Assessment of Respiratory System

1. Assessment of Respiratory System

2. 1. 1. History 2. Inspection/Observations • Subjective • Objective 3. Palpation • Tactile fremitus • Symmetric Chest Expansion 4. Percussion 5. Auscultations 6. Lung Sounds

3. A Stethoscope • A Peak Flow Meter Equipment Needed

4. Anterior • Posterior • Right lateral. • UL:upper lobe • ML:middlelobe • LL: lower lobe • Left lateral • UL: upper Lobe • LL : lower Surface markings of the lobes of :the lung

5. Position – • patient should sit upright on the examination table. • The patient's hands should remain at their sides. • For posterior exam the patient is usually asked to move their arms forward (hug them self position • This is so the scapulaeare not in the way of examining the upper lung fields. • Draping - the chest should be fully exposed. • Exposure time should be minimized.

6. Mnemonic Device IPPA: • Inspection • Palpation • Percussion • Auscultation Basic Steps

7. Risk factors for respiratory disease • smoking • pack years ppd X # years • exposure to smoke • sedentary lifestyle, immobilization • age • environmental exposure • Dust, chemicals, asbestos, air pollution • obesity • family history Health History

8. INSPECTION

9. Normal rate and depth • Regular inhalation and exhalation pattern • Audible on each side of chest • Equal rise and fall of each side • Movement of the abdomen Characteristics of Normal Breathing

10. Adult – Over 8 Years Old • 12 to 20 rpm • Child – 1 to 8 Years Old • 15 to 30 rpm • Infant – Birth to 1 Year Old • 25 to 50 rpm Normal Respirations Rates

11. OBJECTIVE SIGNS • Rate slower than 8 per minute or faster than 20 per minute • Pale or cyanotic skin • Shallow or irregular • Pursed lips • Nasal flaring Sign of Abnormal Breathing

12. Type • dry, moist, wet, productive, hoarse, hacking, barking • Onset • Duration • Pattern • activities, time of day, weather • Severity • effect on Activities of Daily Living • Wheezing • Associated symptoms i.e allergies • Treatment and effectiveness Cough

13. color • amount • presence of blood (hemoptysis) • odor • consistency • Is it productive? Sputum

14. Tracheal deviation (can suggest of tension pneumothorax) Chest wall deformities • Kyphosis - curvature of the spine - anterior-posterior • Scoliosis - curvature of the spine - lateral • Barrel chest - chest wall increased anterior-posterior; normal in children; typical of hyperinflation seen inCOPD • Pectus excavatum: Hollow chest grows inward • Pectus carinatumPointed one side flat on other Inspection

15. Pectus Carnatium with secondary changes in the spine. Kyphosis Pectus exacavatum

16. shortness of breath • Cyanosis: Person has bluish coloring • Pursed lip breathing: eases shortness of breath by prolonging exhalation • Accessory Muscle Use: e.g. shoulders lifted on inhalation. Not enough air getting into lungs by diaphragmatic movement • Diaphragmatic paradox: moves opposite way. i.e. upwards during inspiration and downwards during expirationdue to weak muscles Signs of respiratory distress

17. Blue bloater" pathology : chronic bronchitis. • They have decreased ventilation and increased carbon dioxide retention (hypercapnia).  • Increasing obstruction their residual lung volume gradually increases (the "bloating" part).  • Pink Puffer: Pathology: emphysema • Results from destruction of the airways distal to the terminal bronchiole • destruction of the pulmonary capillary bed decreases ability to oxygenate the blood Blue Bloater/ Pink Puffer

18. ‘blue bloater’ showing ascites from marked cor pulmonale. enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels. ‘pink puffer’. Note the pursed-lip breathing .

19. PALPATION

20. Posterior Chest Tactile fremitus • Vibrations felt by hand during palpation • Place open palm edge on skin • client repeats 99 • Should feel equal vibration bilaterally • Decreases if sound transmission is obstructed by consolidation Palpate chest wall

21. Posterior Chest Symmetric chest expansion • Place hands at T9-T10 • Equal movement of thumbs with inhaling

23. Posterior Chest Percussion • Find predominant note over lung fields • Begin at apices • Use same pathway side to side

24. Percussion Sounds • Resonance: Low pitched hollow sound made by air • Hyper-resonance : slightly musical due to excessive air in chest cavity • Dull: Muffled. Excessive tissue e.g liver or possible tumors • Flat: soft thud: Typically heard over bone

26. To assess breath sounds, ask the patient to breathe in and out slowly and deeply through the mouth. • Begin at the apex of each lung and zigzag downward between intercostal spaces . Listen with the diaphragm portion of the stethoscope. Auscultation

27. Normal breath sounds • Note • Pitch • Intensity • Quality • Duration What are you listening for?

28. Where should I listen?

29. Anterior and Posterior of Patient • Apices– under the clavicular line midpoint • Mid-axillary lines (armpit at nipple line) • Bases – lower border of rib cage • Use Diaphragm of stethoscope • One full breath in each position • Same pathway • Side to side comparison Basic/Quick Auscultation PointsWhere should I listen?

31. Posterior Chest Auscultation • Use diaphragm of stethoscope; place firmly • One full breath at each position • Use same pathway • side to side comparison

32. Bronchial • Loud, harsh sounds over trachea • Bronchovesicular • Moderate, mixed sounds over bronchi • Vesicular • Soft, rustling sounds almost silent on expiration Breath Sounds

33. Obstruction • Secretions, mucus plug, foreign body Emphysema • Loss of elasticity; air already in lungs Silent chest • No air is moving in or out of lungs; ominous sign Decreased or Absent

34. Bronchial Sounds : Not heard in the normal lung but occurring in pulmonary disease, indicating infiltration • Solid tissue conducts sounds to surface better • Found in pneumonia with consolidation or fluid in inter-pleural space INCREASED SOUNDS

35. Crackles (Rales): Fine • Fine, discontinuous high-pitched, short crackling sound on inspiration • Found in bases of lungs Adventitious Sounds

36. Crackles: Coarse • Loud, low-pitched bubbling or gurgling sounds • Start in inspiration, may be in expiration • Decrease with coughing, but comes back • Found in pulmonary edema and terminally ill with suppressed cough reflex Adventitious Sounds

37. Wheeze: High pitch • High-pitched, musical squeaking sound that predominates with expiration • Indicates narrowed passageway • Obstruction from acute asthma or chronic emphysema Adventitious Sounds

38. Wheeze Low-pitch ( Rhonchi) • Single note which is more prominent on expiration • Air flow obstruction • bronchitis or tumor Adventitious Sounds

39. Stridor • High-pitched, crowing sound with inspiration • Louder in neck • Upper airway obstruction • Croup, acute epiglottis, or foreign body inhalation Adventitious Sounds

40. SPIROMETRYINCENTIVE SPIROMETRYPEAK FLOW METERS PULMONARY FUNCTION TESTS

42. Required when lung function is in question • Patients must refrain from smoking or using nebulizers or bronchodilators for 6 hours • Patients must be given full explanation to ensure correct technique Spirometry

43. Assist patient in loosening any constrictive clothing • Ensure Privacy • Seat patient • Gather supplies including spirometer • Inform patient if they feel dizzy during procedure they should let staff know immediately • Ask patient in inhale deeply and then blow as hard as possible • Blast out for 5 seconds • Repeat 3 times Procedure

44. Incentive Spirometry

45. Place mouthpiece and seal lips tightly around it. Inhale slowly and deeply . See piston rise look on left for good or better indicator Hold breath for 5 seconds. Then exhale slowly and allow the piston to fall to the bottom of the column. Rest for a few seconds and repeat at least 10 times every couple of hours Position the yellow indicator on the left side of the spirometer to show your best effort. Use the indicator as a goal to work toward during each slow deep breath.

46. PEAK FLOW METER

47. Move the marker to the bottom of the numbered scale.Stand up straight.Take a deep breath. ... Blow out as hard and fast as you can in a single blow. ... Write down the number you get