skill assessment: pulmonary
Post on 23-Apr-2022
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AnnneMarie Palatnik MSN, APN, ACNS-BC AVP Clinical Learning and Academic Affiliations
Center for Learning Virtua Health
Skill Assessment: Pulmonary
Disclosures
I have no conflict of interest related to this presentation to disclose.
Objectives
Discuss pulmonary anatomy and physiology as it relates to physical assessment.
Identify normal and abnormal breath sounds.
Evaluate case presentations of patients with respiratory compromise.
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Overview
Respiratory Anatomy & physiology
Assessment
Acute respiratory distress syndrome
Pulmonary embolism
PULMONARY ANATOMY & PHYSIOLOGY
The Respiratory Tract
Upper respiratory tract Nostrils & nasal passages Sinuses & nasopharynx Oropharynx & laryngopharynx Larynx
Lower respiratory tract Conducting airways Acinus
Lungs Pleura & pleural cavities
Thoracic cavity Mediastinum Thoracic cage Anterior thoracic cage
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Pulmonary Anatomy
Pulmonary Circulation
Pulmonary artery
Arterioles
Venules
Pulmonary vein
Respirations External respirations
• Ventilation
• Pulmonary perfusion
• Diffusion
Internal respirations
RESPIRATORY ASSESSMENT
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Health History
Chief Complaint Dyspnea Orthopnea Cough Sputum Wheezing Chest pain Other signs & symptoms
History Patient & Family history\
• Operations • Respiratory diseases: pneumonia, tuberculosis
Smoking Allergies Environmental exposure to irritants
• Asbestosis • Mining, construction, or chemical manufacturers
Performing a Respiratory Physical Assessment
Inspection
Auscultation
Palpation
Percussion
Inspection
Inspecting the chest Back then front
Symmetry
Costal angle
Respiratory rate & pattern
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Inspection continued
Inspecting related structures Skin color & nailbeds
Mucous membranes
Clubbed fingers
Palpation the Chest
Crepitus
Pain
Tactile fremitus
Measure the symmetry
Patient position
Sitting upright or lying with HOB 45 to 60⁰
Unaware of “the counting”
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Inspection
RR for 1 minute
Note the depth
Shallow, normal, or deep
Pattern
Regularity and work
Normal – effortless and quiet
Abnormal – labored – accessory muscles, dyspnea, pursed lip breathing, nasal flaring
Characteristics
Slow, fast, shallow – inadequate ventilation or poor gas exchange
Cheyne-Stokes: irregular breathing pattern followed by short period of apnea
Kussmaul’s or air hunger: deep, rapid respirations (seen with DKA)
AP diameter
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Abnormal findings
Kyphosis Scoliosis
Tripod position Use of accessory muscles/retractions (a, b)
Skin – check for cyanosis
Central cyanosis – oral mucosa
Peripheral cyanosis – nail beds
Both may be result of hypoxemia, but peripheral may just be peripheral vasoconstriction
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Clubbing - thickening of finger/toe nails resulting in bulbous ends of fingers and toes
Commonly associated with chronic cardiac disease and respiratory disease
Mucous
Green, yellow, creamy sputum that is purulent – infection
White frothy or pink – pulmonary edema
Blood (frank blood hemoptysis) – could indicate carcinoma, pulmonary embolism, or trauma
Black specks – cigarette smoker or possible smoke inhalation
Palpation
Crepitus Crepitus
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Percussing the Chest
Percussion Sequence
Auscultation
Patient position Lying, sitting, standing
Remove clothing
Have patient breath through mouth
Stethoscope Diaphragm: press firmly against skin
Listen for a full inspiration & expiration
Classify breath sounds Intensity
Location
Pitch
Duration
Characteristics
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Auscultate
Normal – quiet and no noise
Use systematic approach
Ask patient to take deep breath through mouth
Listen for one complete respiratory cycle
Compare side to side from apex distally to the base of lungs
Abnormal Breath Sounds
Absent
Diminished
Crackles Fine
Coarse
Wheezes
Low-pitched wheezes (AKA Sibilant Rhonchi)
Stridor
Pleural friction rub
Auscultation Sequence
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Qualities of Normal Breath Sounds
Breath Sound Quality Inspiration-
expiration ratio
Location
Tracheal Harsh, high-
pitched
I < E Over trachea
Bronchial Loud, high-pitched I > E Next to trachea
Bronchovesicular Medium in
loudness and pitch
I = E Next to sternum,
between scapulae
Vesicular Soft, low-pitched I > E Remainder of
lungs
Location of Normal Breath Sounds
Trachial (anterior)
Bronchovesicular (anterior)
Trachial (posterior)
Normal breath sounds midlung (posterior)
Anterior Posterior
Abnormal Respiratory Patterns
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Respiratory Diagnostic Procedures Blood studies
WBC ABG
Sputum and pleural fluid Sputum culture Nasopharyngeal culture Throat culture
Endoscopy & imaging Bronchoscopy Chest X-ray Fluoroscopy Pulmonary angiography CT scan Thoracoscopy Ventilation-perfusion scan
Biopsies Lung biopsy Pleural biopsy
Pulmonary function tests Pulse oximetry Thoracentesis
Pulse Oximetry
The ratio of oxygen to hemoglobin Normal range 95% to 100% Treat the patient not the number Interfering factors
Elevated bilirubin Lipid emulsions Excessive light Severe peripheral vascular disease Hypothermia Hypotension Vasoconstriction Anemic conditions Vasopressors Nail polish or false finger nails
Arterial Blood Gases
pH Shows the bloods acidity or alkalinity
Normal 7.35-7.45
Partial pressure of carbon dioxide (PaCO2) Respiratory parameter
Reflects lung ventilation and CO2 elimination
Normal 35-45
Partial pressure of arterial oxygen (PaO2) Reflects body’s ability to pick up oxygen from lungs
Normal varies
Bicarbonate (HCO3-) Metabolic parameter
Reflects the kidneys ability to retain and excrete HCO3
Normal 22-26
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Rapid Interpretation of ABGs
Look at pH to obtain first and last name Look at CO2 and HCO3 to determine who gave the last name
First Name Middle Name Last Name Uncompensated Respiratory Acidosis Compensated Metabolic Alkalosis
Normal Values
pH Uncompensated Acidosis ← 7.35-7.45 → Uncompensated Alkalosis Compensated
CO2 Respiratory Alkalosis ← Respiratory Acid → Respiratory Acidosis 35-45 HCO3 Metabolic Acidosis ← Metabolic Base → Metabolic Alkalosis 23-27
Respiratory Acidosis: Accessive CO2 Retention
pH<7.35, PaCO2>45
Causes
Any condition that interferes with O2 & CO2 exchange
COPD, pneumonia, asthma, pulm edema, apnea, hypoventilation
Signs & Symptoms
Rapid deep breathing, light headed, anxiety, fear
Treatment
Tx cause, O2, BiPap, Mechanical Ventilation
Respiratory Alkalosis: Excessive CO2 Excretion
pH>7.45, PaCO2 <35
Causes Any condition that causes hypoventilation
Anxiety, pain, fear
Signs & Symptoms Diaphoresis, HA, tachycardia
Treatment Ask patient to take slow deep breaths
Breath into paper bag: rebreath CO2
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Metabolic Acidosis: HCO2 Loss, Acid Retention
pH<7.35, HCO3<22 Causes
Any condition that interferes with the kidneys ability to produce bicarb
Kidney failure, ASA overdose, diarrhea, shock, DKA
Signs & Symptoms Rapid breathing, fruity breath, fatigue, HA, coma, abd
pain
Treatment Treat underlying cause, give bicard
Metabolic Alkalosis: HCO3 Retention, Acid Loss pH>7.45, HCO3>36 Causes
Any condition that causes loss of acid form the GI tract, loss of K+ from increased renal excretion
Uncontrolled vomiting, excessive NG suctioning
Signs & Symptoms Slow shallow breathing, confusion, irritability, seizure,
coma
Treatment Treat underlying cause
CASE STUDIES
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PATIENTS IN RESPIRATORY DISTRESS
Acute Respiratory Distress Syndrome (ARDS)
A type of pulmonary edema not related to heart failure
Hallmark features of ARDs Bilateral patchy infiltrates on chest X-ray
No signs or symptoms of heart failure
No improvement in PaO2 despite increasing oxygen delivery
Causes Sepsis Trauma Shock
DIC Pancreatitis Massive blood transfusion
Burns Drug overdose Pneumonia
Progression of ARDs
Stage 1: Injury reduces normal blood flow to the lungs. Platelets aggregate and release histamine (H), serotonin (S), and bradykinin (B).
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Progression of ARDs
Stage 2: The released substances inflame and damage the alveolar capillary membrane, increasing capillary permeability. Fluids then shift into the interstitial space.
Progression of ARDs
Stage 3: Capillary permeability increases and proteins and fluids leak out, increasing interstitial osmotic pressure and causing pulmonary edema.
Progression of ARDs
Stage 4: Decreased blood flow and fluids in the alveoli damage surfactant and impair the cells’ ability to produce more. The alveoli then collapse, thus impairing gas exchange.
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Progression of ARDs
Stage 5: Oxygenation is impaired but carbon dioxide (CO2) easily crosses the alveolar capillary membrane, and is expired. Blood oxygen (O2) and CO2 levels are low.
Progression of ARDs
Stage 6: Pulmonary edema worsens and inflammation leads to fibrosis. Gas exchange is further impeded.
Stages of ARDS Stage I
Develops hours to days after initial injury Response to decreasing oxygen levels in blood Dyspnea, especially on exertion Respiratory and heart rates normal to high
Stage II Symptoms sometimes incorrectly attributed to trauma Marked increase respiratory distress Respiratory rate high with use of accessory muscles Restless, apprehensive, agitated Dry cough or frothy sputum Skin cool and clammy Bibasilar crackles
Stage III Obvious respiratory distress, tachypnea, accessory muscles, decrease mental acuity Tachycardia with PVCs, labile blood pressure Skin pale and cyanotic Diminished breath sounds, bibasilar crackles, rhonchi This stage generally requires intubation and mechanical ventilation
Stage IV Decreasing respiratory and heart rates Mental status nears loss of consciousness Skin cool and cyanotic Breath sounds diminished to absent
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Treatment of ARDS
A- antibiotics
R- respiratory support
D- diuretics
S- situate (place in prone position)
Pulmonary Embolism
An obstruction of the pulmonary arterial bed
Usually results from dislodged thrombi that originate in leg vein
If the embolus occludes the pulmonary artery, alveoli collapse and atelectasis develops
If embolus enlarges in can lead to death
Sites of Pulmonary Emboli
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At Risk for Pulmonary Embolism
What to Look For
Dyspnea, may be accompanied by anginal or pleuritic chest pain
Tachycardia
Productive cough (sputum may be blood tinged)
Splinting of chest
Cyanosis
Signs of hypoxia
Audible S3
Crackles and a pleural friction rub
Diagnostic Tests
Chest X-Ray R/O other pulmonary diseases Areas of atelectasis, diaphragm elevation, and pleural effusion
Lung scans Perfusion defects beyond occluded vessel
Pulmonary angiography The most definitive test
ECG Right axis deviation, RBBB Tall, peaked P waves, depressed ST, and inverted T Supraventricular tachycardias
ABGs Decrease PaO2 and PaCo2
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Treatment of Pulmonary Embolism
Prevent recurrence
Oxygen therapy
Anticoagulation
Fibrinolytics
Surgery
PATIENTS WITH CHEST TUBES
Assessment of a chest tube – “STOP”
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Chest tubes
Find out size (in French)
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“S” - Site
Check for subcutaneous emphysema (subcutaneous air, crepitus, tissue emphysema) under the skin around the chest tube, edematous area – can spread up
Lung sounds bilaterally
Dressing should be occlusive (good seal) and free of drainage
Bedside availability of additional Vaseline gauze pad
“T” - Tubing
Connections should be taped
No dependent loops
Should be secured to chest to prevent any
Avoid traction or pulling directly on insertion site
Should not be clamped
Drainage system should be below the chest
“O” - Output
Monitor drainage
Note the highest point of fluid level with the date and time with permanent marker at the end of each shift
If drainage is greater than 100mL/hour (or parameters as ordered), notify physician
Check for bubbling in water seal chamber after ensuring all connections (may indicate air leak)
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“P” - Patient
Drainage in tube and water seal chamber should fluctuate as patient inhales and exhales. This is also known as "tidaling"
Water level in water seal and suction chambers should be at correct level. Need to refill if evaporates.
JEOPARDY
QUESTIONS
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