part i: nursing assessment respiratory system … resp lecture 1.pdf · part i: nursing assessment...
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Part I: Nursing Assessment Respiratory System
Janet Duffey, RN, MS
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Structures and Functions of Respiratory System
• Structures
• Pulmonary functional unit
• Ciliated mucus membrane
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Anatomical Landmarks
Chest wall descriptors• Anterior landmarks
Midclavicular lines Midscapular lines
• Posterior landmarksMid-scapular lineMid-spinal line
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Structures and Functions of Respiratory System
• Upper Respiratory Tract• Lower Respiratory Tract
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Lower Airway Structures
Fig. 26-3. Structures of lower airways. 6
Atalectatsis: Collapsed Alveoli
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Respiratory Membrane
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Structures and Functions of Respiratory System
• Lower Respiratory Tract FactorsSurfactantBlood supply
• Chest Wall
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Structures and Functions of Respiratory System
• Physiology of RespirationVentilationCompliance Diffusion Oxygen-hemoglobin dissociation curve
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Oxygen-Hemoglobin Dissociation Curve
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Normal Arterial Blood GasesABG’s
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Physiology of RespirationMixed venous blood gasesOximetry
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Structures and Functions of Respiratory System
Table 26-3. Critical Values for Pao2 and Spo2 *.
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Respiratory Control
• Chemoreceptors• Mechanical receptors
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Respiratory Defense Mechanisms
Filtration of airMucociliary clearance systemCough reflexReflex bronchoconstrictionAlveolar macrophages
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Gerontologic Considerations: Aging Respiratory System
•Cumulative health alterations
•Decreased cough / gag reflex
•Diminished chest wall movement
•Slowed immune function
•Environmental exposures
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Assessment: Subjective DataPast health historyMedicationsSurgery or other treatments Functional health patternsHealth perception–health management
patternNutritional-metabolic patternElimination patternActivity-exercise pattern
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Functional Health Patterns (continued)
Sleep-rest patternCognitive-perceptual pattern Self-perception–self-concept patternRole-relationship patternSexuality-reproductive patternCoping–stress tolerance patternValues-belief pattern
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Assessment: Objective DataPhysical examinationNose Mouth and pharynxNeckThorax and lungs Inspection Palpation Percussion Auscultation
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Assessment: Thoracic Expansion
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Assessment: Percussion
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Auscultation Sequence
Listen for 1 breath cycle at each site
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Assessment: Percussion of Chest
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Posterior Percussion
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Normal Auscultation
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Physical Assessment of Respiratory System (normal)
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Diagnostic Studies
• Sputum Studies • Skin Tests • Endoscopic ExaminationsBronchoscopy
• CT scan
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Bronchoscopy
• NPO• Assure informed consent signed• Anxiety reduction• IV access• Hydration • Pre-op sedation• Post-op care
• Oxygen• Side-lying position• Re-orientation• Anxiety reduction• Evaluate for gag reflex
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Lung Biopsy
• Performed during bronchoscopy• Data on tumors or subcarinal lymph nodes• Risks
• Bleeding• Pneumothorax• Infection• Aspiration
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Diagnostic Studies: Thoracentesis
• Insertion of needle
• Floroscopicguidance
• Pleural space• Withdrawal of
fluid• Diagnostic • Palliative
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Functional Diagnostic Studies
• Pulmonary Function Tests • Exercise Testing Indications Role of nurse