Assessing respiratory

1. Assessing respiratory Dr. Zyad Saleh

2. Subjective Data • specific respiratory problems: • Shortness of breath (SOB) (Dyspnea) • Pulmonary or respiratory disorders • Orthopnea: ( difficult breathing when supine) • Paroxysmal nocturnal dyspnea ( sever dyspnea that awaken the pt from sleep)

3. Subjective Data • Chest pain • Check whether it is related to cardiac ischemia

4. Subjective Data • Cough • Continuous coughs  acute infections, • early morning  chronic bronchial inflammation or smoking. • late evening  exposure to irritants • night are often related to postnasal drip or sinusitis. • White or mucoid  viral infections • Yellow or green  bacterial infections. • Blood (hemoptysis) • Rust-colored  pneumococcal pneumonia. • Pink, frothy  pulmonary edema.

5. Subjective Data • Wheezing • Wheezing indicates narrowing of the airways • It is heard most clearly when you exhale, but in severe cases, it can be heard when you inhale.

6. Health History respiratory problems thoracic surgery, biopsy, or trauma Allergies treatments at home for your respiratory problems a chest x-ray, tuberculosis (TB) skin test, or influenza immunization traveled outside

7. Family History a history of lung disease Smoker in family member

8. Lifestyle and Health Practices usual dietary intake smoked cigarettes (when and how much) exposed to any environmental conditions difficulty performing your usual daily activities Stress herbal medicines

9. COLLECTING OBJECTIVE DATA

10. INSPECTION: General • Inspect for nasal flaring and pursed lip breathing. • Nasal flaring is not observed. • Normally the diaphragm and the external intercostal muscles do most of the work of breathing. • Nasal flaring is seen with labored respirations (hypoxemia) • Pursed lip breathing  chronic respiratory disorders

11. Observe color of face, lips, and chest. • evenly colored skin tone, without unusual or prominent discoloration. • Ruddy to purple  poloycythemia • Cyanosis

12. Inspect color and shape of nails. • Pink tones  nailbeds. • a 160-degree angle between the nail base and the skin. • Pale or cyanotic nails  hypoxia. • Early clubbing (180-degree angle) • Late clubbing (greater than a 180-degree angle) can occur from hypoxia.

13. INSPECTION: Posterior Thorax posterior thorax  the vertebral (or spinal) line and the right and left scapular lines  extend through the inferior angle of the scapulae when the arms are at the client’s side

14. INSPECTION: Posterior Thorax • Inspect configuration. • Scapulae are symmetric and nonprotruding. • Shoulders and scapulae are at equal horizontal positions. • The ratio of anteroposterior to transverse diameter is 1:2.

15. INSPECTION: Posterior Thorax • Inspect configuration. • Spinous processes that deviate laterally in the thoracic area may indicate scoliosis.

16. INSPECTION: Posterior Thorax • increased ratio between the anteroposterior–transverse diameter (barrel chest). • Trapezius, or shoulder, muscles are used to facilitate inspiration in cases of acute and chronic airway obstruction or atelectasis.

17. Observe use of accessory muscles. • The client does not use accessory (trapezius/shoulder) • diaphragm is the major muscle at work. • Client leans forward and uses arms to support weight and lift chest to increase breathing capacity, referred to as the tripod position

18. Inspect the client’s positioning • Client should be sitting up and relaxed, breathing easily with arms at sides or in lap.

19. PALPATION • Palpate for tenderness and sensation. • Client reports no tenderness, pain, or unusual sensations. • Temperature should be equal bilaterally.

20. Palpate for crepitus. • Crepitus (subcutaneous emphysema) is a crackling sensation (like bones or hairs rubbing against each other) that occurs when air passes through fluid or exudate. • no palpable crepitus. • air escapes from the lung or other airways into the subcutaneous tissue

21. Palpate surface characteristics (lesions and masses) • Skin and subcutaneous tissue are free of lesions and masses.

22. Palpate for fremitus. (a vibration transmitted through the body) • symmetric bilateral and easily identified in the upper regions of the lungs. Apex > base • consolidation accumulation of fluids  increases fremitus • decrease fremitus  bronchial obstruction, air trapping in emphysema, pleural effusion, or pneumothorax

23. Assess chest expansion. • examiner’s thumbs should move 5 to 10 cm apart symmetrically. • Unequal chest expansion can occur with atelectasis (collapse), pneumonia, chest trauma, or pneumothorax (air in the pleural space). • Decreased chest excursion at the base of the lungs  COPD.

24. PERCUSSION • Percuss for tone. • Resonance • Hyperresonance  trapped air such as in emphysema or pneumothorax. • Dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space

25. Percuss for diaphragmatic excursion. • Excursion should be equal bilaterally and measure 3–5 cm in adults. • limited descent can be pain • Uneven excursion may be seen with inflammation from unilateral pneumonia

26. AUSCULTATION • Auscultate for breath sounds. • bronchial, bronchovesicular, and vesicular

28. AUSCULTATION • Auscultate for breath sounds. • Diminished or absent breath sounds often indicate that little or no air is moving in or out of the lung area being auscultated. • Increased (louder) breath sounds often occur when consolidation or compression results in a denser lung area that enhances the transmission of sound.

29. Auscultate for adventitious sounds. • No adventitious sounds, such as crackles (discrete and discontinuous sounds) or wheezes (musical and continuous)

31. Auscultate voice sounds. • Bronchophony, Egophony, Whispered pectoriloquy • Voice transmission is soft, muffled, and indistinct. • actual phrase cannot be distinguished but the letter “E” should be distinguishable.

32. Auscultate voice sounds. • words are easily understood and louder over areas of increased density.

33. INSPECTION: Anterior Thorax • Inspect for shape and configuration. • Inspect position of the sternum. • Sternum is positioned at midline and straight.

34. Anterior  the midsternal line and the right and left mid-clavicular lines

35. lateral  mid-axillary line runs from the apex of the axillae to the level of the 12th rib. The anterior axillary line extends from the anterior axillary fold along the anterolateral aspect of the thorax, the posterior axillary line runs from the posterior axillary fold down the posterolateral aspect of the chest wall

36. INSPECTION: Anterior Thorax • Inspect position of the sternum. • Pectusexcavatum is a markedly sunken sternum and adjacent cartilages (funnel chest). • Pectuscarinatum is a forward protrusion of the sternum (pigeon chest)

37. Watch for sternal retractions. • Retractions not observed. • labored breathing.

38. Inspect slope of the ribs. • Ribs slope downward with symmetric intercostal spaces. • Barrel-chest configuration results in a more horizontal position of the ribs and costal angle

39. Observe quality and pattern of respiration. • Respirations are relaxed, effortless, and quiet. • They are of a regular rhythm and normal depth at a rate of 10–20 per minute in adults. • Labored and noisy breathing • Abnormal breathing patterns include tachypnea, bradypnea, hyperventilation, hypoventilation, Cheyne-Stokes respiration,.

41. Inspect intercostal spaces. • No retractions or bulging of intercostal spaces are noted. • Retraction of the intercostal spaces indicates an increased inspiratory effort. • Bulging of the intercostal spaces indicates trapped air

42. Observe for use of accessory muscles. • sternomastoid and rectus abdominis

43. Palpate for tenderness, sensation, and surface masses. Palpate for tenderness at costochondral junctions of ribs. Palpate for crepitus Palpate for fremitus. Palpate anterior chest expansion.

44. PERCUSSION Percuss for tone. Auscultate for anterior breath sounds, adventitious sounds, and voice sounds.