardia Fear/anxiety Fever Physiologic distress of many kinds Cardiac, respiratory, etc Bradycardia Hypothermia Profound hypoxemia Medication side effect Tachypnea (high rate) Anxiety Hypoxia or hypercarbia Fever Metabolic acidosis Bradypnea (low rate) Head injury Hypothermia Narcotics Ketoacidosis, lactic acidosis, renal failure Oxygen Saturation Normal is % Some patient s are chronically low 88 92% Look for other signs of chronic respiratory illness to assess acute vs. chronic low saturation digital clubbing, barrel chested, etc Physical Inspection Start at the Head Cyanosis around the lips Pursed lip breathing Nasal flaring Oral mucosa and posterior pharynx Cyanosis Pursed Lip Breathing 4

5 Nasal Flaring And Move on to the Neck Position of the trachea Jugular Venous Distension The Trachea Should be Midline Deviated trachea could be a sign of pneumothorax Deviation also occurs in some patient s with Scoliosis Jugular Venous Distension Heart Failure or Fluid Overload Barrel Chest Emphysema And of Course the Chest. 5

6 Thoracic Configuration Thoracic Configuration Pectus Carinatum (Pigeon Chest) Pectus excavatum (Funnel Chest) Kyphosis Scoliosis Palpation Thoracic Expansion Skin and Subcutaneous Structures Percussion tapping over lung fields Used to evaluate underlying structures Not used routinely Used where specific conditions are suspected i.e. Pneumothorax Auscultation The fine art of listening to breath sounds or One Man s wheezes are Another Man s Rales. Auscultation: What am I Listening For? Intensity How loud or soft Symmetry Is it equal on both sides Pitch High or Low Abnormal Breath Sounds Where are they located 6

7 Normal Breath sounds Where do I Listen? Can vary depending on location Tracheal = Harsh and loud, over the trachea Bronchovesicular = Moderate in pitch and volume, over the sternum Vesicular = Low and soft, over the peripheral lung areas Inspiration > Expiration Abnormal Breath Sounds Crackles Wheezes Crackles Created by the popping open of alveoli that are filled with fluid or collapsed Generally heard on inspiration Rhonchi Stridor Wheezes High pitched whistling sound Usually produced from a narrowing of the airways Usually heard on expiration but can sometimes be heard on inspiration Rhonchi Loud, coarse, rattling sound Usually caused by secretions in the large airways 7

8 Stridor Very high pitched inspiratory sound Heard over the trachea Usually suggests an upper airway obstruction Laryngeal edema, foreign body, aspiration Acute stridor with respiratory distress is a medical emergency Other Helpful Assessment Tools Imaging X ray, CT Scans, Perfusion Studies Diagnostic Studies Labs, Pulmonary Function Studies, Bronchoscopy Chest X Ray Pneumonia Useful for diagnosis of pneumonia, heart failure / pulmonary edema, and pneumo/ hemothorax/pleural effusion Useful for evaluating placement of lines tubes and airways Pulmonary Edema Pneumothorax 8

9 Hemothorax/Pleural Effusion Chest CT Better at localizing pneumonias, atelectasis, effusions, etc Can be used to diagnosis pulmonary embolism Pleural Effusion Lab tests CBC Metabolic Panel Microbiology Blood Gases Blood Gas Analysis Arterial Blood Gas Normal ph PaCO PaO Bicarbonate (HCO 3 )

10 Analyzing ABGs: Primary Acid Base Disturbances Acidosis ph < 7.35 Accumulation of too much acid or loss of base Alkalosis ph > 7.45 Accumulation of too much base or loss of acid Analyzing ABGs cont. Is the CO 2 normal? If < 35 = alkalotic >45 = acidic Is the HCO 3 normal? If bicarb < 22 = acidotic >26 = alkalotic Putting it All Together ph & PaCO 2 = respiratory acidosis ph & PaCO 2 = respiratory alkalosis Example Ph 7.32 PaCO2 50 PaO2 56 HCO3 24 ph & HCO 3 = metabolic acidosis ph & HCO 3 = metabolic alkalosis Example Ph 7.50 PaCO2 30 PaO2 93 HCO3 24 References 3M (n.d.). Heart & Lung Sounds: Audio clips to sharpen your auscultation skills. Retrieved from Littmann CA/stethoscope/littmann learning institute/heart lung sounds/ Dugdale, D. (2015, November 18). Gas exchange Health Video: MedlinePlus Medical Encyclopedia. Retrieved from 9.htm Kaufman, D. (n.d.). American Thoracic Society Interpretation of Arterial Blood Gases (ABGs). Retrieved from resources/criticalcare/clinical education/abgs.php Mayo Clinic (2013) Hypoxemia (low blood oxygen). Retrieved from n/sym

11 References continued Nettina, S. (2014). Respiratory Function and Therapy. In Lippincott manual of nursing practice (10th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Sommers, M. S. (2011). Color Awareness: A Must for Patient Assessment. AM Nurs Today. 6 (1). Retrieved from Weinberger, S., & Silvestri, R. (2011). Evaluation of subacute and chronic cough in adults. UpToDate. Retrieved from ofsubacute and chronic cough inadults?source=search_result&search=treatment of subacute andchronic cough in adults&selectedtitle=3~150 11

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