The RespiratoryThe Respiratory SystemSystem

Thorax and LungsThorax and Lungs

Rachel S. Natividad, RN, MSNRachel S. Natividad, RN, MSN

Lobes and LandmarksLobes and Landmarks

Performing the Assessment: Performing the Assessment: Subjective DataSubjective Data ROS -Ask about dyspnea, cough, chest ROS -Ask about dyspnea, cough, chest

pain (PQRST format)pain (PQRST format) Short interview sessions if resp. Short interview sessions if resp.

distress / tiring easilydistress / tiring easily Past health historyPast health history

– AllergiesAllergies MedsMeds– ImmunizationsImmunizations Travel historyTravel history– Childhood illnessChildhood illness Family historyFamily history– HospitalizationsHospitalizations TB, smokingTB, smoking

Psychosocial Assessment Psychosocial Assessment

Assessment Cont.: Assessment Cont.: Objective DataObjective Data

Inspection…Inspection…

……Always first!!!Always first!!!

Assessment begins….Assessment begins….

The moment you see The moment you see the patient.the 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 (con’t)(con’t) InspectionInspection Color, Size and shape & Color, Size and shape &

symmetry of chest, any lesions or symmetry of chest, any lesions or scarsscars

– AnteriorAnterior Lateral Lateral PosteriorPosterior

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

Increased AP:Transverse Increased AP:Transverse DiameterDiameter

Costal angle >90 Costal angle >90 degreesdegrees

1:2

2:1

Barrel ChestBarrel Chest

Asymmetrical chestAsymmetrical chest

Scoliosis

Normal BreathingNormal Breathing

Intercostal Spaces and Intercostal Spaces and MusclesMuscles

Retractions

Focused Assessment Focused Assessment Cont…Cont…

Resp. rate and depthResp. rate and depth Pattern of respiration – regular Pattern of respiration – regular

rhythmrhythm Abnormal patterns Abnormal patterns

– HyperventilationHyperventilation– Tachypnea vs. bradypneaTachypnea vs. bradypnea– Stertorous (Noisy)Stertorous (Noisy)

Looking at related Looking at related structuresstructures

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 Focused Assessment Cont.: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) Sounds (T 11-2) p.132p.132

Continuous soundsContinuous sounds WheezesWheezes

– SibilantSibilant– Sonorous Sonorous

(Rhonchi)(Rhonchi)

Discontinuous soundsDiscontinuous sounds Crackles (Rales)Crackles (Rales)

– FineFine– CourseCourse– *Atelectic crackles*Atelectic crackles

– Pleural friction rubPleural friction rub

Wheezes (Continuous)Wheezes (Continuous)Sibililant wheezeSibililant wheeze

high-pitched musicalhigh-pitched musical sounds heard sounds heard first when a patient first when a patient exhalesexhales

Partial blockage in airflowPartial blockage in airflow

Sonorous wheezeSonorous wheeze (rhonchi) (rhonchi)

low pitched – low pitched – snoringsnoring, rattling sound , rattling sound heard primarily when the pt heard primarily when the pt exhalesexhales

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

CracklesCrackles (Discontinuous) (Discontinuous)•FINE /COURSEFINE /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

•Pleural friction rub – pericarditis

Abnormal BreathAbnormal Breath Sounds Sounds

DiminishedDiminished breath breath soundssounds

AbsentAbsent breath sounds breath sounds

Interpreting what you Interpreting what you hear…hear…

Note whether the sound occur Note whether the sound occur during inhalation or exhalation, or during inhalation or exhalation, or both.both.

Assessment Guide: Gas Assessment Guide: Gas ExchangeExchange

– 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 Describe: clear, rhonchi, inspiratory/expiratory wheezes, crackleswheezes, crackles

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

Cough: present/not presentCough: present/not present

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

Sputum: large amount, thick yellow; moderate pink Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.frothy 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 Oropharyngeal Suctioning: Describe- moderate amount thick tan secretionsthick tan secretions

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