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منت خدای را عزوجل که طاعتش موجب قربت است و به شکراندرش مزید نعمت .

منت خدای را عزوجل که طاعتش موجب قربت است و به شکراندرش مزید نعمت . هر نفسی که فرو می رود ممد حیات است و چون بر می آید مفرح ذات. پس در هر نفسی دو نعمت موجود است و بر هر نعمت شکری واجب .

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منت خدای را عزوجل که طاعتش موجب قربت است و به شکراندرش مزید نعمت .

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  1. منت خدای را عزوجل که طاعتش موجب قربت استوبه شکراندرش مزید نعمت. هر نفسی که فرو می رود ممد حیات است و چون بر می آید مفرح ذات. پس در هر نفسی دو نعمت موجود است و بر هر نعمت شکری واجب. laudation to the theGOD of majesty and glory obedience to him is cause of approach and gratitude in increase of benefits.Every inhalation of the breath prolongs life and every expiration of it gladdens our nature. wherefore every breath confers two benefits and for every benefit gratitiude is due. گلستان سعدي

  2. ASSESSMENT OF THE RESPIRATORY SYSTEM M.MOHSENABADI STUDENT OF CRITICAL CARE NURSING(MSC)

  3. Objectives: The students will be able to: • Discuss assessment of Respiratory system • Discuss important points of assessment of Respiratory system • Obtain health history about respiratory system • Demonstrate physical examination • Differentiate between normal and abnormal findings

  4. Patient History • Respiratory infections or diseases(URI) • Trauma • Surgery • Chronic conditions of other systems • Irritation of airway • Signs of infectious process • History of TB, when treated? • Presence of cough ,Sputum? • Last PPD and/or chest x-ray • Allergies • Medication use URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  5. Patient History (cont,) • Any risk factors for respiratory disease • smoking • lifestyle, immobilization • Age • Environmental exposure • Dust, chemicals, asbestos, air pollution • Obesity URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  6. Patient History (cont,) Family Health History: • Tuberculosis • Emphysema • Lung Cancer • Allergies • Asthma URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  7. Shortness of Breath or Dyspnea • Onset – sudden,…. • Duration • Severity – disrupts activities • Associated symptoms – night sweats, pain, chest pressure, discomfort, ankle edema, diaphoresis, cyanosis • What brings it on? – position, time of day, exercise, allergens, emotions • What makes it better? • What has been tried? – medications, inhalers, oxygen URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  8. Cough • Type • dry, moist, wet, productive,…… • Onset • Duration • Pattern • activities, time of day, weather • Severity • Wheezing • Associated symptoms • Treatment and effectiveness URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  9. sputum • amount • color • presence of blood (hemoptysis) • odor • consistency • pattern of production URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  10. Listen to the patient… …they will tell exactly what is wrong!

  11. Physical Examination

  12. The basic steps of the examination • Inspection • Palpation • Percussion • Auscultation URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  13. Inspection • General • Appearance • Posturing • Breathing effort • Trachea position • Midline ودياليز،عسگری،محمدرضا، 1390. ICU,CCUمراقبتهاي پرستاري ويژه در بخش های

  14. Inspection (cont,) • Tracheal deviation (can suggest oftension 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 URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  15. Inspection (cont,) • Chest Wall Configuration • Form • Symmetry • Muscle development • Anterior-Posterior (AP) diameter • Costal angle ودياليز،عسگری،محمدرضا، 1390. ICU,CCUمراقبتهاي پرستاري ويژه در بخش های

  16. Inspection (cont,) • Oxygenation: cyanosis • Nails • Skin • Lips • Respiratory Effort • Respiratory rate and depth • Breathing pattern • Chest expansion URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  17. Thoracoplasty with secondary changes in the spine. Tension Pneumothorax FLAIL CHEST Kyphosis

  18. Reference Lines • Anterior Chest • Midsternal line • Anterior axillary lines • Midclavicular lines • Posterior Chest • Vertebral line • Midscapularlines • Axilla • Anterior axillary lines • Midaxillary lines • Posterior axillary lines BURGHARD.J ,2011,Critical care nursing made incredibly easy.

  19. Anterior Chest

  20. Posterior Chest

  21. Axilla

  22. Palpation • Thoracic Expansion (Excursion) • Place both thumbs at about 7th rib posteriorly along the spinal process • Extend the fingers of both hands outward over the posterior chest wall • Have the person take a deep breath and observe for bilateral outward movement of thumbs • Normal: bilateral, symmetric expansion • Abnormal: unilateral or unequal URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  23. Palpation(cont,) • Vocal Fremitus • Use palmar surfaces of hands • Systematically position hands over both sides of posterior chest • Have person repeat “1 – 2 – 3” or “99” as you move from the apices to the bases • Normal: bilaterally symmetrical vibrations • Decreased or absent: obstruction of transmission 0bronchitis, emphysema) • Increased: consolidation (compression) of lung tissue (pneumonia)

  24. Percussion • Helps to identify if underlying tissues are air-filled, fluid-filled, or solid • Hyperextend middle finger of either hand and press against chest wall • Strike with flexed middle finger of opposite hand • Always percuss symmetrically on chest wall

  25. Percussion(cont,) • Flatness • Thigh • Dullness • Liver • Resonance • Lung • Hyperresonance • None • Tympani • Stomach, puffed cheek URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  26. Percussion(cont,) • Dullness replaces resonance when fluid or solid tissue replaces air containing lung • Pleural Effusions • Hemothorax • Tumor • Unilateral Hyper resonance • Pneumothorax • Generalized Hyperresonance • COPD URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  27. Auscultation • Auscultate in a systematic manner • Compare one side to the other • Listen one full respiration at each spot • Displace breast tissue to listen directly over chest wall • DO NOT listen through gowns, clothes, etc. • Place your stethoscope over bare skin URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  28. Auscultation(cont,) • Evaluate posterior, lateral, and anterior chest • Instruct person to sit upright and breathe in and out slowly through the mouth • This makes it easier to hear the air movement • Use the diaphragm of the stethoscope • To assess breath sounds, ask the patient to breathe in and out slowly and deeply through the mouth. URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

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

  30. Normal Tracheal Bronchial Bronchovesicular Vesicular Abnormal Absent/Decreased Bronchial Adventitious Crackles (Rales) Wheeze Rhonchi Stridor Pleural Rub Breath Sounds URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  31. 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

  32. Normal Breath Sounds (cont,) • Bronchovesicular • Intermediate intensity • Inspiratory = Expiratory sound duration • Heard best 1st and 2nd ICS anteriorly, and between scapula posteriorly • If heard in any other location suggestive of consolidation • Vesicular • Soft, low pitched sound • Inspiratory > Expiratory sounds • Major normal BS, heard over most of lungs

  33. Adventitious Breath Sounds • Crackles (Rales) • Discontinuous, intermittent, nonmusical, brief sounds • Heard more commonly with inspiration • Classified as fine or coarse • Crackles caused by air moving through secretions and collapsed alveoli • Associated conditions • pulmonary edema, early CHF,… URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  34. Adventitious Breath Sounds • Wheeze • Continuous, high pitched, musical sound, longer than crackles • Hissing quality, heard > with expiration, however, can be heard on inspiration • Produced when air flows through narrowed airways • Associated conditions • asthma, COPD URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  35. Adventitious Breath Sounds • Rhonchi • Similar to wheezes • Low pitched • continuous, musical sounds • Implies obstruction of larger airways by secretions • Associated condition • acute bronchitis URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  36. Adventitious Breath Sounds • Stridor • Inspiratory musical wheeze • Loudest over trachea • Suggests obstructed trachea or larynx • Medical emergency requiring immediate attention • Associated condition • inhaled foreign body URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  37. Adventitious Breath Sounds • Pleural Rub • Discontinuous or continuous brushing sounds • Heard during both inspiratory and expiratory phases • Occurs when pleural surfaces are inflamed and rub against each other • Associated conditions • pleural effusion, PTX URDEN, L. D. 2010. diagnosis and management. Thelan's critical care nursing, 567-595.

  38. Crackles (Rales) CHF Pneumonia Rhonchi Pneumonia Aspiration COPD Sometimes Asthma Stridor FBAO Croup Anaphylaxis Epiglottitis Airway burn Wheezing Asthma CHF COPD Adventitious Breath Sounds

  39. Summary Laryngeal-tracheal Stridor,Grunting,SubQ,Wheezing Tracheal-bronchiole Rhonci,Wheezing Bronchiol-alveoli Rales

  40. Refrences: • Urden, Linda D, 2010, Thelan's critical care nursing: diagnosis and management, St.Louis,Mosby - Elsevier, 5th • Burghard.J,2011, Critical care nursing made incredibly easy,3rd ed.Williams & Wilkins. • ذاكري مقدم م،علي اصغر پورم، 1381، مراقبتهاي پرستاري ويژه در بخش هاي ICU,CCU, ودياليز،انديشه رفيع. • عسگری،محمدرضا،1377، مراقبتهاي پرستاري ويژه در بخش هاي ICU,CCU, ودياليز،بشری.

  41. QUESTION?

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