pulmonary assessment for nurses

Respiratory Assessmentfor nurses

Sachika Gaude Nursing Tutor

Global Hospital School Of Nursing

History To know physical and functional problems of the patients.

To identify chief medical problem of seeking help.

To know about risk factors . Psycho social factors affecting health.

Signs and symptoms

Dyspnea : Difficult or laboured breathing

Significance : acute causes more dysnea .

Orthopnea: inability to breathe except in an upright position .

Noisy breathing: narrowing of airway.

Questions to ask How much exertion triggers

shortness of breath? Is there an associated cough? Is dyspnea related to other

symptoms? Sudden or gradual? Time? Position? With rest or exercise?

Relief measures Identify and correct its causes.

Place patient at rest with head elevated.

Severe cases administer oxygen.

Cough Results from either irritants in the air or through infectious process.

Significance : Dry irritative cough: upper respiratory tract infection of viral origin.

Brassy cough :Tracheal lesion

Severe or changing cough : cancer

Chest pain with cough: chest wall infection

Evaluation Character of cough Time

Sputum production Patient who cough long enough produces sputum.

Violent causes bronchial spasm , obstruction and irritation of bronchi and result in syncope.

Significance Purulent or change of colour : infection

Thin , mucoid sputum: viral bronchitis.

Gradual increase of sputum: bronchitis

Pink tinged mucoid: lung tumor Profuse, frothy , pink material: pulmonary edema

Foul smelling: lung abscess

Relief measures If thick , adequate hydration Inhalation of aerosolized solution

Smoking cessation

Chest pain Sharp, stabbing, intermittent Dull, aching and persistent. Felt at the place of pathology.

Significance Lung disease does not always

produce pain as lungs and visceral pleura lacks nerves.

Only parietal pleura has sensory innervations.

Relief Analgesics Splinting Positioning Non steroidal anti inflammatory

drugs.

Wheezing Airway narrowing It is a high pitched , musical sound

heard mainly on expiration. Relief Oral or inhalant broncho dilators.

Clubbing Sponginess of nail bed and loss

of nail bed angle. Chronic hypoxic conditions.

Hemoptysis Expectoration of blood from the respiratory tract.

Sudden onset and intermittent.

Significance Nose / nasopharynx: considerable sniffing with blood

appearing in nose. Lung: Bright red, frothy and mixed with

sputum. Alkaline ph Tickling sensation in throat.

Cyanosis Bluish discolouration of skin. Occurs only when 5g/dl of deoxygenated

hb is present in body

Physical examination

Physical examination Inspection Palpation Percussion Auscultation

Nose and sinuses

Technique: observe for lesions, inflammation, assymmetry .

Tilt head back, and gently push tip of nose:

Mucosa, colour, swelling, exudate, bleeding.

While the head is tilted back,the nurse inspects inferior and middle turbinates.

Palpate frontal and maxillary sinuses.

Palpation of frontal sinuses Using the thumbs , the nurse

applies gentle pressure in an upward fashion at suborbital ridges.

Normal findings Mucosa : more reddish than oral mucosa

Nasal septum : not deviated Turbinates : gray appearance gelatinous and freely movable.

Transillumination test for sinuses

Pass a light through the sinus . If light fails to penetrate , cavity is likely to be filled with fluid or pus.

Pharynx and mouth Technique : instruct the patient to

open mouth wide and take a deep breathe.

Assess anterior and posterior pillars , tonsils, uvula, and posterior pharynx.

Trachea Direct palpation Technique : Place thumb and index fingerof one

hand on either side of trachea just above sternal notch.

Findings : midline behind sternum.

Thorax Note assymmetry Skin for colour Skin turgor

Chest configuration Normal : Antero-posterior: lateral

diameter= 1: 2 Abnormal : i. Barrel chestii. Funnel chest iii. Pigeon chestiv. Kyphoscoliosis

Barrel chest Cause : overinflation of lungs Increase in antero-posterior diameter. The ribs are more widely spaced Intercostal spaces tend to bulge on

expiration.

Funnel chest Depression in lower portion of

the sternum. Compresses the heart and great

vessels leading to murmurs.

Pigeon chest Cause: displacement of sternum. Increase in antero-posterior

diameter.

Kyphoscoliosis Elevation of scapula S-shaped spine Limits lung expansion in thorax

Breathing patterns Normal: 12-18 breaths per min

Bradypnea : slow breathing Tachypnea: rapid breathing Hyperpnea : increase in depth of respiration.

Hyperventilation : an increase in both rate and depth.

Kussmaul’s respiration : Hyperventilation marked by an increase in rate and depth associated with severe diabetic acidosis or of renal origin is called kussmaul’s respiration.

Cheyne’s stokes respiration. It is characterized by alternating episodes of apnea and periods od deep breathing.

Associated with heart failure and damage to respiratory centre.

Other observations Bulging during expiration: obstruction of expiratory airflow.

Marked retraction on inspiration , if asymmetrical : blockage of a branch of the respiratory tree.

Asymmetric bulging of intercostal spaces: hemothorax.

Thoracic palpation Respiratory excursion Tactile fremitus

Respiratory excursion Nurse places thumb along the costal margin , and tells patient to inhale deeply.

Posteriorly, the nurse places the thumbs adjacent to the spinal cord at the level of 10th rib.

Observations : Normal symmetry Decrease in chest excursion in case of splinting due to trauma.

Tactile fremitus Sound generated by larynx travels the bronchial tree to set the chest in resonant motion.

The detection of resulting vibrations on chest wall is called tactile fremitus.

Procedure Patient is asked to repeat words like ninety nine,”eee,eee”, or one two three....

While the nurse’s hands move down the patients thorax.

The vibrations are felt by the palms.

Observations “Air does not conduct sound well, but a solid substance do.”

If lungs is filled by fluids or tissues , there is increased fremitus.

If air is trapped within, there is decreased fremitus.

Thoracic percussion Sets the chest walls and the underlying structures in motion producing audible and tactile vibrations.

Posterior thorax. Thoracic percussion begins with posterior thorax.

Position: sitting , with head flexed forward, and arms crossed on the lap.

Nurse percusses from shoulder tops to down.

Anterior thorax Position: sitting , with shoulder arched back, and hands on the side.

Nurse percusses from supraclavicular area downwards.

Observations Dullness is noted and checked.

Diaphragmatic excursion Patient is instructed to inhale

deeply and hold. Nurse percusses to mark the

dullness with a pen The patient is than told to exhale

and hold that way. Mark dullness with pen. Normal findings: 5-7 cm.

Thoracic auscultation

Normal breathe sounds Vesicular sounds : Location : entire lung field except over upper sternum and between scapulae.

Intensity : soft Pitch: low pitched Duration: inspiratory lasts longer than expiratory

Bronchial sound Location : heard over trachea.

Intensity : loud Pitch : high pitched Duration : expiratory lasts longer than inspiratory sound.

Broncho-vesicular

Location: between scapul;ae on either sides of sternum

Intensity : intermediate Pitch: intermediate Duration: both are equal.

Tracheal Location :in the neck Intensity : very loud Pitch: high pitched Duration: inspiratory and expiratory sounds.

Abnormal sounds Crackles : soft , high –pitched , dis continous popping sounds that occur during inspiration.

Wheezes Sonorous wheezes: deep low pitched rumbling sounds heard primarily during expiration

Sibilant wheezes : continous , musical , high-pitched, whistle-like sound

Friction rubs Hard crackling sounds.

BIBLIOGRAPHY BRUNNER AND

SUDDHARTH’S ,TEXTBOOK OF MEDICAL SURGICAL NURSING. Pg 382-392 .9th Edition .

Pictures taken from GOOGLE source

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