Thorax and Lungs Respiratory Assessment Flashcards
Respiratory Assessment
Subjecive Data
Health History Questions
Cough (freq., morning, sputum colour 4, Hemoptysis ) Shortness of breath (Orthopnea, Paroxysmal nocturnal dyspnea) Chest pain with breathing History Smoking history Environmental exposure Self-care behaviours Medication
Cough: How often? Productive? Color sputum -Frequent cough = acute illness -Morning cough = smoking -Sputum colour: indicates sinus problem White/clear- normal cold; could be bronchitis Yellow/green- bacterial infection Rust- tuberculosis Pink/frothy- pulmonary edema -Hemoptysis - blood in sputum
Shortness of breath: any difficulty breathing, is it one time or all the time?
Orthopnea – difficulty breathing when laying down
Paroxysmal nocturnal dyspnea – attacks of shortness of breath at night
Chest pain with breathing: PQRSTU + associated symptoms
History: family, asthma, COPD, lung issues, allergies
Smoking history: how long, how many/day, 2nd hand smoke
Environmental exposure: occupational exposure
Self-care behaviours: exercise, sleep apnea, immunizations
Medication: medications that produce respiratory distress (adverse effects)
Objective Data
POSTERIOR CHEST
Inspection
Shape & configuration of chest wall 2
Anteroposterior to Transverse diameter 1
Position of person
Skin color and condition
Shape & configuration of chest wall
- Spinous process in straight line
- Thorax symmetrical
Anteroposterior to Transverse diameter
-AP diameter should be LESS than transverse diameter (normal ratio 1:2)
Position of person
-Tripod?
Leaned over – helps us expand lungs by using accessory muscle
Skin color and condition
Objective Data
POSTERIOR CHEST
Inspection
Shape & configuration of chest wall 2
Anteroposterior to Transverse diameter 1
Position of person
Skin color and condition
Thoracic Cage Configurations 3
Shape & configuration of chest wall
- Spinous process in straight line
- Thorax symmetrical
Anteroposterior to Transverse diameter
-AP diameter should be LESS than transverse diameter (normal ratio 1:2)
Position of person
-Tripod?
Leaned over – helps us expand lungs by using accessory muscle
Skin color and condition
Thoracic Cage Configurations
- Barrel Chest
- Scoliosis
- Kyphosis
Objective Data
POSTERIOR CHEST
Inspection
Thoracic Cage Configurations
Barrel Chest -what is the ratio -How do the ribs look -It is due to -Associated with Scoliosis -Shape of it? -Ribs interspaces do what -Mild is -Severe may do what Kyphosis -Describe it -severe may -associated with
Barrel Chest: AP:T ratio is equal Ribs horizontal Due to hyperinflation of the lungs Associated with: Normal aging Chronic Emphysema Asthma Scoliosis: Lateral S-shaped curvature of the thoracic & lumbar spine Rib interspaces flared on convex side Mild is asymptomatic Severe may reduce lung volume Kyphosis: Exaggerated posterior curvature of thoracic spine (humpback) Severe may impair lung function Associated with aging
Objective Data
POSTERIOR CHEST
PALPATION
Symmetric expansion
- place hands where
- pinch what
- ask pt to
- what is Asymmetrical expansion
Tactile Fremitus
- Fremitus is what
- use what part of hand
- have pt say
- move in what pattern
- vibrations should feel
-when does fremitus increase and decrease
Fremitus- a palpable vibration caused by sounds
Use BALL of had & touch pt’s chest while they repeat “ninety-nine” or “blue moon”
Move in Z pattern
Vibrations should feel SYMMETRICAL
Increases with: consolidation
-Occurs with conditions that increase the density of lung tissue, making a better conducting medium for vibrations
Example: pneumonia
Decreases with: obstruction
-Occurs when anything obstructs the transmission of vibrations
Objective Data
POSTERIOR CHEST
PALPATION
What should be noted 5
-What is crepitus and where does it occur
Tenderness
Skin temperature & moisture
Lumps or masses
Skin lesions
- Crepitus- a coarse crackling sensation palpable over skin surface
- Occurs in subcutaneous emphysema when air escapes the lung & enters subcutaneous tissue
Objective Data POSTERIOR CHEST Percussion Lung Fields -What is the goal -where do you start -what do you avoid -What are the percussion notes 3
Goal: determine predominant note over lung fields
Start at apices then move to the interspaces, making a side to side comparison
AVOID scapula & ribs
PERCUSSION NOTES:
- Resonance- Low pitched, clear, hollow sound made over HEALTHY lung tissue
- Hyperresonance- lower pitch, booming sound made when there is TOO MUCH air
- Dullness– soft, muffled thud sound made when there is an abnormal density in lungs (may hear this over organs)
Objective Data POSTERIOR CHEST Auscultation -how should pt be set uo -how should they breath -what part of steth should you use -how long do you listen -what are Adventitious Sounds and what are they causes by
Pt should be sitting, leaning forward, with arms on lap
Ask pt to breath through the mouth, a little deeper than usual, but stop if dizzy
Place DIAPHRAGM of stethoscope against bare chest
Listen to 1 full breath in each location- comparing side to side
-Adventitious sounds- additional sounds not normally heard in the lungs
-Caused by:
Secretions in airways (crackles)
Narrowed airways (wheezes)
Popping open of previously deflated alveoli (atelectatic crackles)
Adventitious Sounds
Sound/ Description/ Clinical example
Fine crackles Course crackles High-pitched wheeze low-pitched wheeze stridor Atelectatic crackles
Fine crackles / Sound like rolling a hair between fingers near ear
/ Pneumonia, heart failure
Course crackles / Bubbling, gurgling sounds / Pneumonia, pulmonary edema
High-pitched wheeze / Musical squeaking sounds / Acute asthma, chronic emphysema
low-pitched wheeze
stridor / Musical snoring sounds
/ Bronchitis
stridor / High-pitched crowing sound / Croup, epiglottitis, airway obstruction (all may be LIFE THREATENING)
Atelectatic crackles / Like fine crackles but disappear after first few breaths/ NOT pathologic
Older adults, bedridden pts, those just aroused from sleep
Objective Data
ANTERIOR CHEST
Inspection
Thoracic cage 7
Shape & configuration of chest wall
- Ribs downward sloping with symmetrical interspaces
- Costal angle within 90°
Facial expression
Level of consciousness
Skin & nails- colour & condition, nail clubbing, lesions
Respiratory rate & quality
Rib interspaces- bulging or retractions?
Accessory muscle use
- Trapezius, sternomastoid, abdominal, anterior neck
- Seen in COPD pts
Objective Data
ANTERIOR CHEST
Palpation
Symmetric expansion Tactile Fremitus Chest Wall Lung Fields Expected findings:
Symmetric expansion
-Place hands on anterior chest wall with thumbs along costal margins pointing toward xiphoid process
Tactile Fremitus
- Begin in the supraclavicular areas
- 99 or blue moon
- Symmetrical vibrations
- Avoid breast
Chest Wall
-Tenderness, Lumps or masses, Skin mobility, turgor, temperature & moisture
Lung Fields
- Start at apices (supraclavicular)
- Then percuss the interspaces, compare side to side
- Avoid breast
Expected findings: -Cardiac dullness
- Liver dullness
- Gastric tympany
Objective Data
ANTERIOR CHEST
Auscultation
Lung field
Lung field
Begin at the apices down to the 6th rib on bare chest
Listen to 1 full breath in each location- comparing side to side
Be sure to assess the lateral chest as well
Objective Data: Pulmonary Function Status
Pulse oximeter 4
6-minute distance walk 5
A non-invasive method of assessing arterial oxygen saturation (SpO2)
Normal range: 95-100%
A SpO2 of <93% on room air should be attended to immediately
COPD normal range: 88-92%
-6-minute distance walk
Clinical measure of functional status in aging adult
Ask to cover as much ground as possible in 6 mins
Wearing good shoes with pulse oximeter on
Stop of SpO2 is below 85% or extreme breathlessness
Patient who covers 300m in 6 mins is more likely to participate in ADLs
Developmental Considerations
Infants & Children
- how is thorax shaped
- by age 6?
- newborn breath how
- How many RR
- What brief period are normal
- abnormal
Pregnant Women
- Cage and angle might be
- uterus elevates what
- what occurs for demands of the fetus
Older Adult
- What is decreased
- loss of what due to
Infants & Children
• Thorax rounded with equal diameters
• By age 6 reaches adult AP:T ratio of 1:2
-Newborns are obligate nose breathers until 3 months
• Newborn RR: 30-40 resp/min
• Brief periods of apnea 10-15 seconds common
• ABNORMALS: nasal flaring, tracheal tug, sternal or intercostal retractions
Pregnant Women
• Thoracic cage and costal angle may be wider
• Enlarging uterus elevates diaphragm 4 cm
• Deeper breathing occurs to meet the oxygen demands of the growing fetus
Older Adult
• Chest expansion somewhat decreased ( lung elasticity + costal cartilage calcified)
• Decreased respiratory strength
• Gradual loss of alveoli increases the risk of SOBOE
Promoting Health
-What is second/third hand
• NO risk-free level of exposure
• Second-hand Smoke- exposure to exhaled smoke
• Third-hand Smoke- toxic chemicals in smoke that linger in the air & materials after cigarette is put out
-Increased risk of adverse health effects d/t exposure (especially children) including respiratory & inner ear infections, asthma, heart disease, lung cancer
