Assessment of Oxygenation

1. Assessment of Oxygenation

2. Subjective Data • Past History • Upper resp infections • Lower resp problems (asthma, TB, pneumonia, COPD) • Related illness that affect resp system – AIDS, CHF • Immunizations, TB skin tests, CXRs • Allergies • Medications

3. Subjective Data • Family History • Focus on resp illnesses • Personal and social history • Occupational history • Factory, chemical plants, coal mines, farming, heavy traffic are all high risk for respiratory system • Smoking history • How long? How much? (pk yrs = # pks/day X # years) • Substance abuse • ETOH – risk for aspiration pneumonia • IV drugs and AIDS risk for pnuemonia • Activity Tolerance • SOB or fatigue with daily activities? How far/fast can you walk?

4. Subjective Data • Specific Symptoms • Cough • How long? • Onset (gradual, sudden); • When (a.m., all day?) • How often? Productive? How much? • Color (yellow/green – bacteria; frothy pink – pulmonary edema) • Odor? • Blood?

5. Subjective Data • Specific Symptoms • Shortness of breath (SOB) • Precipitating factors, severity, duration • Effect of position (lying down? Upright?) • Association with other symptoms (chest pain, cough) • What makes it better/worse (rest, oxygen, inhalers, meds) • Effect on activities? • Chest pain • PQRST (does breathing affect the pain?)

6. Objective Data • Mouth, nose, pharynx, neck, heart • Lungs and thorax

7. Objective Data: Inspection • Note position (upright, leaning on table?) • Evidence of respiratory distress/quality of respirations • Nasal flaring, accessory muscles, intercostal retraction or bulging • Shape and symmetry of chest • Normal AP:transverse ratio is 1:2 – 5:7 • Barrel chest: increased AP diameter in relation to transverse

8. Objective Data: Inspection • Respiratory rate (N = 12 – 20) • Respiratory pattern • Tachypnea – rapid, shallow, > 24/min • Bradypnea – slow (< 10/min) • Hyperventilation – increased rate and depth • Hypoventilation – shallow • Cheyne-Stokes

9. Objective Data: Inspection • Skin color • Cyanosis (indicative of deoxygenated blood) • Nails • Clubbing (increased angle between base of nail and fingernail to 180 degrees or more • Usually accompanied by increased depth, bulk and sponginess of end of fingers

10. Objective Data: Palpation • Symmetric expansion • Tactile fremitus • Palpable vibration generated by vocal cords “99” • Using palmar base of fingers, palpate from side to side • Increased when lung is fluid-filled/more dense • Decreased when lung is farther from hand or if hyper-inflated • Absent over areas of collapse (pneumothorax, atelectasis)

11. Objective Data: Percussion • To assess density or aeration • Dull over areas of consolidation (e.g. pneumonia) • Hyper-resonance over areas of hyper-inflation (e.g. asthma, COPD)

12. Objective Data: Auscultation Normal breath sounds • Vesicular • Soft, low pitch, gentle rustling • Heard over peripheral lungs • Bronchial • Loudest, high pitch, like air through hollow pipe • Over trachea and larynx • Bronchovesicular • Medium pitch and louness • Mix of above qualities • Anteriorly – over bronchi, either side of sternum • Posteriorly – between scapula

13. Objective Data: Auscultation • Abnormal/adventitious breath sounds • Discontinuous sounds • Crackles (fine) • Crackles (coarse) • Pleural friction rub • Continuous sounds • Rhonchi • Wheeze • Stridor

14. Objective Data: Auscultation • Discontinuous sounds • Crackles (fine) • Short, crackling, popping sound at end-inspiration • When collapsed alveoli or bronchioles snap open • Associated with pneumonia, early pulmonary edema, atelectasis • Crackles (coarse) • Short, low-pitched bubbling sounds, mostly during inspiration • Caused by air passing through airway that is intermittently occluded with secretions in larger airways • Associated with pnuemonia, pulmonary edema • Pleural friction rub • Creaking, grating sound (like leather being rubbed together) • During inspiration and/or expiration • Due to inflamed pleural surfaces rubbing together • Associated with pleurisy, pneumonia

15. Objective Data: Auscultation • Continuous sounds • Rhonchi • Low pitch, snoring, moaning sound mostly on expiration • Air passing through large airways with secretions • COPD, pneumonia • Wheeze • High pitched squeaking sound, mostly on expiration • Sometimes audible without stethescope • Caused by air passing through narrowed airways (d/t spasm, swelling, tumors, secretions) • Stridor • High pitch crowing sound; often audible without stethescope • Caused by partial obstruction of larynx or trachea • Associated with croup, epiglottitis, laryngeal edema or spasm (post extubation)

16. Diagnostic Tests • Sputum studies • C & S • Gram stain (classifies as gram + ve or – ve) • AFB (acid fast bacilli) – for TB • Cytology – examination for abnormal cells • Bronchoscopy • Bronchi visualized with fiberoptic tube inserted through nose into airways • Can take biopsy, remove foreign bodies, mucus plugs • NPO and sedation pre-test • Post procedure: NPO until gag returns; assess for laryngeal edema,, hemorrhage (if bx taken), recovery from sedation

17. Diagnostic Tests • Pulmonary Function tests • Measures lung volumes and airflow • Arterial blood gases (ABGs)