Islamic University of Gaza Faculty of Nursing

1. Islamic University of GazaFaculty of Nursing Chapter 7 Assessment of respiratory system

2. Anatomy of Respiratory System • Nasopharynx • Larynx • Trachea • Bronchi • Bronchioles • Alveoli

3. Anatomy Respiratory tract extends from mouth/nose to alveoli: Upper airway filters airborne particles, humidifies and warms inspired gases Lower airway serves for gas exchange

4. Assessment of respiratory system Subjective data: * You must ask about: • Coughing (productive, non productive). • Sputum (type & amount). • Allergies, dyspnea or SOB (at rest or on exertion). • Chest pain, history of asthma, bronchitis, emphysema, tuberculosis. • Cyanosis, pallor. • Exposure to environmental inhalants (chemicals, fumes). • History of smoking (amount and length of time)

5. Technique for Respiratory Exam • Before beginning, if possible: • Quiet environment • Proper positioning (patient sitting for posterior thorax exam, supine for anterior thorax exam) • Expose skin for auscultation • Patient comfort, warm hands and diaphragm of stethoscope, be considerate of women (drape sheet to cover chest) • Inspection • Palpation • Percussion • Auscultation

6. Initial Respiratory Survey • Observe the patient’s breathing pattern • Rate (normal vs. increased/decreased) • Depth (shallow vs. deep) • Effort (any sign of accessory muscle use, inspect neck) • Assess the patient’s color (ex. cyanosis)

7. Normal Respiratory Rates • Infant 30-60 • Toddler 24-40 • Preschooler 22-34 • School-age child 18-30 • Adolescent 12-16 • Adult 16-20

8. *Inspection for measurement and assessment of respiration patterns. • Assess the skin and overall symmetry and integrity of the thorax. • Assess thoracic configuration. -Client must be uncovered to the waist, and in sitting position without support. -Observation of skin may give you knowledge about, nutritional status of the client. -Anterior-posterior diameter of thorax in normal person less than the transverse diameter = (1 – 2).

9. -Assess for abnormality of configuration, e.g. pigeon chest (a deformity of the chest characterized by a protrusion of the sternum and ribs), funnel chest (Several ribs and the sternum grow abnormally and produce a caved-in or sunken appearance of the chest), spinal deformities (Kyphosis,scoliosis, lordosis).

10. Pigeon chest

11. Funnel chest

12. Assess ribs and inter-spaces on respiration – may give you information about obstruction in air flow e.g. bulging of inter-spaces on expiration may be from obstruction to air out flow “tumor, aneurysm, cardiac enlargement” *Assess pattern of respiration: • Normally: men and children – breathe diaphragmatically and Women breathe thoracically or costally. • Tachypnea: respiratory rate over than 20/m. • Bradypnea: respiratory rate less than 10/m. -Palpate areas of chest especially areas of abnormalities. If a client complains: all chest areas must be palpated carefully for tenderness, bulges, or abnormal movements

13. *Assess thoracic expansion: • Anterior – put your hands over anterior-lateral chest and thumbs extended along costal margin pointing to xiphoid process. • Posterior—thumbs placed at level of 10th rib with palms placed on posterior-lateral chest. -By the two ways, you feel amount of thoracic expansion during quiet and deep breathing, and symmetry of respiration between left and right hemi thoraces. • * Assessment of fremitus: which is vibration perceptible on palpation". • * In subcutaneous emphysema: you must palpate the tissue, audible cracking sounds are heard – these sounds are termed “Crepitation”.

14. Anterior assessment

15. Posterior assessment

16. Percussion of chest: to determine relative amounts of air, liquid, or solid material in the underlying lung, and to determine positions and boundaries of organs. • * Percussion done for posterior and anterior and lateral aspects of chest with all directions, and with about “5”cms intervals. *Auscultation: To obtain information about the function of respiratory system & to detect any obstruction in the passages. • Instruct the client to breathe through the mouth more deeply and slowly than in usual respiration before beginning • Auscultate all areas of chest for at least one complete respiration

17. Auscultation cont.. • 12 anterior locations • 14 posterior locations • Auscultate symmetrically • Should listen to at least 6 locations anteriorly and posteriorly

18. Breathe sounds: are analyzed according to pitch, intensity, quality, and relative duration of inspiratory and expiratory phases. • * Bronchial breathe sounds: are normally heard over the trachea, if heard over lung tissue – indicate pathologic condition, these sounds “high- pitched, loud sounds with decrease inspiratory and lengthened increase expiratory phases. *Absent or decreased breath sounds can occur in: -Foreign body – in pleural space. -Bronchial obstruction. -Shallow breathing. -Emphysema

19. Normal Breath Sounds • Tracheal • Very loud, high pitched sound • Inspiratory = Expiratory sound duration • Heard over trachea • Bronchial • Loud, high pitched sound • Expiratory sounds > Inspiratory sounds • Heard over manubrium of sternum • If heard in any other location suggestive of consolidation

20. Rale: is short, discrete, interrupted, crackling or bubbling sound that most commonly heard during inspiration “similar to sounds, produced by hairs being rolled between the fingers close to ear.” *Important points when Auscultate rales: • Low pitched, coarse rales, occurring early in inspiration means bronchitis “originate from bronchi” • Medium pitched rales in mid-inspiration means disease in small bronchi e.g. bronchiectasis. • High pitched, fine rales means disease affecting bronchioles and alveoli this occurs in late inspiration

21. * Rhonchi: are continuous sounds produced by movements of air through narrowed passages in the tracheal- bronchial tree "musical sounds heard in expiration". • Low pitched rhonchi“Sonorous rhonchi usually heard in early expiration originate in larger bronchi” • High pitched: “Sibilant rhonchi or wheezes” – in late expiration, this originates in small bronchioles. • Stridor • Inspiratory musical wheeze • Loudest over trachea • Suggests obstructed trachea or larynx • Medical emergency requiring immediate attention • Associated condition inhaled foreign body • * Pleural friction rub: is aloud dry, cracking or grating sound indicating of pleural irritation, heard over lateral and anterior lung in sitting position &not clear with coughing )

22. Causes of decreased or absent breath sounds • Asthma • COPD • Pleural Effusion • Pneumothorax • Atelectasis

23. Common Respiratory Disorders • Pneumonia: Community-acquired pneumonia • Hospital-acquired pneumonia • Bacteria • Viruses • Mycoplasma • Fungi • Chemical

24. Common Respiratory Disorders cont.. • Pleural EffusionAccumulation of pleural fluid secondary to increased fluid formation • Increased capillary permeability • Deceased colloid osmotic pressure of the blood • Increased intrapleural negative pressure • Impaired lymphatic drainage • Increased pressure in the capillaries or lymphatics

25. Common Respiratory Disorders cont.. • Pneumothorax: Sudden onset of pleuritic chest pain • Dyspnea, shortness of breath, increased work of breathing • Diagnostic test • CXR • Management • Oxygen • Possible placement of chest tube

26. Common Respiratory Disorders cont.. • Pulmonary Embolism Part of a deep vein thrombosis that has traveled and lodged in the pulmonary arteries • Severity depends on the extent of occlusion • Mismatch of ventilation and perfusion • Testing ( pulmonary angiogram)

28. Common Respiratory Disorders cont.. • COPD History • Exposure to risk factors, co-morbidities, current medical treatment (beta blockers) • Tests • Spirometry, ABGs • Management • Oxygen, education, drug therapy, nutrition, exercise, surgical intervention

29. Common Respiratory Disorders cont.. • AsthmaA chronic inflammatory disease of the airways • Airway hyper responsiveness • Variable airway obstruction • Resolves spontaneously or after using a bronchodilator • Testing : • Spirometry • Pulmonary function testing • Management • Education, prevent exacerbation, optimize pharmacotherapy

30. Common Respiratory Disorders cont.. • Acute Respiratory FailureA sudden and life–threatening deterioration in gas exchange • Type I – Acute hypoxemic respiratory failure • Type II - Acute hypercapnic respiratory failure • Type III – Combined hypoxemic and hypercapnic failure • *Hypercapnia: is a condition where there is too much carbon dioxide (CO2) in the blood.  • Tests • ABGs, CXR, CT, thoracentesis • Management • Correction of gases, oxygen therapy • Reversal of any narcotics • Possible mechanical ventilation

31. The end Thank you