513 Respiratory Assessment

• oxygen is needed to sustain life
• blood is oxygenated through ventilation, perfusion and transport of respiratory gasses
• the cardiovascular system provides the transport mechanisms to distribute oxygen to the cells and tissues

the whole process of respiration is neurologically and chemically regulated- neural and chemical regulators control the rate and depth of respiration in response to changing tissue oxygen demands and levels in the blood

• nose
• mouth
• pharynx- naso, oro, laryngo
• larynx
• epiglottis
• trachea

• bronchi (main stem, secondary aka lobar, tertiary aka segmental)
• bronchioles
• alveolar ducts
• alveoli

• right has 3 lobes
• left has 2 lobes

• gases move into an out of the lungs through pressure changes
• the diaphragm contracts to pull downward and external intercostal muscles contract and pull upward to create a negative pleural pressure and increase the size of the thorax for inspiration
• chest opens and expands because the throax expands and opens to allow for diffusion of gases

the process for the exchange of resp gases between the alveoli of the lungs and the capillaries of the body tissues

moves blood to and from the alveolar capillary membrane for gas exchange

• a bony structure with a conical shape, that is narrower at the top
• lungs reside in here

• sternum
• 12 pairs of ribs 
• 12 throacic vertbrae
• floor is the diaphragm, which separates thoracic cavity from abdomen

• first 7:true ribs- attached to the sternum by castal cartilages
• 8,9, and 10: attach to the the costal cartilage of the ribs above them
• 11 and 12: free floating ribs with free palpable tips that end in the thoracic muscle tissue
• 8-12 are all false ribs

• costal cartilages become calcified, which produces a less mobile throax
• as a result of the tighter rib cage, you cant take deep breaths as well and the chest doesnt rise as well

• aging lung is more rigid structure thats harder to inflate, which along with the tighter rib cage results in small airway closure
• histologic changes also occur- ie gradual loss of intra-alveolar septa and a decreased number of alveoli so less surface area available for gas exchange
• lung bases become less ventilated as a result of the closing off of a number of airways
• histologic changes also increase the older persons risk of pulmonary complications after surgery

• midsternal line
• midclavicular line
• anterior axillary line

goes down the sternum on anterior side

2 of them, go down the middle of each clavicle

2 of them, go down the side of each armpit

• scapular line
• vertebral aka midspinal line

• aka midspinal line
• goes down the spinal column

extends through the inferior angle of the scapula when arms are at the sides of the body (if arm goes up this changes)

• anterior axillary line
• posterior axillary line
• midaxillary line

extends down from the anterior axillary fold where pectoralis major muscle inserts

continues down from posterior asillary fold where latissimus dorsi muscle inserts

runs down from apex of axilla and lies between and parallel to the other two

the upper part of the sternum

the dipped notch in the top of the manubrium

the angle where the lower false ribs meet the true ones' cartilage

• 12 
• t1-t12

• also called the manubriosternal junction
• joins the manubrium to the sternum

lowest tip of the sternum right above the costal angel

normal breath sounds

• bronchial
• bronchiovesicular
• vesicular

depending on where you are listening

• aka tracheal or tubular breath sounds
• youll hear them over the trachia and main bronchi
• course and loud sounds
• hollow and louder pitched than vesicular
• hear at 2nd-3rd intercostal space
• there is a pause between inspiration and expiration

• mid chest area over bronchi after the main
• a mix of the bronchial breath sounds heard near the trachea and the vesicular sounds in the lung
• inspiration to expiration periods are equal

• in the lungs
• low pitched, breezy
• soft and blowing- sounds like air moving in and out
• heard continuously on inspiration and then goes right into expiration and fades out about 1/3 of the way through expiration

• rhonchi
• wheeze
• rub
• crackles

• course, low pitched sound
• rattling, may sound like a snore
• heard where the bronchial breath sounds are heard- over trachia/bronchi
• often will clear with a cough

• a whisle, high pitched sound heard in the bronchus
• described as musical
• bronchial sound, sound is more coarse, but heard with consolidation in the brochioles

• scratchy, high- pitched
• indicates inflammation of the pleura- pleural friction
• creaking or grating sound
• sounds like what it is, something sliding over another
• cough will not help it

• can be fine or coarse
• fine- are high pitched and discontinuous, sound like rubbing of twisted hair
• course crackles- louder, lower pitched and longer lasting, sound more like velcro
• crackles are heard in the vesicular area usually in the lower lobes and indicate fluid

adventitious sounds

• fine crackles
• course crackles
• wheezes
• stridor
• pleural friction rub
• rhonchi

• Stridor sound is a type of wheezing and is heard on inspiration and is a high-pitched whistling or gasping sound with a harsh sound quality. It may be seen in children with conditions such as croup or epiglottitis, or anyone with an airway obstruction.
• stridor is more of an emergency

• as long as the patient is stable, do subjective assessment first
• 1. in depth hisotry of patients normal and present cardiopulmonary function
• 2. past history of impairments in respiratory functioning
• 3. Methods that they use to optimize oxygenation
• 4. Review of drug, food, and other allergies
• 5. Physical examination
• 6. Laboratory and diagnostic tests

• pain
• fatigue
• dyspnea
• cough (how long, productive, color etc)
• wheezing
• smoking
• allergies
• medications
• self-care behaviors
• environmental exposures
• health risks
• respiratory infections

• do you have it?
• how long?
• how often? any special time of day or night?
• phelgm? what color and how much?
• cough up blood? streaks or frank blood? does sputum have foul odor?
• describe cough- hacking, dry barking, hoarse congested, bubbling?
• activity make it better or worse?
• treatments/meds tried?
• chest or ear pain? are you concerned about it?

• Ever had it?
• what brings it on?
• how severe?
• how longs it last?
• does position change it?
• any specific time of day or night?
• episodes of it with night sweats?
• cough, chest pain or blue lips/nails with it?
• wheezing?
• episodes related to any allergens? or emotions?
• what do you do in an attack to help?
• how does it affect your life?

• alone or with sob?
• point to exact location
• when did it start?
• constant or comes and goes?
• describe pain, burning, stabbing?
• brought on by respiratory infection, cough or trauma?
• associated with fever, deep breathing, unequal chest inflation?
• what have you done to treat it, meds, heat application, etc?

• any past history of breathing trouble or lung diseases? bronchitis, emphysema, asthma or pneumonia?
• any unusually frequent or severe colds?
• any family history of allergies, tb asthma?

• do you smoke cigarettes or cigars?
• at what age did you start?
• pack per day for how long?
• do you live with someone who smokes?
• have you ever tried to quit? why didnt it work?
• what activities do you associate with smoking?
• why do you smoke?

• any environmental conditions that may affect your breathing?
• where do you work and whats there?
• do you do anything to protect lungs like a mask or ventilator system?
• do you do anything to monitor exposures?
• do you have periodic examinations, pulmonary function tests or xrays?
• do you know what specific symptoms to note that may signal breathing problems

• when was your last
• tb test
• chest x ray
• pneumonia (after age 65) or flu shot

• ask about their priorities and expectations, why are they here
• establish realistic short term outcomes that build to a larger goal
• educate them on opportunities for support
• have cultural awareness esp on physical exam

• physical exam: thorax and lungs- inspection, palpation, percussion and auscultation
• in that order

• skin and mucous membrane color
• level of consciousness
• breathing patterns
• chest wall movement
• general appearance

• capillary refill
• color
• texture
• turgor
• any moles/lesions

• the chest 
• the spine

• for normal and adventitious breath sounds
• listen in 14 places on front, 12 on back

• infection control: hand hygiene, standard precautions, PPE if needed, clean stethescope
• Environment: well lit, quiet, warm (esp for elderly), warm stethescope diaphragm, private examination time with no interruptions
• equipment: all required, make sure it works
• promote comfort: positioning and privacy- are they comfortable with position, are they fatigued when moving? drape body areas your not examining
• psychological prep: reduce anxiety, fatigue and stress, explain everything, encourage questions, note body language

• ask about any beliefs before starting
• consider: health beliefs, use of alternative therapies, nutrition habits, family relationships, personal comfort zone
• dont sterotype

• systematic and organized flow pattern
• compare sides for symmetry
• offer rest periods if needed
• perform painful things last
• be specific when documenting
• quick notes during and larger notes at the end

• obviously promote comfort by examining the side they are on first
• usually you will perform posterior exam first then move to anterior

• gender
• race
• age
• signs of distress
• body type
• posture
• gait
• body movement
• hygene/grooming
• dress
• body odor
• affect and mood
• speech
• signs of abuse
• substance abuse

• height
• weight
• bmi
• vital sign
• pulse oximetry

• a noninvasive method to asses arterial oxygen saturation
• a healthy person normally has 97-98%
• every result must be evaluated in context of a persons hemaglobin level, acid base balance and ventilatory status

• uses sight and smell
• use adequate lighting
• position and expose body parts as needed to maintain privacy and still view surfaces
• compare side to side symmetry
• validate findings with patient

first in an examoccures incidentally- when interacting with pt- and purposefully when examining a body system

• size
• shape 
• color
• symmetry
• position
• any abnormaliites

• skin: color and condition
• any lumps, signs of abuse, lesions, syanosis, palor
• state that youre examining the skin
• examine visible skin surfaces first (head, neck)

• oxygenation
• circulation
• nutrition
• disease processes
• local tissue damage/inflammation
• hydration

• quality of respirations
• look at pattern or resp, rate, any struggling, symmetrical chest expansion

• normal relaxed automatic effortless breathing
• regular and even with no noise
• chest expands symmetrically
• accessory muscles not used to breathe
• rate in normal limits for persons age
• pattern is regular
• occasional sighs normally punctuate breathing

• persons position
• retraction or bulging of interspaces with inspiration

• the thoracic cage
• note the shape and configuration of chest wall

• neck muscles and trapezius muscles should be developed normally for age- look for symmetry between them
• anteroposterior diameter should be 1/3 of the transferse diameter

• barrel chest
• scoliosis
• kyphosis

• common with COPD
• AP diameter is same width of transverse diameter

• spinal disorder where an excessive outward curve of the spine results in a hump on upper back
• one area is lumped (usually upper chest) vs the barrel chest thats the whole chest, so AP diameter not changed
• person is hunched so everything is compressed so they cant take deep breaths

dowager's hump

• fractures of some vertebrae or regidity/tightening of the thorax
• osteoporosis is the most common cause

• abnormal curvature of the spine in an s or c shape
• can be born with it or develop it over time
• makes it hard to fully expand chest

• surgery
• hamden rod put in if caught early

• second step after inspection
• uses touch to assess skin and underlying tissue and organs
• gather info by touch

• make sure patient relaxed
• proceed slowly, gently, deliberately, respecfully
• observe pt facial expression/responses
• explain what youre doing
• use light palp followed by deep
• employ different parts of the hands to detect different characteristics
• hands warm, fingernails short

• spine and scapulae
• check scaplulae for pain masses
• run your fingers down spinal column to check straightness and for tenderness
• feel for chest expansion

• confirm symmetric chest expansion by placing warmed hands on posterolateral chest wall with thumbs at the level of T9 or T10
• slide your hands medially and ask patient to take a deep breath
• as patient inhales deeply, your thumbs should move apart symmetrically. note any lag in expansion
• you can count vertebrae to get to the 10th rib, the one sticking out of the neck is c7

lightly pinch a little skin with your thumbs, if it flattens out it expanded

• taping skin with fingertips to produce a vibration in underlying tissues and organs
• dullness over solid of fluid filled
• tympany over air filled

• last step in exam
• dont listen through any clothing
• make sure good hearing and good stethescope
• concentrate and practice
• quiet room

• bell: low pitched sounds- vascular, certain heart sounds
• diaphragm: high pitched sounds- bowel, lung sounds

• created by blood air or fluids as they move against body structures
• listen for audible sounds before placing stethescope

• frequency
• loudness
• quality
• duration

• stand behind person
• posterior position from apices at c7 to around T10
• ladder pattern
• laterally from axilla down to 7th or 8th rib
• progress from side to side as you move downward and listen to one full respiration in each location
• evaluate normal breath sounds and note any abnormal or adventitious ones

• what am i hearing over this spot
• what should i expect to be hearing

• done after posterior exam is over
• patient should be conscious- alert and cooperative
• note facial expression- should be relaxed indicating unconscious effort of breathing
• note skin color and condition, lips and nailbeds- clubbing, cyanosis, capillary refill
• observe breathing effort, rate and accessory muscles

downward with symmetric interspaces

• done after inspecting
• compare right and left sides
• palpate anterior chest wall- sternum, any movement, depression, cripidus
• palpate for stability of chest wall
• palpate muscles and skeleton
• note any tenderness, superficial lumps or masses
• note skin mobility, turger, moisture and temp

• rice crispies popping feeling when palpating
• in joint or lungs
• can be a sign of bone fracture

• done after palpating
• go in ladder again 12 places
• do not place stethescope directly over female breast- displace breast and listen directly over chest wall

• record findings 
• give pt time to dress, assist if needed
• delegate cleaning of examination area
• record complete assessment, review for accuracy and thoroughness
• communicate significant findings

consult health care provider before informing the patient

• activity intolerance
• decreased cardiac output
• fatigue
• impaired gas exchange
• impaired verbal communication
• ineffective airway clearance
• risk for aspiration
• ineffective breathing pattern
• ineffective health maintenance

• use critical thinking skills to synthesize information from multiple sources
• select realistic goals and measurable outcomes
• set priorities
• teamwork and collaboration

• vaccinations: influenza, pneumococcal (esp over 65)
• healthy lifestyle: eliminating risk factors, eating right, regular exercise
• Environmental health pollutants: secondhand smoke, work chemicals, pollutants

• remember: through the patients eyes
• focus on evaluating how the disease is affecting day-to-day activities and how the patient believes he or she is responding to treatment
• patient outcomes: compare pt progress to the goals and expected outcomes of the nursing care plan to determine his or her health status

• most common inhaler
• requires breathing coordination
• use a spacer to get more medication

• take off cap and shake it
• breathe out all the way
• hold inhalor the way the doc precribes
• breath in slowly through mouth while pressing down one time on inhaler, keep breathing in slowly as deeply as you can
• hold breath and count to 10 slowly
• wait 1 min between puffs for rescue meds, dont need to for others

• dry powder inhaler
• doesnt require coordination, works with your inhale

• without spacer: 10% stays in device, 81% in mouth/throat, 9% in lungs
• with spacer: 57% in device, 22% in mouth/throat, 21% in lungs

upright flow meter with adjustment valve

• nasal cannula
• oxygen masks
• may include use of humidification

• nasal canula
• simple face mask

• prevents patient from breathing back in any co2 to get most o2
• 8-15 liters, delivers a high flow of o2

• method of high oxygen flow
• mixes oxygen with room air
• delivered when there is worry of co2 retention or when respiratory drive is inconsistant