Respiratory Assessment Flashcards
Where does the trachea split? And where can tracheal sounds be heard?
T4 vertebrae the trachea splits into the left and right bronchus. Breath sounds heard at bottom cervical spine.
Diaphragm
Moves down and pressure increases during inspiration and moves up and decreases pressure during expiration. Negative pressure during inspiration.
Right lobe of lungs
Contains three lobes contains right oblique fissure and horizontal fissure. Right upper, middle and lower lobe
Left lobe of lungs
Contains two lobes left upper and left lower with one oblique fissure separating the lobes.
Lower border of lungs
Normally found on T10, but during inspiration, moves down to T12
Pneumonia is most commonly found it what lobes?
Middle and lower
When documenting, be sure to indicate location of sounds.
Crackles heard at posterior axillary line at 6th ICS
HPI
Coughing - ACE?
Onset/duration - w/ fever could be infection (without fever could be foreign body, inhaled irrittant)
Nature of cough - frequency, regularity, pitch, loudness, quality, circumstances
Sputum production
Sputum character - bloody could be viral infection
Pattern - regular cough may be pertussis
Severity
Associated symptoms
Efforts to treat
HPI: SOB
Onset/duration Pattern Position most comfortable, pillows used Related to exercise, certain activities, time of day, eating Harder to inhale or exhale Severity Associated symptoms Efforts to treat
HPI: Chest Pain
Palpatable? Bone/Muscle Onset and duration - no radiation? constant achiness? Fleeting, needle-like jab? Situated in shoulders Associated symptoms Effort to treat Medications (recreational?)
PMHx
Thoracic trauma or surgery, dates of hospitalization for pulmonary disorders
Use of CPAP, BiPAP or home oxygen
Chronic pulmonary diseases
Other chronic disorders
Testing
Immunization against Strep pneumoniae and influenza
FHx
TB CF Emphysema (smokers) Allergies, asthma, atopic dermatitis Malignancy (solid mass in lungs) Bronchiecstaiss Bronchitis Clotting disorders
What increases clotting risk
Sedentary lifestyle
Birth control (women older than 35 should not be on birth control)
Smoking
Positive homon sign may be DVT
Personal and Social Hx
Employment (landscaping, miner) Home environment Tobacco or VAPOR use Exposure to infections like TB or flu Nutrition Use of herbal or other remedies Travel exposure Hobbies alcohol or drugs Exercise
What is walking pneumonia?
Patch pneumonia all over lungs
common in younger
Older Adults
Increased risk of exposure and frequency (Hx of vaccines)
Weather effects on respiratory efforts and infection occurrence
Immobilization and sedentary habits
Dysphagia
Altered activities from respiratory symptoms
What should be emphasized in older adults?
Smoking hx Cough Dyspnea on exertion Fatigue Weight changes fever and night sweats
Infants and Children
Low birth weight and prematurity Coughing and sudden SOB (aspiraton) Possible ingestion of aerosols/household cleaners Apneic episodes Swallowing dysfunction (GERD) Hx of vaccienes
Sound travels best through what medium?
Solid > liquids > gas
Solid objects (mucus, phlegm or others) in the lungs allow for enhanced sounds
Lower sound means only air
Observing Respirations
Inspect chest wall for movement
Symmetry
Retractions = concave at sternum, between ribs and suprasternal notch, above clavicles and lowest costal margins (using accessory muscles)
Suggestive of obstruction to inspiration
Tripodding
Leaning forward, uses sternocleidomastoid and clavicles to support breathing
Paradoxic breathing
On inspiration, lower thorax is drawn in, and on expiration, the opposite occurs
Inspection
Shape and symmetry Chest wall movement Superficial venous patterns Prominence of ribs Anteroposterior vs transverse diameter (Barrel chest) Sternal protrusion (pidgeon chest) Spinal deviation (scoliosis) Funnel chest (pectus excavatum)
Inspection of peripheries
Clubbing Odor on breath Cyanosis or pallor of skin, nails and lips Pursed lip breathing Flaring of nostrils (more so in infants)
Inspection of Respiration
Rate
Quality
Pattern
Count rate
Palpation
Pulsations Tenderness bulges and depressions Masses Unusual movement or positions Elasticity of rib cage Immovability of sternum Ridgidity of thoracic spine Crepitus
Thoracic Expansion
Look for loss of symmetry in the movement of the thumbs suggest a problem on one or both sides
Tactile Fremitus
Palpable vibrations of the chest wall that results from speech or other verbalizations
Use balls of hand and go side to side. Increased vibrations means obstruction in lungs. Easier posterioryl and underarm
Check for pleurisy
Respiratory excursion
Thumbs connected on posterior to see thumb movement
Tracheal deviation
Take a deep breath. Is the trachea midline?
Thyroid enlargement or pleural effusion
Pneumothorax
Tumors
Percussion
Percuss anterior, posterior and lateral
Compare tones bilaterally
Measure diaphragmatic excursion (3-5cm) Usually higher in right lobe because of liver
Dullness over lungs may be tumor or phlegm
Percussion sounds
Palpate with hand hyperextended to use finger tips instead of finger pads
Resonance is normal and hyperressonance is normal in lower lobes of lungs
Dullness means obstruction
Anterior percussion sounds
Flatness over heavy muscles and bones
Resonance over lungs
Dullness over cardiac, liver
Tympany over stomach
Percuss for diagphragmatic excursion
T10-T12 is diaphragm
Measure distance diaphragm travels during inspirational hold and expirational hold
Should be between 2-4cm
Auscultation
Intensity Pitch Quality Duration use diaphragm
What are breath sounds
Length of inspiration vs expiration
wheezes, crackles
Should be same on both sides
Vesicular breath sounds
3:1 (adults)
Low=pitched, low-intensity heard in healthy lungs
Bronchovesicular
1:1 (Children)
Heard over major bronchi and are typically moderate in pitch and intensity
Middle of lungs
Bronchial/trachial
Highest in pitch and intensity
Heard over trachea (1:1)
When are bronchovesicular and bronchial considered abnormal?
When heard over peripheral lung tissue of adults
Adventitious breath sounds
Crackles (formerly called rales) more common on inspiration POS for pneumonia Discontinuous sound heard on inspiration Fine: high pitched, short in duration Coarse: low pitched, longer in duration
Rhonchi (snorous weezes)
deeper, rumbling, pronounced on expiration, prolonged continuous
Airway obstructed by secretions, muscular spasm, new growth or external pressure
Expiratory wheeze = asthma
Wheezes
Continuous, high-pitched, musical sound (almost whistle) heard on inspiration and expiration
High-velocity air flow through narrow or obstructed airway
Bronchospasm, or acute or chronic bronchitis
Friction Rub
Pleural inflammation
Outside respiratory tree
Dry, crackle, grating, low-pitched, heard on both inspiraiton and expiration
Caused by inflammed, roughened surfaces rubbing together
Friction rub of heart is continuous
Equal breath sounds
may be a sign of infiltration or obstruction
Patterns of Respiration
Tachypnea - restrictive lung dx, pain, sepsis, obesity, anxiety, fever (faster than 20 breaths/min)
Bradypnea - CNS depression, tissue damage, diabetic coma (<12 breaths per min)
Hyperpnea
Metabolic acidosis, pain, anxiety, hypoxia or hypoglycemia if comatose
>20 breaths per min, deep breathing
Hypopnea - shallow breaths
Kussmaul
DKA
Rapid, deep, labored
Cheyne-Stokes
CHF, Kidney failure, CNS damage, normal in sleep and elderly and children
Periods of increasing depth with apnea
Biot’s
Severe CNS damage
Irregularly interspread periods of apnea in a disorganized sequence of breaths
Adventitious Breath Sounds
Fine Crackles - discontinuous, heard during inspiration
Medium Crackles - moist sound heard mid inspiration
Coarse - loud and bubbly
Rhonchi - loud, low, coarse sounds during both phases
Vocal Sounds
Egophony - say “eee” same as bronchophony
Bronchophony - stethescope over consolidated area (say a phrase to listen for muffles) Non-muffled sound is obstruction
Whispered Pectoriloquy - whisper instead
Vocal Resonance
Diminishes and loses intensity when there is loss of tissue in respiratory tree (barrel chest of emphysema)
Classify as bronchophony, pectoriloquy and egophony
Peak Flow
Deep breath in and forced expiration to test asthma
Measured by age/gender and height
Find expected, measured and actual peak flow
This check expiratory volume
A&P of Respiratory
Sternum, manubrium, xiphoid process, costal cartilage, 12 pairs of ribs and 12 thoracic vertebrae
Ribs 11 and 12 are floating ribs
Lung apex is found about 4cm above first rib
Increased AP diameter in adults d/t
loss of muscle strength in thorax and diaphragm
loss of lung resiliency - trapped air can lead to inflation of lungs
Air trapping = prolonged but ineffcient expiratory effort
dorsal curve of thoracic spine
stiffening, decreased expansion of chest wall
Dry cough
nonproductive?
Could be cardiac problem, allergeis, GERD, with pharyngeal irritation
Pain from Cocaine
Acute, severe?
Can cause tachycardia, HTN, coronary artery spasm (with infarction) and pneumothorax
Causes of tachypnea
broken rib or pleurisy
liver enlargement, abdominal ascites
Causes of bradypnea
neurological/electrolyte imbalance
infection
irritative pneumonia
cardiorespiratory fitness
Depth and rate of breathing increases with
acidosis CNS lesions (pons) anxiety aspirin poisoning Hypoxemia Pain
Depth and rate of breathing DECREASES with
metabolic alkalosis CNS lesions (cerebrum) Myasthenia gravis Narcotic overdose Obesity (extreme)
Chest asymmetry
Unequal expansion and respiratory compromise
D/t collapsed lung, extrapleural fluid or air or mass
Unilateral or bilateral bulging caused by obstruction
Prolonged exp c bulging could be airway outflow obstruction or compression d/t tumor,aneurysm,enlarged heart
Costal angle widens above 90 degrees
Retractions in chest
Usually an inspirational obstruction
Muscles pull back in an effort overcome blockage on inspiration.
Obstruction high in the respiratory tree; breathing is characterized as stridor
Paradoxic breathing causes abdomen to be drawn in during inspiration d/t to weakened diaphragm, OAD, or during sleep
Foreign body in bronchus (usually right side)
Causes unilateral retraction, but suprasternal notch is not involved.
Retraction of lower chest occurs with asthma and bronchiolitis
Airway Patent or Obstructed
Obstructed when there is inspiratory stridor, hoarse cry or cough, flaring of nostrils, retraction at suprastern
Severely when: stridor is both insp and exp, cough is barking, retractions also involve subcostal and intercostal spaces, cyanosis is obvious
When obstruction is above the glottis
Stridor tends to be quieter Voice is muffled Swallowing is difficult Cough is not a factor Head and neck awkwardly positioned to preserve airway. Could be an abscess
Obstruction below glottis
stidor tends to be loud and raspy voice is hoarse swallowing is not affected cough is harsh, barking positioning of head is not a factor
Hyperresonance of lungs
pneumothorax, emphysema, asthma
Expected findings in lungs
On inspection - symmetry, absence of retractions
Palpation - Midline to trachea without tug, symmetric, unaccentuated tactile fremitus
Percussion - range of 3-5cm, resonant and symmetric percussion notes
Auscultation - absence of adventitious breath sounds
Vesicular breath sounds, except for bronchovesicular sounds beside the sternum, or in areas of larger bronchi
