-
What is the purpose of the upper respiratory tract?
Warms and filters air
-
What is the purpose of the lower respiratory tract?
Gas exchange
-
What information should be obtained to identify risk factors during a respiratory system assessment?
- Hx of trauma to the ribs or lung Sx
- Number of pillows used when sleeping
- Associated chest pain
- Cough
- Sputum production
- Hx of allergies
- Environmental exposures
- Hx of smoking
- Family Hx of lung disease
- Chronic or frequent respiratory infections
- Signs and symptoms (why are they being seen or at the hospital?)
-
What are sign and symptoms which could represent a problem with the respiratory system?
- Dyspnea or Orthopnea
- Cough
- Sputum production
- Chest pain
- Wheezing
- Clubbing of fingers - sign of chronic hypoxia
- Hemoptysis - bloody sputum
- Cyanosis
-
When conducting a respiratory assessment, what should be inspected?
- Skin moisture & color - pale, cool, diaphoretic, cyanotic
- Mentation - Confusion or agitation, alteration in LOC
- Posture - upright, tripod
- Respiratory pattern - rate, depth & degree of distress
- Edema - location, pitting vs non-pitting
- Accessory Muscle Usage - Intercostal retractions, abd. muscle usage
- Shape/contour of chest - Anterior/Posterior diameter, barrel chest (COPD)
- Symmetry of chest rise and fall - should be equal
-
What should be assessed when auscultating lung sounds?
- Duration
- Pitch
- Intensity
- Abnormal Sounds
-
What methods should be used when auscultating the lungs?
- Snake-like pattern from top to bottom of thorax
- Listen for full resp. cycle
- Use both bell and diaphragm of stethoscope
- Ask pt. to breathe slowly and deeply
-
Locations for Respiratory Auscultation
- Vesicular - All lung fields except over sternum & scapula
- Broncho vesicular - 1st & 2nd ICS
- Bronchial - Manubrium (broad, upper part of the sternum)
- Tracheal - Trachea
-
What are stertorous respirations?
Abnormal breath sound characterized by strenuous breathing
-
What is stridor?
Abnormal breath sound characterized by harsh, high pitched sounds on inspiration as a result of narrowing of the upper airways. Croup
-
What are crackles?
- Abnormal breath sound characterized by fine to course crackling which is made as air moves through wet secretions.
- Course sounds may also be called rhonchi
-
What are wheezes?
Abnormal breath sounds characterized by high-pitched musical sounds on inspiration and/or expiration which is made as air passes through small passages narrowed by edema, secretions or tumors.
-
What should be palpated when assessing the respiratory system?
- Chest Expansion - symmetry and degree of expansion
- Tactile Fremitus - vibration felt on the patient's chest during low frequency vocalization
-
What age related (pediatric) variations should be expected when conducting a respiratory system assessment?
- Louder breath sounds on auscultation
- More rapid rate (until approx. age 8-10)
- Abdominal muscle usage
- Rounded chest wall in infants & children up to age 6 - AP vs. transverse diameter are equal
-
What age related (geriatric) variations should be expected when conducting a respiratory system assessment?
- Increased AP diameter
- Kyphosis (dorsal spine curvature)
- Decreased thoracic expansion
- Accessory muscles used to exhale
-
What are common diagnostic tests used when assessing the respiratory system?
- CXR - identifies fluids, masses, shifting, etc..
- PFT - Pulmonary Function Test - evaluation of pulmonary status & identify abnormalities using spirometry & peak flow
- Pulse Oximetry - measure of SaO2 (95% and above is normal)
- ABGs - exact amount of O2 in the blood
-
What is a bronchoscopy?
- Direct visualization of the resp. tract structures.
- Can obtain biopsies, remove foreign substances or drain abscesses
-
What is a Lung Scan?
- Dye is injected and circulated through the lungs
- Images are taken of the radioactive waves emitted
-
What is VQ?
- Ventilation (V) Perfusion (Q) Scan
- detects ventilation abnormalities and measures integrity of pulmonary blood vessels and blood flow.
-
What is the purpose of sputum cytology?
Detects malignant cells & identifies organisms causing infection and/or blood/pus in sputum
-
Respiratory Nursing Diagnoses
- Ineffective airway clearance r/t increase mucous production
- Impaired gas exchange r/t bronchoconstriction
- Ineffective breathing pattern r/t pain or ALOC
- Activity intolerance r/t fatigue and weakness
- Pain r/t fever and pleuritic irritation
- Anxiety r/t difficulty breathing
-
What might percussion be used to assess during a respiratory assessment?
- Lung position and size
- Detect the presence of air, liquids or solids in the lungs
|
|