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NUR240

NUR240. Assessment of the Respiratory System. Anatomy and Physiology Review. Upper respiratory tract -nose, sinuses, oropharynx, larynx Lower respiratory tract- trachea,bronchi, bronchioles,alveolar ducts and alveoli Lungs Accessory muscles of respiration

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NUR240

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  1. NUR240 Assessment of the Respiratory System J Borrero 10/08

  2. Anatomy and Physiology Review • Upper respiratory tract -nose, sinuses, oropharynx, larynx • Lower respiratory tract- trachea,bronchi, bronchioles,alveolar ducts and alveoli • Lungs • Accessory muscles of respiration • Respiratory changes associated with aging

  3. Controls of Ventilation and Respiration • Reflex Control- receptors in brainstem/medulla coordinate diaphragm and intercostals Effects of pCO2 Effects of pO2 Other stimuli Voluntary control

  4. Respiratory Terms Ventilation- process of moving gases into and out of the lungs Diffusion- process for the exchange of respiratory gases in the alveoli and the capillaries: O2 from lungs to blood CO2 from blood to alveoli and exhaled Perfusion- circulation of blood through lungs

  5. Assessment Techniques Collect history of client data on family, personal, smoking, drug use, allergies, travel, place of residence, dietary history, occupational history, and socioeconomic level. Assess current health problems such as: chief complaint cough sputum production chest pain dyspnea

  6. Physical Assessment • Assessment of the nose and sinuses • Assessment of the pharynx, trachea, and larynx • Assessment of the lungs and thorax • Inspection • Palpation, check fremitus • Percussion • Auscultation

  7. Breath Sounds Rate, Depth, Symmetry, Absence or diminished sounds Note: Dyspnea, Kussmaul’s, Cheyne-Stokes Normal breath sounds include: -Bronchial -Broncholvesicular -Vesicular Adventitious breath sounds include: • Crackle • Wheeze • Rhonchi • Pleural friction rub

  8. Other Assessments Assess for vocal resonance: • Bronchophony • Whispered pectoriloquy • Egophony Skin and mucous membranes General appearance Endurance

  9. Psychosocial Assessment • Some respiratory problems may be worsened by stress. • Chronic respiratory disease may cause changes in family roles, social isolation, and financial problems due to unemployment or disability. • Discuss coping mechanisms and offer access to support systems.

  10. Laboratory Tests • Blood tests- (CBC :*RBC) , ABG • Sputum tests • Radiographic examinations including standard chest x-rays (PA and lateral), digital chest radiography, CT • V/Q scan-identify area of lung being ventilated and distribution of blood in the lungs, to dx PE • Pulse oximetry-identify hemoglobin saturation.Ideal normal is 95%-100% SaO2 or SpO2

  11. Measuring oxygen concentration • 02 Saturation- SpO2 uses pulse oximeter. This measures % of available Hgb saturated O2 (SaO2) • ABG- determines actual % of O2 in blood (PaO2)

  12. Pulmonary Function Testing • These tests evaluate lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation. • Client preparation • Procedure for performing tests at the bedside

  13. Measurements Vital Capacity (VC) -maximal amount of air that can be inhaled/exhaled in one breath Inspiratory and Expiratory Reserve Volume (IRV,ERV)- amount of air that can be forcibly inspired/expired at the end of normal breath Residual Volume-(functional residual capacity)- Air trapped in alveoli after forcible expiration Tidal Volume -volume of each breath (inhaled and exhaled) during normal breathing Peak expiratory Flow- useful indicator of airway status and effectivrness of bronchodilators.

  14. Other Testing and Follow-Up Care • Exercise testing-WHY? • Skin testing- WHY? • Endoscopic examinations- bronchoscopy,laryngoscopy, mediastinoscopy • Pulmonary Angiogram- outlines obstruction in pulmonary blood vessels eg.PE

  15. Thoracentesis • Used for both Dx and Tx • Aspiration of pleural fluid or air from the pleural space • Obtain consent • Client prep for stinging sensation and feeling of pressure • Correct position & motionless • Follow-up assessment for complications: pneumothorax and mediastinal shift Vital signs and breath sounds Observe puncture site and dsg Assess for SQ emphysema, infection, tension pneumthorax Encourage client to C&DB Document procedure, volume & character of fluid removed, location of site and client respiratory status.

  16. Lung Biopsy • Performed to obtain tissue for histologic analysis, culture, or cytologic examination • Client preparation- • Closed vs Open • Follow-up care: • Assess vital signs and breath sounds at least every 4 hours for 24 hours. • Assess for respiratory distress. • Report reduced or absent breath sounds immediately. • Monitor for hemoptysis.

  17. ABG Interpretation • What is acidosis??? • What is alkalosis??? Let’s look at: • pH acidotic or alkalotic? • PaO2 • PaCO2 • HCO3 • O2 Saturation

  18. ABG Normal Ranges

  19. Acid/Base MnemonicRemember ROME • RRespiratory • OOpposite pH up PCO2 down = AlkalosispH down PCO2 up = Acidosis • MMetabolic • EEqualpH up HCO3 up = AlkalosispH down HCO3 down = Acidosis

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