Physical Assessment of the Respiratory System

1
Physical Assessment of the Respiratory System

• Day 2

2
History

• Physical problems
• Function problems
• Life style
• Smoking
• Family Hx
• Occupation hx
• Allergens / environment
• Recreational exposure
• Anxiety
• SS

3
Inspection

• Normal chest
• Slight retraction of intercostal spaces
• 2x as wide as deep
• Anterior/posterior diameter
• 12

4
Inspection

• Barrel chest
• D/t over inflation of lungs
• anterior-posterior diameter
• 22

5
Inspection

• Funnel chest
• Depression of the lower portion of the sternum
• Complications
• Heart damage
• i Cardiac output
• Nrs management
• Murmurs

6
Inspection

• Pigeon chest
• Sternum protrudes outward
• anterior-posterior diameter
• h

7
Pigeon Chest
8
Inspection

• Scoliosis
• Lateral curvature of thoracic spine
• Assessment
• Shoulders elevated?
• Complications
• Lung heart damage
• Back problems
• Body image

9
Scoliosis
10
Scoliosis
11
Quiz?

• How many hours a day should a child wear a brace
  for treating scoliosis?
• 8 hr
• 12 hr
• 23 hr
• 24 hr
• It can be removed for 1 hour a day for hygiene
  purposes

12
Inspection

• Kyphosis
• AKA
• Hunchback
• Abnormal curvature of the thoracic spine

13
Kyphosis
14
Inspection

• Lordosis
• AKA
• Sway-back
• Abnormal curvature of the lumbar spine

15
Lordosis
16
Inspection

• Uniform expansion of the chest
• Pneumonia
• Pleural effusion
• Pneumothorax
• Bulging intercostal spaces
• Obstruction
• Emphysema

17
Inspection

• Marked retraction of intercostal spaces
• Blockage
• Shoulder rise
• Accessory muscles
• Posture

18
Inspection Breathing patterns

• Rate
• Eupnea
• Normal
• 12-20 / min
• Tachypnea
• h rate
• Pnuemonia, pulm edema, acidosis, septicemia, pain
• Bradypnea
• i rate
• h ICP, drug OD

19
Inspection Breathing patterns

• Depth
• Hyperpnea
• h depth
• Hyperventilation
• h depth rate
• Hypoventilation
• i depth rate

20
Inspection Breathing patterns

• Depth
• Kussmaul's
• h rate depth
• Assoc. with sever acidosis
• Apneustic
• Prolonged gasping I following by short

21
Inspection Breathing patterns

• Rhythm
• Apnea
• Not breathing
• Cheyne-stokes
• Varying depth f/b apnea
• Death rattles
• Death rales

22
Inspection Breathing patterns

• Rhythm
• Biots
• h rate depth w/ abrupt pauses
• Assoc w/ h ICP

23
Inspection

• Trachea
• ? Deviation
• Pleural effusion
• Tension pneumothorax
• Atelectasis
• Color
• LOC
• Emotional state

24
Palpation

• TML
• Tenderness (T)
• Masses (M)
• Lesions (L)
• Sinuses
• Palpate below eyebrow Cheekbone
• Crepitus
• Subcutaneous emphysema
• Air leaks into the sub-c tissue

25
Percussion

• Rational
• To determine if underlying tissue is filled with
  air or solid material
• Procedure
• Pt sitting
• Tap starting at shoulder
• compare rt to lf

26
Percussion results

• Resonance drum like
• Normal
• Hyper-resonance
• Too much air
• Emphysema
• Flatness / dull
• Fluid or solid
• Pleural effusion
• Pneumonia
• Tumor

27
Auscultation

• Purpose
• Asses air flow through bronchial tree
• Procedure
• Diaphragm of stethoscope
• Superior ? inferior
• Compare rt to lf

28
Auscultation Results

• Normal
• Vesicular
• Lung field
• Soft and low
• Bronchial
• Trachea bronchi
• Hollow
• Bronchovesicular
• Mixed
• Between scapulae
• Side of sternum
• 1st 2nd intercostal space

29
Auscultation Results

• Fine crackles
• Air ? suddenly reinflated
• Course Crackles
• Moist

• Adventitious
• Crackles
• Rales
• air ? bronchi with secretions

30
Auscultation Results

• Wheezes
• Sonorous wheezes
• Deep low pitched
• Snoring
• gt E
• Caused by air ? narrowed passages
• D/t h secretions

• Sibilant Wheezes
• High pitched
• Whistle-like
• I E
• Caused by air ? narrowed passages
• D/t constriction
• Asthma

31
Auscultation Results

• Pleural friction rub
• D/t inflammation of pleural space
• Grating, creaking
• I E
• Best heard
• Anterior, Lower, lateral area

32
Auscultation Results

• Stridor
• Crowing
• Partial obstruction of the larynx or trachea

33
Quiz?

• A child with difficulty breathing and a barking
  cough id displaying signs associated with which
  condition?
• Asthma
• Croup
• Cystic fibrosis
• Epiglottitis

34
Quiz?

• When assessing the lung sounds of a child with
  asthma, which sound are you most likely to hear?
• Murmurs
• Sonorous Wheezing
• Sibilant Wheezing
• Crackles
• Pleural friction rub

35
Early late signs of hypoxia

• Anxiety
• Bradycardia
• Cyanosis
• Depressed respirations
• Diaphoresis
• Disorientation
• Dyspnea

• Restlessness
• Headache
• Agitation
• Poor judgment
• Retraction
• Tachycardia
• Tachypnea

36
Early late signs of hypoxia

• Anxiety
• Bradycardia
• Cyanosis
• Depressed respirations
• Diaphoresis
• Disorientation
• Dyspnea

• Restlessness
• Headache
• Agitation
• Poor judgment
• Retraction
• Tachycardia
• Tachypnea

37
Dyspnea

• Definition
• SOB
• SOB, flat affect, BS x 4

38
Dyspnea

• Significance
• Common with cardiac resp. disease
• Sudden onset healthy person ?
• Pneumothorax
• Sudden onset ill, post-op or injury ?
• Pulmonary emboli

39
Dyspnea

• Orthopnea
• Sit up to breath
• COPD
• CHF

40
Dyspnea

• Right ventricle
• If chronic airway resistance ?
• h pressure ?
• Rt ventricle h work ?
• Rt. Vent damage

41
Dyspnea

• Nrs Management
• Find cause
• Give O2
• HOB h
• Communication
• KISS

42
Cough

• Definition
• To expel air from the lungs suddenly
• Irritation of mucous membrane

43
Cough

• Significance
• Infection
• Irritants
• Protective mechanism
• Dry, irritating
• URT
• Cough chest pain
• Pleural or musculoskeletal

44
Cough

• Nrs management
• Assess
• Describe
• Directed
• Pain control
• Splinting
• Infection control
• Suppressants / Anti-tussives

45
Sputum Production

• Definition
• Matter discharged from resp. track that contains
  mucus and pus, blood, fibrin, or bacteria

46
Sputum Production

• Significance
• Purulent
• Thick, yellow/green
• Bacteria
• Rusty
• Strep or staph
• Thin, mucous
• Viral

47
Sputum Production

• Pink-tinged
• Lung CA
• TB
• Pink tinged, profuse, frothy
• Pulmonary edema
• Malodorous
• Lung abscess

48
Sputum Production

• Nrs Management
• Thick
• Hydrate
• h water
• Nebulizer
• Humidifier
• TCDB
• No smoking
• Oral care
• h Appetite

49
Do You Know?????

• What breath sound would you expect to head on a
  patient with increased sputum production?
• Vesicular
• Crackles
• Sonorous wheezes
• Sibilant wheezes

50
Obtaining a sputum specimen

• Explain
• From lungs
• Sterile cup
• Deep breath x 3 ?
• Cough deeply
• Expectorate
• Best time for specimen collection?
• AM

51
Chest pain

• Definition
• Cardiac or pulmonary

52
Chest pain

• Significance
• CA (late stage)
• Pneumonia
• Pulmonary embolism
• Pleurisy

53
Chest pain

• Pleurisy
• Inflammation of pleura
• Sharp with breath
• i breath sounds

54
What?????

• What breath sound would you expect to hear on a
  patient suffering from pleurisy?
• Crackles
• Sonorous wheezes
• Sibilant wheezes
• Pleural Friction Rub

55
Chest pain

• Nrs Management
• Assess
• Analgesics OK, but
• Position for pain
• Affected side
• Splint

56
Clubbed fingers

• Definition
• Sponginess of the nail bed
• Loss of the nail bed angle
• Finger tip is round and bulbous

57
Clubbed fingers
58
Clubbed Finger

• Significance
• chronic hypoxia
• Nrs Management
• Marker

59
Mr. Caveman

• Mr. Caveman enters the ER unconscious following
  an Automobile accident. The paramedics report
  that his O2 sats are 86. You note that Mr.
  Caveman has clubbed fingers. What does this tell
  you?

60
Hemoptysis

• Definition
• Expectoration of blood from the respiratory tract

61
Hemoptysis

• Significance
• Pulm or cardiac
• Common causes
• Pulm infection
• CA of lungs
• Pulm. Emboli
• Pulm. Infarction
• TB

62
Hemoptysis

• Hemoptysis
• Definition?
• Coughed up blood
• From?
• Pulm hemorrhage
• Description
• Pink, red, mixed with sputum
• Blood pH
• Alkaline blood

• Hematemesis
• Definition?
• Vomited blood
• From?
• Stomach / GI
• Description
• Coffee ground
• Blood ph
• Acidic blood

63
Hemoptysis

• Nrs Management
• Determine source
• Serious

64
Cyanosis

• Definition
• Bluish coloring of skin

65
Cyanosis

• Significance
• Very late indicator of hypoxia
• Appears when O2 sats lt 85
• NOT a reliable sign of hypoxia
• Esp. with anemia

66
Cyanosis

• O2 sat definition
• of hemoglobin carrying oxygen compared to total
  of hemoglobin

67
Cyanosis

• Normal
• Breath 100 O2 molecules ? 98 cross into blood
• Blood 100 Hgb
• O2 SATS
• 98
• No cyanosis

68
Cyanosis

• Hypoxia
• Breath 100 O2 molecules ? 75 cross into blood
• Blood 100 Hgb
• O2 SATS
• 75
• Cyanosis

69
Cyanosis

• Anemic and hypoxic
• Breath 100 O2 molecules ? 75 cross into blood
• Blood 75 Hgb
• O2 SATS
• 100
• No Cyanosis

70
Cyanosis

• Nrs. Management
• Know color of Pt. skin
• Assess color of tongue lips
• Fingernail polish
• African-American
• Vasoconstriction (cold weather) ? peripheral
  cyanosis