Respiratory Assessment Flashcards
Area of Assessment to focus on (respiratory)
- How are they seated?
- How fast are they breathing?
- Are they speaking in complete sentences?
- What is their mental status?
- What is their ETCO2?
- What is their SPO2?
- What are their lung sounds?
- How loud are their lung sounds?
How is auscultation performed?
In a ladder fashion
1. Apices
2. Superior lobes
3. Inferior lobes
4. Lung bases
Treatment considerations for Respiratory Patients
- O2
- Bronchodilators via MDI
- Bronchodilators via nebulizer
- Bronchodilators via MDI with BVM
- Advanced airway placement
- ALS support
Priorities for reassessment in Respiratory Patients
- Positioning
- Should speak in complete sentences
- LOC should normalize
- Lung sounds should be easier to hear
- Wheezes should start to go away
- ETCO2 should trend back to normal
- SpO2 should trend back towards 100%
Stages of Respiratory Distress
Stage 1: Respiratory Distress
Stage 2: Increased Respiratory Distress
Stage 3: Worsening Respiratory Distress
Stage 4: Worsening Respiratory Distress
Physical findings for stage 1 of respiratory distress
- Tracking your entry
- Relaxed in a neutral position with little anxiety noted
- Lungs sounds are loud
- Slight increased WOB
- Speaking near complete sentences
Physical findings for stage 2 of respiratory distress
- Tracking your entry
- Maintaining muscle tone in whatever position found but not relaxed
- lung sounds are still loud
- A little breathless when speaking
Physical findings for stage 3 of respiratory distress
- Aware of your presence but focusing on breathing
- Mental status appears drowsy, tired, lethargic
- Difficulties following instructions without help
- Lung sounds harder to hear
- Increased WOB
- If speaking, 2-3 word sentences
Physical findings for stage 4 of respiratory distress
- Head bobbing
- Not paying attention to you
- Head is rolling around without purpose
- Unaware of what’s happening to them
- Lung sounds are silent!
- Increased WOB
- Cannot speak (DO NOT MAKE THEM)
What do wheezes mean?
- Swelling is present in the bronchial tree
- Mucous present in the alveoli
Differential diagnosis regarding Wheezes
- Asthma
- Exacerbation of COPD
- Anaphylaxis
- Pneumonia
- Lower airway burn
Risk Factors of Asthma
- Allergies
- Exercise induced
- Smoking
- Common cold
- Emotions
Assessment finding for Asthma
- Chest tightness, worse with deep breath
- Auscultation: Wheezes
- Increased WOB seen
- Difficulties speaking
- tripod position or arms lifted away from body
Risk Factors for Exacerbated COPD
- Adults
- Occupational exposure
- Asbestos exposure
- Air pollutants
- Asthma
- Genetics
Assessment finding for Exacerbated COPD
- Chest tightness, worse with deep breathe
- Auscultation: Wheezes
- Increased WOB seen
- Difficulties speaking
- Barrel Chested and performing self PEEP
- Tripod position or arms lifted away from body
Risk Factors of Anaphylaxis
Exposure to allergen:
- Food
- Environment
- Insects
- Medications
- Aerobic exercise (rare)
Assessment finding for Anaphylaxis
- Thick speech due to swollen tongue
- Difficulties swallowing
- Stridor (impending airway failure)
- Potential altered mental status
- Skin pale, clammy, diaphoretic
- Loss of distal pulses
- Severe nausea/vomiting
- Rash, hives, swelling to any part of body
- Auscultation: wheezes
What do crackles mean?
Fluid is present in the alveoli
What can cause Crackles?
- Right sided heart failure
- Drowning
- Aspiration
Risk Factors of right sided heart failure
- CAD
- Uncontrolled diabetes or HTN
- Previous myocardial infarction
- ETOH abuse
Assessment finding for Right sided heart failure
- Difficulties breathing
- SOB
- Increased WOB
- Auscultation: crackles
- Cough with clear sputum
- JVD
- Pedal edema
Risk factors for aspiration
- recent choking event
- recent drowning or near drowning event
- Condition that prevents patient from protecting their own airway
Assessment finding for aspiration
- Confusion or agitation
- Speaking with a hoarse or scratchy voice
- Auscultation: unilateral or bilateral crackles
- Auscultation of anterior neck: stridor
- low SpO2
- high ETCO2
