Lecture 3: Respiratory Assessment Flashcards
Anterior
Front View
Posterior
Back View
Mechanics of Respiration
Four functions of respiratory system
- Control of respiration
- Changing chest size during respiration
- Inspiration
- Expiration
2. Diaphragm drops, intercostals expand rib cage. Negative pressure in lungs, air rushes in, chest size expands
3. Forced Inspiration
- Heavy exercise, resp distress
- Neck muscles bring up the sternum and rib cage (accessory muscles of respiration)
4. Forced Expiration
- Abdominal muscles contract to push abdominal viscera in and up against diaphragm causing it to move upwards as a dome and squeeze against the lungs
Developmental Considerations: Infants and children
- Vulnerability related to small size and immaturity of pulmonary system + because they need air
- Typically problems occur because of resp. system
- Flexibility in sequence of the exam
- Crying enhanced palpation of tactile fremitus
- Thoracic cage soft and flexible
- Sternal or intercostal retractions indicate distress
- Respiratory rate and pattern
- On auscultation, localization of breath sounds more difficult
- Percussion of limited use in newborns
Developmental Considerations: Pregnant Women
- Enlarging uterus elevated diaphragm; decreases vertical diameter of thoracic cage, compensated by increase in horizontal diameter
- Decreases are used to take breathe
Developmental Considerations: Older Adults
- Lungs more rigid and harder to inflate
- Decrease in vital capacity
- Increase in residual volume
- Decrease in number of alveoli
- Increase shortness of breath on exertion
- Increased risk for postoperative complications
- Typically the heart that causes problems
- Round, barrel-shaped thoracic cage and kyphosis
- Chest expansion somewhat decreased
- Less mobile thorax
Developmental Considerations: Acutely Ill Patients
- Second examiner needed to support patient in upright position for exam
Cultural and Social Considerations
- New and re-emerging of TB in Canada (2010) at unprecedented national low
- Variation in rates by jurisdiction; disproportionately high in Nunavut
- Asthma rates down, but contributing factor in 10% of hospital admissions of children age less than 5 years
- Preventable risk factors for respiratory disease: tobacco smoke, poor air quality
- Lung cancer is leading cause of cancer death in Canada
- Women incur greater lung damage from exposure to environmental tobacco compared with men
- Health practices are modifiable
- Women have worse repercussions from tobacco than men
Environmental Tobacco Smoke
- Second-hand/third-hand smoke risk
- Exposure to both increases risk of adverse health effects
- Especially harmful to young children
- Increased
- Respiratory infection
- Inner ear infection
- Aggravation of asthma
- Increased risk of allergies
Health History Questions
- Cough (wet or dry, is anything coming up, how long does it last, when did it start)
- Shortness of breath (when it occurs, is there a pattern, chest pain)
- Chest pain with breathing
- History of respiratory infections (another resp infection, new infection)
- Smoking history (have you ever smoked? do you smoke? how much did you smoke? have they considered quitting?)
- Environmental exposure (their occupation, living environment)
- Self-care behaviours (nutrition, allergies, using scents, vaccines, sleeping behaviours, stress)
- OPQRSTU (Onset, quality, radiation, timing, what do you think it could be?)
Additional Health History Q’s: Infants and children
- Illness - frequent cold
- Allergy
- Chronic respiratory illness
- Safety - childproofing; inhalation of toxic substances
- Environmentals smoke
Additional Health History Q’s: Older Adults
- Activity intolerance (shortness of breath?)
- Level of activity
- Lung disease (any history for for them or in family)
- Pain
Mandatory Health History Questions to ask
- PMHx
- Fam/SC Hx
- Meds
- Allergies
- ROS
- Immunizations
History Questions for infants and children
- 4-6 colds per year?
- Smokers at home?
- Child-proof/choking hazards?
- New foods introduced?
- Emergency care interventions? Do parents know CPR?
Physical exam: Preparation
- Position
- Draping
- Timing during a complete examination
- Cleaning stethoscope endpiece
Equipment needed
Stethoscope
Resp Assessment (IPPA): Inspect
- Thoracic cage (posterior)
- Shape and configuration of chest wall
- Anteroposterior/transverse diameter
- Position patient takes to breathe
- Skin colour and condition - Thoracic cage (anterior)
- Shape and configuration of chest wall
- Facial expression
- LOC
- Skin colour and condition
- Quality of respirations
- Rib interspaces
- Accessory muscles
(LOC) Level of Consciousness
- AVPU Scale
- Alert: answers questions
- Voice: responds to commands
- Pain: responds to painful stimuli
- Unresponsive: no response to voice or painful stimuli - Function of resp system is to exchange gases
- Inhales oxygen
- Breathe out carbon dioxide - Purpose of oxygen in our body?
- Cells need oxygen to function
- Limited ability to function without it
- Keeps brain, heart, and other tissues working
No oxygen = hypoxia brain starts to shut down, decreasing LOC
Facial Expressions
- Calm, relaxed
- Easily breathing, focused on other things - Fearful, panicked
- Trouble breathing expercing anxiety
Skin colour and condition
- Look at face, fingers/toes, posterior and anterior chest
- Cyanotic = blue
- Cyanosis = deoxygenated blood
- Pallor = reduced or absent blood flow (ischemia)
- Pallor = pale
Clubbing
Nail clubbing occurs when the tips of the fingers enlarge and nail curve around the fingertips, usually over the course of years
What is the normal anteroposterior to transverse diameter?
AP:T
Normal is 1:2
What is barrel chest?
Chest wall compensates by expanding, bad
Supine
Lying flat on their back
Prone
Lying flat on their abdomen
Fowler’s position
Sitting upright
Inhalation
Diaphragm contacts (Moves down)
Exhalation
Diaphragm relaxes (Moves up)
Normal Respiration
- Inspiration: Active process, uses energy
- Expiration: passive process, doesn’t use energy
Difficulty Breathing
- Inspiration: Active process + accessory muscle use
- Expiration: Active processTr
Tripod Position
- Easier inspiration and expiration
- Decreases work of accessory muscles in inspiration
- Engages pectoralis minor muscle in lifting rib cage
- i.e. post workout, asthma attack
Palpation
- Chest Wall
- Symmetrical chest expansion
- Tactile fremitus
- Superficial lumps or masses
- Skin - temperature, moisture, turgor
- No pain or tenderness
- No hypertrophy of the neck muscles (trapezius, sternocleidomastoid)
- Straight line of spinous process, symmetrical scapula (posterior)
Steps of Symmetrical Chest Expansion
- Place your hands on the anterior/posterior chest
- Thumbs pointing upwards
- Ask the patient to take a deep breath
- Watch your thumbs. Both should move equally and smoothly
Asymmetrical Lung Expansion
What if only one of your thumbs moves when the patient takes a deep breath?
There is UNEVEN lung expansion which is abnormal:
- Pneumothorax
- Pneumonectomy
Tactile Fremitus
- Vibration of chest wall
- Result of sound transmitting through lung tissue - Assessment
- Examiner feels for changes in intensity of fremitus by palpating chest wall - Causes of decreased fremitus
- Excess air in lungs
- Increased thickness of chest wall - Causes of increased fremitus
- Lung consolidation
- Air in healthy lung replaced with something else (inflammatory exudate, blood, pus, cells)
Have the patient say 99, feel the vibration, is it symmetrical?
Percussion
- Predominant note over lung fields
- Resonance
1) Place one hand, with your middle finger flat, on the patient
2) Use the middle finger of the other hand to tap on the middle phalanx
3) Produce a hollow tapping sound - Usually only hear resonance from back (you shouldn’t hear anything else because no organs)
*Flatness: bones such as the clavicle, ribs, sternum
*Dullness: dense organs such as the liver, spleen, heart
*Resonance: adult lung
*Hyperresonance: child lung
*Tympany: abdominal area such as intestines and stomach
Hyperresonance
- Lower pitched booming sound when too much air is present
i.e pneumothorax, emphysema
Dull
- Abnormal density in lungs
i.e. pneumonia, pleural effusion, atelectasis tumor
Auscultation
Anterior:
- Breath sounds: Abnormal breath sounds, adventitious sounds, include lateral chest
Posterior:
- Breath sounds: Technique, bronchial breath sounds - characteristics, bronchovesicular breath sounds - characteristics, vesicular breath sounds - characteristics
- Adventitious sounds: crackles, wheeze, atelectatic crackles
Adventitious Lung Sounds
Discontinuous:
- Crackles - fine
- Crackles - coarse
- Atelectatic crackles
- Pleural friction rub
Continuous:
- Wheeze - high pitched (sibilant)
- Wheeze - low pitched (sonorous rhonchi); almost leading to crackles
- Stridor - inability to get air in
Breath Sounds: Broncial
High pitch, loud volume (trachea, larynx) = HARSH
Breath Sounds: Bronchovesicular
Moderate pitch, moderate volume (major bronchi around sternum in 1st and 2nd intercostal spaces around scapula posteriorly) = MIX
Breath Sounds: Vesicular
Low pitch, low volume (peripheral lung field with bronchioles, alveoli) = RUSTLING LEAVES
Adventitious breath sounds
- Added sounds not normally heard
- Superimposed on normal breath sounds
- Location?
- Right Lower Lobe?
- Right Middle Lobe
- Left Upper Lobe - Timing during resp cycle?
- Cleared by coughing or deep breaths?
- Crackles (rales)
- Fine and coarse
- Atelectatic crackles cleared by coughing
- Wheeze (rhonchi)
- High and low pitched
- Pleural Friction Rub - like hair rubbing on your stethoscope sound
- Stridor - a gasp
Tachypnea
“Fast breathing”
> 20 breaths/min
Bradypnea
“Slow breathing”
< 10 breaths/min
Apnea
“Lack of breathing”
Period of time without breathing
Hyperventilation
Increased rate and depth
Cheynes-Stokes Respiration
Can tell us they are nearing death, waxing and waning sound (breathing sound) -> shows the end is near
Normal infants and older adults during sleep
Developmental Considerations: Infants/Children
- Assess while sleeping
- Count resp. for one minute
- Round thorax, apneic periods
- Bronchovesicular up to 6 years
Developmental Considerations: Older Adults
- Kyphosis
- Fatigue during auscultation
Measurement: Pulmonary Function Status
Pulse Oximeter
- Values evaluated in context of patient’s hemoglobin level, acid-base balance, and ventilatory status
Measurement: % of Hemoglobin Carrying Oxygen
> 92% for most clients, exception: 88-92% with COPD need to look at all respiratory data
Abnormal Findings
- Configurations of the Thorax
- Barrel chest (when lungs become overfilled, keeping the rib cage extended for a longer period of time)
- Scoliosis (sideways curvature of the spine)
- Kyphosis (an increased front-to-back curve of the spine)
Respiratory: Infants
- Bronchovesicular sounds auscultated
- Thin chest wall means louder breath sounds
- Normal newborn respirations between 30-40/minute
- Diaphragm is main source of inspiration/expiration
- Poorly developed intercostal
Respiratory: Pregnancy
- Increased costal angle
- Deeper respirations
- Increased tidal volume (need more O2 for the fetus)
