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When assessing the present health status of a patient, symptoms of allergies, difficulty breathing and orthopnea could indicate respiratory disorders. The patient should be asked about?
The use of inhalers or oxygen at home
Assessing a patients smoking history is an important aspect of the respiratory assessment. The information should be recorded as?
The number of pack years the individual has smoked, even if he or she has already quit.
There are multiple environmental factors that can affect breathing. These include?
Air pollution, allergens in the home, and any air filtering systems in the home, hobbies and exposure to secondhand smoke.
During the part of the interview process that focuses on the respiratory system, the nurse should ask questions about the patients?
Home environment, occupational environment, and any travel that may have affected the function of the lungs
A cough may be associated with respiratory condition or caused by other problems. The patient should be asked to describe?
the cough, any sputum that is produced, and other symptoms, and what measures are used to treat he cough.
Causes of shortness of breath in a patient should be clarified. Dyspnea can be indicative of?
Respiratory or cardiac conditions. The patient should be asked to describe what makes the difficult breathing better or worse.
Common infectious respiratory conditions that may be encountered are?
acute bronchitis, pneumonia, tuberculosis, and pleural effusion.
chronic conditions include asthma, emphysema, and chronic bronchitis
Pneumonothorax and hemothorax are most often related to a?
traumatic incident. These conditions can also be associated with surgical procedures.
Inspection-Inspect for general appearance, posture, and breathing effort
Normal-
Abnormal-
Normal- The general appearance and posture should be relaxed. Breathing should be effortless, quiet, and rate is age appropriate
Abnormal- Indications or respiratory distress include an appearance of apprehension with restlessness, nasal flaring, retractions, and tripod positioning.
Observe respiration for rate, breathing pattern, and chest expansion.
Normal-
Abnormal-
Normal- Adult passive breathing is 12-20 BPM known as eupnea. The pattern should be smooth with an even respiratory depth. Symmetric rise and expansion should occur.
Abnormal-Bradypnea, tachypnea, hyperventilation, kussmaul respirations, Biot’s and cheyne-strokes patterns.
Inspect patients nails, skin, and lips for color.
Normal-
Abnormal-
Normal- Nail beds should be pink with an angle of 160 degrees at the nail bed. Skin tones vary among individuals thereby noting the general color of the client and observing if it is consistent with skin and lip color. Note presence of pallor or cyanosis
Abnormal-Cyanosis may be noted in a client with shortness of breath or dyspnea. Long term lung disease can cause spooning of the nail base greater than 180 degrees.
Inspect posterior thorax for shape, symmetry, and muscle development.
Normal-
Abnormal-
Normal- The ribs should slope down at about 45 degrees relative to the spine. The thorax should be symmetric. The spinous processes should appear in a straight line. The scapulae should be bilaterally symmetric. Muscle development should be equal.
Abnormal- Asymmetry or unequal muscle development is abnormal. Skeletal deformities such as scoliosis or kyphosis may limit the expansion of the chest. Patients with COPD may have a barrel-shaped chest.
Bronchovesicular breath sounds are?
moderate in pitch, medium in intensity, auscultated over the 1st and 2nd ICS at the sternal border and the inspiratory and expiratory duration should be equal
Vesicular breath sounds are?
Low in pitch, soft in intensity, auscultated over the inspiratory phase duration is greater that the expiratory phase duration.
Bronchial breath sounds are?
are high in pitch, loud in intensity, auscultated over the trachea, and the duration of the inspiratory phase is less than the duration of the expiratory phase.
Adventitious breath sounds are?
if heard, have patient cough, and then repeat the auscultation to note whether the adventitious sounds changed or disappeared
Fine crackles
Fine, high-pitched crackling and popping noises heard during the end of inspiration; not cleared by cough
Clinical examples- may be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases.
Medium crackls
Medium pitched, moist sound heard about halfway through inspiration; not cleared by cough.
clinical examples- may be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases but condition is worse than those with fine crackles.
Coarse crackles
Low pitched, bubbling, or gurgling sounds that start early in inspiration and extend into the first part of expiration.
clinical examples- may be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases. condition is worse in terminally ill patients with diminished gag-reflex; also heard in pulmonary edema and pulmonary fibrosis.
Wheeze
High-pitched, musical sound similar to a squeak; heard more commonly during expiration but may also be heard during inspiration, occurs in small airways
clinical example- heard in narrowed airway diseases such as asthma.
Rhonchi
Low-pitched, coarse, loud, low snoring or moaning tone; actually sounds like snoring; heard primarily during expiration but may also be heard during inspiration; coughing may clear
clinical example- heard is disorders causing obstruction of the trachea or bronchus such as chronic bronchitis
Pleural friction rub
superficial, low pitched, coarse rubbing or grating sound; sounds like two surfaces rubbing together, heard throughout inspiration and expiration; loudest over the lower anterolateral surface; not cleared by cough
clinical example- heard in individuals with pleurisy (inflammation of the pleural surfaces)
Inspect the anterior thorax for shape, symmetry, muscle development, and costal angel. The costal angel should be? The anteroposterior diameter is about?
The costal angel should be <90 degrees
the anteroposterior diameter is about 1/2 the lateral diameter or about a 1:2 ratio of AP to lateral diameter.
Older Adult: Assessing the respiratory status of an older adult follows the same procedures as for an adult, although structural and functional differences may be noted
posterior thoracic stooping or bending or kyphosis may alter the thorax wall configuration and make thoracic expansion more difficult
When conducting a comprehensive assessment, the patient should be asked about the presence of disease affecting mobility. This includes?
Osteoporosis, arthritis, fractures, and a history of accidents or trauma.
The point where two or more bones come together
Joints
Ligaments-
Tendons-
Ligaments are flexable connective tissues that adhere bones to bones.
Tendons are nonelastic cords that are located at the end of muscles and attach muscles to bones
Common problems associated with bones are?
fractures and osteoporosis. Conditions associated with the joints are rheumatoid arthritis, osteoarthritis, burtitis, and gout.
Conditions related to the spine are?
herniated nucleus pulposus and scoliosis.
Problems linked with ligament or muscle conditions are known as?
carpal tunnel syndrom
Observe patient standing and straight from front, back, and sides.
Normal
Abnormal
Normal- the body should be symmetric. The spine should be straight with expected curvatures-cervical is concave; thoracic is convex; and lumbar is concave
Abnormal- Kyphosis, scoliosis,and lordosis
Inspect muscles for size and symmetry.
Normal-
Abnormal-
Normal- Muscle size should appear relatively symmetric
Abnormal- Atrophy of muscle mass bilaterally may indicate lack of nerve stimulation such as spinal cord injury. Fasciculations (muscle twitching) may be caused by adverse effects of drugs. Fasciculations are localized whereas spasms are more generalized.
Palpate bones for tenderness; joints for tenderness, heat, and edema; and muscles for tenderness, heat edema, and tone.
Normal
Abnormal
Normal- Bones should be non-tender on palpation. No tenderness or edema should be detected on palpation of joints or muscles. The joints and muscles should be the same temperature as the surrounding tissue. Muscles should feel firm, not hard or soft.
Abnormal- Tenderness, heat, or edema over bones, joints or muscles may indicate tumor, inflammation, or trauma. Muscle atrophy may be evident by decrease in muscle tone.
Assess range of motion for major joints and adjacent muscles, for tenderness on movement, joint stability, and deformity. (know which types of movements are associated with each type of joint, refer to table 14-1)
Normal-
Abnormal-
Normal- There should be full range of motion actively and passively with joint stability but without tenderness, heat, edema, crepitus, deformity, or contracture.
Abnormal- Crepitus which occurs after injury; limited range of motion; increased range of motion; joint instability or deformity may indicate a number of disorders including muscle weakness, fracture, inflammation, strained ligaments, or meniscus tear.
Observe gait for conformity, symmetry, and rhythm
Normal-
Abnormal-
Normal- Expected findings are cnformity (ability to follow gait sequencing of both stance and swing); regular smooth rhythm; symmetry in length of leg swing; smooth swaying; and smooth, symmetric arm swing.
Abnormal- An unstable or exaggerated gait, limp, irregular stride length, arm swing that is unrelated to gait, or any other inability to maintain straight posture or asymmetry of body parts requires further assessment.
Head and Neck INSPECT PALPATE OBSERVE PALPATE OBSERVE TEST
INSPECT musculature of the face and neck for symmetry.
PALPATE each temporomandibular for movement, sounds, and tenderness.
OBSERVE jaw for range of motion.
PALPATE the neck for pain.
OBSERVE the neck for range of motion.
TEST neck muscles for strength.
Objective: Identify findings from a musculoskeletal system assessment that would require further evaluation.
- Rheumatoid arthritis flares
* Gout
Tissue integrity refers to the?
intactness and function of the skin, hair, and nails. To maintain tissue integrity, the body needs adequate nutrition and oxygenation to carry nutrients to the tissue.
There are three main components of the skin.
- The epidermis is the outermost layer and provides no blood supply.
- The dermis is a layer which is highly vascular and regulates body temperature. It also contains sensory nerve fibers, which provide reactions to touch, pain, and temperature.
- The hypodermis is a subcutaneous layer composed of fat. Fatty cells help with heat regulation and provide protection against injury.
The most common reported skin condition is?
Pruritus (Itching).
Other common findings associated with the skin are rashes, pain, discomfort, lesions, wounds, and changes in skin color or texture.
Skin conditions common in infants and children are related to?
Diaper rashes and allergies
The most common concern in the adolescent is?
Acne
Significant changes occur in older adults with regard to?
Skin and hair
Common skin conditions that may be encountered are
corns, dermatitis, and psoriasis
Skin lesions caused by viral infections are?
warts, herpes simplex, herpes varicella (chickenpox) and herpes zoster (shingles)
Lesions of a fungal nature are ?
tinea infections and candidiasis
