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The RespiratoryThe Respiratory SystemSystem
Thorax and LungsThorax and Lungs
Rachel S. Natividad, RN, MSNRachel S. Natividad, RN, MSN
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Lobes and LandmarksLobes and Landmarks
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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
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Assessment Cont.: Assessment Cont.: Objective DataObjective Data
Inspection…Inspection…
……Always first!!!Always first!!!
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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
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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
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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
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Barrel ChestBarrel Chest
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Asymmetrical chestAsymmetrical chest
Scoliosis
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Normal BreathingNormal Breathing
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Intercostal Spaces and Intercostal Spaces and MusclesMuscles
Retractions
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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)
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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
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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
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Focused Assessment:Focused Assessment:AuscultationAuscultation
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Normal Breath SoundsNormal Breath Sounds
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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
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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
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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
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Abnormal BreathAbnormal Breath Sounds Sounds
DiminishedDiminished breath breath soundssounds
AbsentAbsent breath sounds breath sounds
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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.
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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.
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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