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The Respiratory System

The Respiratory System. Thorax and Lungs Rachel S. Natividad, RN, MSN. Lobes and Landmarks. Performing the Assessment: Subjective Data. ROS -Ask about dyspnea, cough, chest pain (PQRST format) Short interview sessions if resp. distress / tiring easily Past health history

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The Respiratory System

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  1. The Respiratory System Thorax and Lungs Rachel S. Natividad, RN, MSN

  2. Lobes and Landmarks

  3. Performing the Assessment: Subjective Data • ROS -Ask about dyspnea, cough, chest pain (PQRST format) • Short interview sessions if resp. distress / tiring easily • Past health history • Allergies Meds • Immunizations Travel history • Childhood illness Family history • Hospitalizations TB, smoking • Psychosocial Assessment

  4. Assessment Cont.: Objective Data Inspection… …Always first!!!

  5. The moment you see the patient. What position is most comfortable for him? Does he appear relaxed, anxious, uncomfortable? Is he having any trouble breathing? Assessment begins…. Tripod Position

  6. Focused Assessment (con’t) • Inspection • Color, Size and shape & symmetry of chest, any lesions or scars • Anterior Lateral Posterior

  7. Increased AP:Transverse Diameter Costal angle >90 degrees Altered size/shape:Barrel Chest 1:2 2:1

  8. Barrel Chest

  9. Asymmetrical chest Scoliosis

  10. Normal Breathing

  11. Intercostal Spaces and Muscles Retractions

  12. Focused Assessment Cont… • Resp. rate and depth • Pattern of respiration – regular rhythm • Abnormal patterns • Hyperventilation • Tachypnea vs. bradypnea • Stertorous (Noisy)

  13. Looking at related structures • Skin: cyanosis, pallor • Nails: Clubbing • Spongy nail matrix and nail angle of greater than 160 degrees

  14. Check for tenderness (normally nontender) Crepitus – SQ air pockets Tactile fremitus – increased with fluid accumulation Abnormal if tumor, fractured ribs, chest tubes, wound site, fluid Focused Assessment Cont.:Palpation

  15. Focused Assessment:Auscultation

  16. Normal Breath Sounds

  17. Continuous sounds Wheezes Sibilant Sonorous (Rhonchi) Discontinuous sounds Crackles (Rales) Fine Course *Atelectic crackles Pleural friction rub Adventitious/AbnormalBreath Sounds (T 11-2) p.132

  18. Wheezes (Continuous) Sibililant wheeze • high-pitched musical sounds heard first when a patient exhales • Partial blockage in airflow Sonorous wheeze (rhonchi) • low pitched – snoring, rattling sound heard primarily when the pt exhales • Air passes through large airways filled with fluid/ secretions

  19. Crackles (Discontinuous) • FINE /COURSE • Caused by collapsed or fluid-filled alveoli popping open • usually heard in the lung bases during inhalation • Atelectic crackles • Pleural friction rub – pericarditis

  20. Abnormal Breath Sounds • Diminished breathsounds • Absent breath sounds

  21. Interpreting what you hear… • Note whether the sound occur during inhalation or exhalation, or both.

  22. Assessment Guide: Gas Exchange • Respiratory • Rate: 18 resp/min • Depth: deep, even, shallow • Effort: labored, unlabored • Breath Sounds • Describe: clear, rhonchi, inspiratory/expiratory wheezes, crackles • Location: all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat. • Cough: present/not present • Describe: productive, moist, nonproductive • Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.

  23. Interventions in use: • Position, Turn, Cough, Deep breathe • O2 Method: nc, venti mask, rebreathing mask • Flow rate: 2L/min; 3l/min • Humidity: yes/no • Pulse Oximeter: continuous, spot monitoring • Incentive Spirometer: in use, n/a • Time used: 10 am, 11 am, 1 pm, 3 pm • Volume: 500 cc, 500 cc, 600 cc, 800 cc • Oropharyngeal Suctioning: Describe- moderate amount thick tan secretions • Med List: Albuterol inhaler, Prednisone, Theophylline

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