Respiratory Assesment Flashcards
External Signs of Respiratory Distress
- Wheezing/coughing/gurgling
- Abnormal resp rate
- Anxiety
- Cyanosis/buccal mucosa
- Flared nostrils/pursed lips
- Intercostal recession
- Positioning eg tripod position
- Reduced lvl of consciousness
- Unable to complete a sentence in one breath
- Use of shoulder and neck accessory muscles
Environmental Indicators
- Cigarettes
- Home oxygen
- Medication - inhalers
- Infection
- Smells - gas, damp
- Chemicals, farming, fire
Meaning of Abnormal Auscultation; gurgling, snoring, stridor, wheezing
- Gurgling - fluid in the airway
- Snoring - partial occlusion caused by relaxed tissue eg tongue
- Stridor - partial obstruction of larynx or trachea
- Wheezing - lower respiratory - narrowing/inflammation
Breathing Assessment Steps (6)
- Obtain resp rate
- Expose and examine pt’s chest
- Palpate chest feeling for equal rise and fall, crepitus, tenderness, abnormalities. Feel for trachea being in the midline (sign of pneumothorax)
- Percuss for hypo/hyperresonance
- Auscultate for abnormal sounds
- Measure SpO2 and EtCO2
PC Questions
Do you have any pre-existing respiratory health problems? (asthma, COPD, emphysema, lung cancer)
Do you have any shortness of breath?
Is this normal for you?
Do you have any other symptoms?
Are these new or old?
HPC Questions
When did the problems start?
What were you doing when the problems started?
Has this ever happened before?
Do you have a cough? (dry? productive? sputum? yellow/green=infection, pink frothy=pulmonary oedema, blood?
Have you taken any prescribed medication? Did it help?
Do you have any pain, if so where?
PMH Questions
- Are you diagnosed with anything? specifically COPD, asthma and heart disease.
- Do you take any regular medication?
- Any allergies?
- Do you smoke?
Peak Expiratory Flow, what does it measure? Percentages for Asthma
Measures adequacy of ventilation, in the form of forced expiratory volume (FEV). Essential for asthmatic pt’s
- 33-50% (acute asthma)
- > 33% (life-threatening)
- In severe dyspnoea, pt may be unable to perform task
- Peak flow meter with a disposable mouth piece
- PEF should be recorded as best of 3 then compare to PEF flow chart or known normal value
- Take recordings pre and post treatment to note effectiveness
Ur looking at the chest, what coud be there?
Respiratory Assessment; Inspection. What are we inspecting for?
- Expose the chest incl posterior, anterior and axilla surfaces
- Chest wall marking = wounds, bruising, bleeding, swelling
- Implanted devices = pacemaker, implantable cardioverter defibrillator (ICD)
- Medication patches = analgesia, glyceryl trinitrate (GTN), nicotine
- Normal chest shape and equal rise
- Rashes = hives indicative of allergy or petechial haemorrhage indicative of meningoccal septicaemia (Meningitis)
- Resp rate noting abnormal patterns (Kussmaul’s, Cheyne-stokes)
- Scars with credible history
Respiratory Assessment; Where to Palpate (what to look for)
- Use both hands/finger to palpate the anterior, posterior and axilla walls starting above each clavicle then systematically progress down the anterior chest wall followed by posterior chest wall then axilla. Note:
-crepitus - fractures
-surgical emphysema - popping under the skin caused by trapped air
-Tenderness - bruising, muscle dmg
Respiratory Assessment; Palpate, Auscultation, Consolidation in pneumonia
- Palpate for equal and bilateral air entry. This can be done by placing your hands on each posterior wall w/ their thumbs meeting in the middle at the spine
- Equal and symmetrical hand movement should be seen where the thumbs separate and return to the same position at the same time. Lack of symmetry = problem to the thorax
- Using the steth, get pt to say ‘99’ while moving over the anterior/posteriori/axilla points of the chest
- Consolidation for pneumonia increases fremitus and decreases air entry eg emphysema decreases fremitus
How to Percuss and Where
- Must be in a clam and quiet environment to perform
- The percussing finger is the middle finger with the opposites hands’ finger used to strike the other onto the chest
- Percussion starts above the clavicle, moving down every 3-4cm. Compare both sides
- Don’t percuss the scapula
- Percuss to the 6th rib anteriorly and to the 8th rib of the axilla and the 10th rib posteriorly
Percussion Sounds and what they mean
Normal Lung - resonant
Pneumothorax - hyper ressonant at site
Empysema (COPD) - bilateral hyper ressonant
Fluid - Dull
Abnormal Auscultation Sounds; Apnea, Coarse Crackles, Expiratory Wheeze, Fine Crackles, Inspiratory Wheeze, Pleural Rub
- Absence/Apnea - life threatening eg pneumothorax
- Coarse Crackles - insp/exp due to fluid or sputum in larger airways (indicative of pneumonia)
- Expiratory Wheeze - air forced through small spaces (indicative of COPD)
- Fine Crackles - sound created at the end of expiration by the reopening of small airways. Or air passing though intra-alveolar fluid, normally heard in the basal lung fields (indicative of pulmonary oedema)
- Inspiratory Wheeze - high pitches (indicative of foreign body obstruction)
- Pleural Rub - creaking on deep inspiration/expiration (indicative of pleurisy)
Mechanical Factors Affecting Respiratory System
- Abdo Distension - due to fluid from ascites, impacted faces, fat, foetus, flatus (5F’s)
- Obesity - w/ increased weight on the chest, requires more effort to breath normally. Also, increased abdo mass may impede lung expansion
- Pregnancy - gravid female may not be able to expand lungs due to splinting of the diaphragm by the in-sita foetus
What is Anaphylaxis?
A severe, life threatening hypercreativity reaction that is characterised by rapidly developing life-threatening problems that involve the airway, (pharyngeal or laryngeal oedema) breathing (bronchospasm with tachypnoea) and/or circulation (hypotension and/or tachycardia)
Obs (3) Symptoms (4) Signs (4)
Signs + Symptoms of Anaphylaxis
- Airway swelling
- Cyanosis
- Dyspnoea
- Hives (urticaria)
- Reduced LOC
- Myocardial ischaemia
- Signs of shock - pale/clammy
- Stridor/hoarse voice
- Tachypnoea
- Hypotension
- Lethargy/confusion
- Pruritus (itching)
- TachycardiaSigns + Symptoms
Possible Actions to Take for Anyphalxis
- Remove trigger
- Administer drugs
- Provide supplementary oxygen to maintain sats
- Adrenaline therapy
- Pre-alert hospital
Life Threatening Signs for Anaphylaxis
- Extreme airway and/or breathing and/or circulation problems
- Sudden onset and rapid progression of symptoms
- Skin and/or mucosal changes inducing flushing, urticaria and (hives) angioedema (swelling)
Signs + Symptoms of Asthma
- Breathlessness
- Cough
- Tight Chest
- Wheeze
- Cyanosed
Possible Actions for Asthma
- Auscultate to confirm wheeze
- Exclude pneumothorax
- Drugs; salbutomol, ibotropium, adrenaline
- pre-alert hospital
- O2 therapy if sats below 94%
Mild and Severe Presentations of Asthma
Mild: PEF = 50-75%
Severe: PEF = 33-50%, Inability to complete a full sentence in one breath, HR <110, SpO2 >92%, RR >25Life Threat: Altered lvls of consciousness/LOC (remember unexplained confusion/agitation can be from hypoxaemia and/or hypercapnia, Arrythmias, Cyanosis, exhaustion, hypotension, PEF >33%, poor respiratory effort, silent chest, SpO2 >92%
Signs + Symptoms Bronchitis
- Aches and pains
- Blocked or runny nose
- Cough (clear/yellow - grey/green phlegm)
- Headache
- Sore throat
- Tiredness
Obs (3) Signs (5) Symptoms (6)
Signs and Symptoms of Exacerbated COPD
Signs:
- Acute confusion
- Cyanosis
- Dyspnoea
- Increased wheeze on auscultation
- Wheeze
Symptoms:
- Chest tightness
- Fatigue
- Reduced exercise tolerance
- Breathlessness (particularly on exertion)
- Increased sputum production
- Chronic Cough
Obs:
- Tachycardia
- Tachypnoea
- SpO2 decreased
Obs (3) Symptoms (9)
Symptoms of Pneumonia
- Body pain
- Chest pain while coughing
- Dyspnoea
- Sweating
- Diarrhoea
- Weakness, feeling tired
- Loss of appetite
- Nausea/vomiting
- Productive cough
Obs: - Pyrexia
- Tachycardia
- Tachypnoea
Possible Actions of Pneumonia
- O2 therapy
- Collect sputum for analysis
- Think sepsis
- Pre-alert hospital
What is Pneumonia?
An infection caused by bacteria, virus or fungi resulting in inflammation and oedema of the alveoli. Many acquire in the community
Whats a PE?
A PE is a blood clot in the lungs. Can be caused by thrombosis from a lower limb or pelvic veins which dislodges them doggers the pulmonary artery. An acute, massive pt can be life-threatening.
Obs (2) Signs (2) Symptoms (5)
Signs + Symptoms PE
Symptoms:
- Acute onset of chest pain or upper back pain, often sharp/stabbing (worse on inspiration, bending, stooping)
- Light headed/dizzy
- DIB/SOB
- Pain/swelling in the leg (usually calf)
- Coughing, usually dry, maybe blood mucus
Signs:
- Confusion
- Discoloured skin
Obs:
- Tachycardia
- Tachypnoea
History Taking PE
- Family history of DVT/PE?
- Malignancy?
- Oral contraceptive pill?
- Pregnancy/recent childbirth?
- Prolonged immobility?
- Recent MI?
- Recent surgery?
Possible Actions PE
- O2 therapy
- Thorough history
- Be prepared for cardiorespiratory arrest
- Pre-alert hospital
What is Pulmonary Oedema?
An accumulation of fluid in the lungs which inhabits gas exchange
History Taking Pulmonary Oedema
- 2wqa333Have you been waking at night w/ SOB?
- Have you been sleeping ‘sitting up’ or with more pillows?
- Have you had swollen legs recently?
- Do you suffer from heart failure?
- Have you had a previous MI, angina attack, angioplasty, coronary bypass?
Possible Actions Pulmonary Oedema
- Upright pt positioning
- Consider early sublingual glyceryl trinitrate (GTN) if systolic pressure >90mmHg
- Consider positive airway pressure (CPAP)
- O2 therapy
Chest Trauma Injuries
- fail chest segment
- haemothorax
- open pneumothorax
- tension pneumothorax
What are Flail Segments?
Occurs when two or more adjacent ribs are broken in 2 or more places. A paradoxical movement of the lungs occurs due to the free-floating flail segment moving independence from the ribs. It will move with inhalation/exhalation. Mucus inadequate ventilation.
Signs + Symptoms Flail Segment
- Dyspnoea
- Pain
- Paradoxical breathing
- Reduced chest expansion on affected side
- Significant blunt trauma to the chest
Possible Actions Flail Segment
- 15L/min O2 for trauma pt’s
- Positioning
- Analgesia
- Pre-alert MTC
Possible Actions Flail Segment
- 15L/min O2 for trauma patients
- IV access and IV fluids on route
- Pre-alert MTC
What is an Open Pneumothorax?
Caused by penetrating chest injury, cause air to enter the pleural space. The negative pressure created in the thoracic cavity can draw air through the hole in the chest wall. May present as a sucking chest wound.
Signs and Symptoms Open Pnuemothorax
- Dyspnoea
- Hyper-resonance on percussion
- Penetrating chest trauma
- Reduced air entry on effected side
- Surgical emphysema
Possible Actions Open Pnuemothorax
- Administer O2 at 15L/min for trauma pt’s
- 3-sided dressing w/ opening on the inferior side eg chest seal such as Russel Chest seal
- Suspect/reassess for tension pneumothorax
- Pre-alert MTC
What is a Tension Pneumothorax?
- An open pneumothorax happens, increasing intrapleural pressure causing a collapsed lung
- As the pneumothorax increases in size, the pressure pushes the contents of the mediastinum to the opposite side of the body, obstructing blood flow/compression on diaghram. May result in respiratory arrest, then cardiac arrest.
Signs + Symptoms Tension Pnuemothorax
Signs:
- Absent air sounds on injured side
- Blunt/penetrating trauma to chest
- Decreased LOC
- Deviated trachea
Obs:
- Deviated often seveer RR >30 bpm
- Hyper-resonance on percussion
- Decreased air entry on injured side
- Decreased SpO2
- Surgical emphysema
Possible Actions Tension Pneumothorax
- 15L/min for O2 for trauma pt’s
- Needle decompression
- Constant reassessment
- Pre-alert MTC
What’s Tactile Fremitus?
- Tactile Fremitus = palpable vibration from speaking and indicates areas of consolidation of the lungs
