Tracy Petleski, MSN, RN

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Tracy Petleski, MSN, RN

• Respiratory Patterns- Skills Lab

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Concepts, Assessment and diagnostics for pt. w/
altered respiratory status Unit II

• Respiratory assessment
• Diagnostic studies for the pulmonary system

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Review of Respiratory Assessment Normal findings

• Respirations easy, regular and for adults rate
  12-24 minute
• Absences of accessory muscle use
• Sputum is thin, small amount and white, clear or
  tan.
• Sputum in am is normal
• AP diameter 21 is normal in adults

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Review of Respiratory Assessment

• Mucous membranes pink and moist
• Chest rises symmetrically w/ good diaphragmatic
  excursion 3-6 cm
• Ability to breath lying flat and sleeping
• Absences of persistent cough
• Tolerates ADLs and light exercise w/o DOE

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Review of Respiratory Assessment

• BBS clear AP
• w/o adventitious breath sounds
• Resonance on percussion over lung fields
• w/o bronchophony, egophony or whispered
  pectoriloquy
• w/o increased tactile fremitus

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Normal Assessment findings

• Chest symmetrical in appearance
• Chest wall appears normal
• Effortless respirations
• Tolerates conversation
• Tolerates sitting up or lying down
• Appears w/o acute distress

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Older Adult Assessment considerations

• Ask the patient about general respiratory history
• Consider that patients response may not
  correlate with physical assessment
• direct interview towards specific questions that
  will promote a more accurate history

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Older adult

• Appearance
• Skin color
• Chest structure
• Breathing patterns

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Patient Interview

• Focused history with focused questions
• Because of age some older adults will not
  necessarily complain. They have adapted or become
  accustomed to living with their symptoms. They do
  not necessarily consider their symptoms as being
  unusual

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Focused interview

• Do you ever experience wheezing?
• How often do you get colds?
• Do you have any problems breathing?
• How many pillows do you sleep on?
• Do you have a cough?
• Did you ever smoke?
• What kind of work did you do in your lifetime?

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Focused questions

• Focused questions increase the likelihood of
  obtaining a more accurate history and or factors
  relating to current illness

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Abnormal findings

• Shape of chest
• Barrel chest
• Funnel chest (pectus excavatum)
• Thoracic kyphosis
• scoliosis

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Nursing Management

• Vital signs
• Measure IOs
• Pt.s LOC
• Muscles movement strength
• Oxygen therapy
• Cardiac monitor

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Diagnostic studies

• Chest radiograph
• Pulse oximetry
• Sputum specimen
• V/Q scan
• Pulmonary function test
• Thoracentesis
• Bronchoscopy
• ABGs

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Diagnostic studies

• Angiography
• Laryngoscopy
• Mediastinoscopy
• Thoroscopy
• Biopsy

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Chest Radiograph

• Identify normal anatomy
• Presence of fluid, infiltrates, mass or shift
• Chest x-rays are used to stage symptoms if a pt.
  Has an acute cardiac or pulmonary complaint

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Nursing considerations with CXR

• Patient must be relatively alert and cooperative
• Patient must be able to sit upright
• Patient most be able to hold their breath
• The nurse may have to assist with xray if the
  patient is not capable

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Pulse Oximetry

• Check O2 saturation of arterial blood in finger
• Non-invasive
• Easy
• Quick
• Cheap
• Initial assessment

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Nursing consideration with pulse oximetry

• Patient must have a pulse
• Patient must be warmed if extremities are cold to
  touch
• Nurse may move probe to another location
• If pulse oximetry is low. Assess patient to
  correlate symptoms

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Sputum Specimen

• RN collects specimen
• Teach pt. On use of trap
• Send to lab
• Analysis
• Treatment usually begins

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Sputum specimen

• Assess color, quantity of specimen, blood.
• Am collection is optimal
• Brush teeth
• Gram sensitive
• Antibiotic treatment

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Abnormal Sputum

• Copious, thick and tenacious
• Yellow or green Bacterial
• Green with odor Pseudomonas
• Rusty Klebsiella
• Pink and thin Pulmonary edema
• Blood Hemoptysis TB, Pulmonary embolus or
  possible trauma.

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Nursing considerations with sputum collection

• Educate patient about procedure- sterile
• First sputum of the morning
• Brush teeth first
• Expectorate into specimen container

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VQ Scan

• Is performed to R/O a pulmonary emboli

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VQ Scan
Pt. Must be able to corporate, lay flat and still
Minimum 30-45 minute may requires follow up films
Identification of PE if inconclusive Angio-gram
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VQ scan
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Nursing considerations of a VQ scan

• Patient allergies to radiographic dye
• Lengthy test
• Lye flat
• Comfort medicate for pain or anxiety
• Patient Closter phobic? Scanner will be close to
  chest
• May have to return for more films

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Pulmonary function test

• Measures peak expiratory flow rate (PEFR)
• Helps determine severity of asthma exacerbation
• Evaluate the effectiveness of treatment in
  reversing airway obstruction

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Nursing considerations with pulmonary function
test

• Patient must be capable of following directions
• Patient must be able to tolerate their nose being
  clothes-pinned
• Patient must be able to blow/ exhale on command

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Bronchoscopy

• Why?
• Evaluate sputum
• Tissue sample
• Remove lesions
• Direct view of pathology
• Can clear airway of tenacious mucous bronchial
  wash

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Bronchoscopy

• Nursing Assessment
• Verify consent
• NPO 6 hrs prior
• Monitor resp. status
• Gag returns- po, swallowing and NO risk of
  aspiration
• Assess for pneumothorax

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Nursing considerations with bronchoscopy

• Patient will receive anesthesia
• Patient will have to recover from anesthesia
• Patient must have a gag reflex after procedure
• Must have a CXR after procedure to identify
  potential pneumothorax

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Pulmonary angiogram

• Invasive mapping
• Diagnostic
• Much more accurate
• Consent, radiology, physician, recovery and
  conscious sedation
• CV back up

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Nursing considerations with a pulmonary angiogram

• Patient will have anesthesia
• Patient will have to recover from anesthesia
• Potential for hemorrhage post-op
• Potential for pulmonary infarct during or post-op
• Potential for femoral hemorrhage
• Potential for cold extremity during or post-op

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Thoracentesis

• Drains fluid or air from pleural space
• Informed consent
• Position upright and lean forward over table
• Assess post for lung expansion, vs, BS changes in
  respiratory assessment
• Record amt. of fluid, color and consistency

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Throacoscopy
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Nursing consideration with a thoracentesis

• Patient has to be alert and corporative
• Patient has to be able to sit up at the bedside
  and dangle feet
• Patient should get immediate relief of symptoms
• Potential for pneumothorax-post-op CXR
• Specimen 1-2 liter of drainage
• Documentation of color, amount and appearance of
  fluid. Send specimen to lab for pathology