3.1 Respiratory Assessment Flashcards
Respiratory System
The stimulus to breathe includes
Hypercapnia - Increased CO2
Hypoxia - Decreased O2
Inspiration (Breathing In) - Creates negative pressure
Expiration (Breathing out) - Creates positive pressure
Review of Systems Cough (ROS)
Cough - When did it start? - How Often? - Hacking? - Dry Acute Cough - Lasts 2-3 Weeks Chronic Cough - More than 2 Months Timing of the cough is important. - Respiratory Illness cough is continuous - Work irritants cough is in the afternoon - Sinus issues cause coughing at night - Bronchial Cough (Smokers Cough) happens in the morning
Review of Systems (Sputum)
Color and consistency - White is Viral - Yellow/Green is Bacterial - Pink and Frothy is indictive of Pulmonary Edema Bloody (Hemoptysis) - May indicate tuberculosis
Review of Systems (SOB)
What brings it on? How long does it last? What time of day does it occur? Noticeable Cyanosis? How many pillows do you sleep with? Orthopnea: SOB when supine
Review of Systems (Other Issues)
Chest Pain? Muscle Soreness from coughing? History of smoking? Flu/PNA Vaccines? Screened for TB?
Respiratory System Physical Inspection
- Begin inspecting the Thorax
- Anything you inspect Anterior you must also inspect Posterior
Inspect Thoracic cage shape, configuration, and color
- Anteroposterior (AP) diameter should be less than Transverse diameter roughly 1:2
- Skeletal deformities can limit Thoracic Cage Excursion (How much it expands and closes)
Barrell Chest - AP diameter equals Transverse Diameter
Chest looks like it is in constant inspiration. Common in COPD Patients.
Respiratory System Physical Assessment
Skeletal Deformities
Kyphosis - Outward curve of spine “Hunchback”
Scoliosis - Sideways curve of spine
- Patient facial expression indicates unconscious breathing patterns.
- Lips and nail bed should be free of cyanosis. Nails should not be clubbing (hypoxia)
Respiratory System Palpation
- Palpate chest over lung fields. Note lumps lesions and temperature
- Assess chest expansion by placing hands on posterolateral chest wall with thumbs at T9 and T10 vertebrae
Ask patient to take a deep breath, thumbs should move symmetrically.
Atelectasis, Pneumonia, Pleural Effusion - Unequal Expansion
Respiratory System Palpation
Pain when palpating could mean Pleural Inflammation
99 Test - Test Tactile Fremitus (Vibration)
- Place ulnar side of palm over lung fields and have patient repeat 99 noting vibration of palm
- Decreased Fremitus (vibration) may suggest obstruction or thickening, increased fremitus may mean consolidation (air that fills small airways is replaced with something else) (pneumonia).
Respiratory System Palpation
- Assess for Crepitus (crackling) with light palpations
ABNORMAL - Coarse Crackling felt over skin caused by air escaping from lungs into subcutaneous tissue. Common with COPD and Emphysema.
Respiratory System Percussion
Resonance - Low pitch, clear, hollow sound over lung tissue.
Hyperresonance - Lower pitched booming sound. Too much air (emphysema, pneumothorax).
Dull - Soft and muffled thuds signals abnormal densities. (Pneumonia, pleural effusion, atelectasis)
Respiratory System Percussion
Percuss borders of lungs (resonance)
Percuss abdominal viscera (tympani)
Space between the 2 sounds is the diaphragm, which should be 3-5 cm.
- Resonance can sound duller in obese or muscular people.
Auscultation of Respiratory System
- When listening, stand behind patient on posterior side of apices (top of lung) at c7 vertebra to base around t10 vertebra. Then from axilla down to 7-8th rib.
- Press hard enough with stethoscope to make imprint.
- Patient should take deep breath at each side
Normal Sounds for Respiratory System
Bronchial - Heard on anterior side, high pitched, loud, prominent during expiration. Harsh and hollow.
Vesicular - Low-pitched, soft, heard more during inspiration. “Rustling winds through trees”
Bronchovesicular - Moderate pitch and amplitude, heard equally in inspiration and expiration.
Abnormal Sounds
- Decreased or absent sounds maybe obstruction, mucus plug, loss of elasticity (emphysema), pleural thickening, and presence of fluid.
Fine Crackles
(Heard when air collides with previously deflated airways)
Fine Crackles - High pitched, short, crackling sounds during inspiration. NOT CLEARED when coughing.
Late inspiration - restrictive disease, pneumonia, or heart failure.
Early inspiration - Obstructive disease, chronic bronchitis, asthma, emphysema.
Coarse Crackles
(Air inhaled collides with secretions in the trachea and large bronchi)
- Loud, low pitched, bubbling or gurgling. Decrease with coughing and suctioning but reappear.
- Due to pulmonary Edema, pneumonia, depressed cough reflex.
Atelectasis Crackles
(Alveoli are not fully aerated, they deflate and accumulate secretions.)
- Similar to fine crackles but do not last. They disappear with deep breathing and coughing.
- Common in post-op patients, or bedridden patients.
High pitched Wheeze
Musical squeaking that sound polyphonic (multiple pitches at once)
- Usually heard during expiration but sometimes inspiration as well.
- Occurs when air is squeezed through narrow airways.
- Common with diffuse airway obstructions like Asthma or Chronic Emphysema.
Low Pitched Wheeze
- Monophonic single pitched musical snoring or moaning, may clear somewhat with coughing.
- Caused by airway obstruction with bronchitis, bronchus obstruction, or an airway tumor.
Stridor
High-pitched monophonic inspiratory crowing sound.
- Louder in neck than chest walls and can be heard with stethoscope.
- Caused by upper airway obstruction and indicates inflamed tissue, lodged foreign object, croup.
- In children signifies acute epiglottis.
- No air is being let in or out (LIFE THREATENING)
Pleural Friction Rub
- Superficial sound that is coarse.
- Caused when pleurae become inflamed and lose normal lubrication.
- If pain is present with a rub it is called “Pleuritis”
Developmental Concerns for Infants
- Let infants hold infant, supported by head or chest.
- Children can sit in parents lap
- Infants have barrel chest until age 6.
After age 6 maybe asthma or cystic fibrosis. - Depressed Respiratory rate can be from maternal drugs, low intrauterine blood supply, or obstruction.
Special Conditions for Newborns
- Chest circumference should be smaller than head circumference until 2 y/o. Chest wall should be thin with little musculature.
- Newborns first respiratory assessment is part of APGAR scoring.
- Infants breathe through nose rather than mouth until 3 months. (No flaring of nostrils, sternal retractions, or intercostal retractions unless infant is in respiratory distress)
- Diaphragm is major respiratory muscle for newborns, not intercostal, so inspirations are seen more in abdomen.
Special Conditions in Pregnant Women
- Thoracic Cage may be wider
- Respirations may be deeper. (Can only be quantified with pulmonary function tests)
- Due to pressure of growing uterus on women’s diaphragm.
Special Conditions in Elderly
- May have increased anteroposterior (AP) diameter.
(Barrel Shape, Kyphosis) - Because of decreased subcutaneous fat you may palpate bony prominences
- Patient may fatigue easily, especially during auscultation, when deep mouth breathing is required.
Broncophony (Special Lung Test)
Tell patient to repeat 99 while listening to chest wall with stethoscope.
- Normal is soft, muffled, and indistinct.
- Pathology that increases lung density enhances transmission voice sounds. Hearing a clear voice indicates consolidation.
Egophony (Special Lung Test)
Auscultate chest while patient goes “eeee”
- Should hear “eee”
- Areas of consolidation you hear “aaaa”
Whispered pectoriloquy (Special Lung Test)
- Ask patient to whisper phrase
- Normal response should be faint and muffled
- Phrase can be heard over areas of consolidation
Abnormal Findings
Sigh - Psychological condition, inhalations expand alveoli and can lead to hyperventilation
Tachypnea - Increased respirations (20+) possibly due to fever or exercise
Bradypnea - Decreased respirations (10-) due to diabetic coma or an overdose
Hyperventilation - Increased rate and depth of respiration. Blows off CO2 from ketoacidosis.
Hypoventilation - Shallow and decreased breathing that does not allow o2 in. Common with overdose
Cheyne-Strokes Respiration - Fast with periods of apnea (regular). Common with renal failure or overdose.
Biots - Like Cheyne strokes but irregular. Possibly due to heat stroke or meningitis.
Order of Assessment
- Inspect breathing pattern and position
- Remember you must assess front and back
- Assess rib cage symmetry and breathing
- Check thoracic expansion (put thumbs under the end of thorax and check for symmetry when breathing.
- Assess for crepitus (popping) on upper lungs
- Assess Terminus (ulnar hand saying 99)
- Percuss for resonance
- Check for diaphragmic excursion. (Have patient exhale , and hold her breath. Percuss until you feel dull sound (beginning of diaphragm). Then deep breath in and continue percussing until dull again.) end of diaphragm.
- Next is auscultation for wheezing
- Next auscultate with patient saying 99
