The document provides information on assessing clients with respiratory disorders. It discusses taking a clinical history including chief complaints, past medical history, and symptoms. Common symptoms include dyspnea, cough, chest pain, sputum production, and wheezing. The physical exam involves inspection of the chest, palpation, percussion, and auscultation to evaluate breath sounds and identify adventitious sounds that could indicate underlying conditions. Signs on exam include use of accessory muscles, symmetry, tactile fremitus, percussion notes, crackles, wheezes, and pleural rubs. Together, the history and physical exam aim to understand the patient's respiratory status and underlying causes of symptoms.
The document provides information on assessing clients with respiratory disorders. It discusses taking a clinical history including chief complaints, past medical history, and symptoms. Common symptoms include dyspnea, cough, chest pain, sputum production, and wheezing. The physical exam involves inspection of the chest, palpation, percussion, and auscultation to evaluate breath sounds and identify adventitious sounds that could indicate underlying conditions. Signs on exam include use of accessory muscles, symmetry, tactile fremitus, percussion notes, crackles, wheezes, and pleural rubs. Together, the history and physical exam aim to understand the patient's respiratory status and underlying causes of symptoms.
The document provides information on assessing clients with respiratory disorders. It discusses taking a clinical history including chief complaints, past medical history, and symptoms. Common symptoms include dyspnea, cough, chest pain, sputum production, and wheezing. The physical exam involves inspection of the chest, palpation, percussion, and auscultation to evaluate breath sounds and identify adventitious sounds that could indicate underlying conditions. Signs on exam include use of accessory muscles, symmetry, tactile fremitus, percussion notes, crackles, wheezes, and pleural rubs. Together, the history and physical exam aim to understand the patient's respiratory status and underlying causes of symptoms.
The document provides information on assessing clients with respiratory disorders. It discusses taking a clinical history including chief complaints, past medical history, and symptoms. Common symptoms include dyspnea, cough, chest pain, sputum production, and wheezing. The physical exam involves inspection of the chest, palpation, percussion, and auscultation to evaluate breath sounds and identify adventitious sounds that could indicate underlying conditions. Signs on exam include use of accessory muscles, symmetry, tactile fremitus, percussion notes, crackles, wheezes, and pleural rubs. Together, the history and physical exam aim to understand the patient's respiratory status and underlying causes of symptoms.
ASSESSMENT OF CLIENTS WITH It can occur after exercise in people
RESPIRATORY DISORDERS without disease
1. Patient Clinical History Acute disease of the lungs produces A review of patient clinical history is an more severe grade of dyspnea than essential component of the overall chronic chronic disease physical assessment process Sudden dypsnea in healthy person may Conducting review of the patient’s indicate Pneumothorax (air in the history serve as a guide for the pleural cavity) respiratory obstruction, remainder of the physical allergic reaction or MI. examination and the first step to In immobilized patients sudden dypsnea develop relationship with the client. indicates Pulmonary embolism, Health history is initially focuses on the Dyspnea and tachypnea (abnormal rapid patients presenting problems and respirations) accompanied by associated signs and symptoms. hypoxemia (low blood oxygen level) In conducting health history, the nurse indicates lung trauma, shock, should explore the onset, location, cardiopulmonary bypass, ARDS due to duration, character, aggravating or multiple blood transfusion. alleviating factors and timing of the Dyspnea with expiratory wheeze in presenting problems and associated COPD signs and symptoms Can be associated with noisy breathing The clinical history of the respiratory result from narrowing of the airway or system is divided into six components. localized obstruction of a major (1) chief complaint, (2) history of bronchus by a tumor or foreign body present illness, (3) past medical High pitch sound (during inspiration) history, (4) family history (5) personal due to partially blocked upper airway and social history and (6) review of Orthopnea- shortness of breath when the respiratory system. lying flat, relieve by sitting or standing. The nurse should also explore how these It is found in patients with heart disease factors impact the patient’s activities of and occasionally in COPD daily living, usual work and quality of To help better understand the cause of life. dypsnea, the nurse should ask the following questions? 2. Common Symptoms Is the shortness of breath related to other 1. Dyspnea symptoms? Is cough present? Subjective feeling of difficult or labored Was the onset of shortness of breath breathing, breathlessness, shortness of sudden or gradual? breath Is the shortness of breath occurs when Commonly seen in patients with lying flat? pulmonary and cardiac disorders where Does the shortness of breath or dypsnea there is increased or decreased lung awakes you at night? (paroxysmal compliance nocturnal dyspnea and orthopnea signify Associated with allergic reactions, heart failure but may occur in anemia, neurologic or neuromuscular pulmonary disorders. disease and advance disease. Does the dypsnea occur only with 3. Chest pain exertion? , How much exertion triggers shortness of 4. Sputum production breath? Does it occur with exercise? 5. Hemoptysis Climbing stairs? Or at rest? 6. Wheezing, Stridor How severe is the shortness of breath? On a scale of 1-10. If 1 is not at all Chest Inspection breathless and 10 is very breathless, how observe the diaphragm and intercostal hard it is to breath? muscles with breathing. It is important to assess the patient’s Frequent use of accessory muscles rating of the intensity and distress of indicates respiratory problem breathlessness, what breathing feels like, -look at the diameter of the chest, from and it’s impact on the patient’s health. front to back function and quality of life A variety of -look for symmetry valid and reliable instruments including -Note for masses, scars that indicate various Likert scale as a tool in decribed trauma or surgery the dypsnea experiencing by the patients Chest palpation Visual analogue Scale- The patient - Place the palm over the thorax. The marks on the line the point that they feel chest wall should be smooth, warm represents their perception of their and dry current state. The VAS score is - Palpate for tenderness, bulging, determined by measuring in millimetres retractions of the chest from the left hand end of the line to the - Assess the patient for crepitus-feels like point that the patient marks. puffed rice cereal crackling under the Borg Scale- a type of numeric rating skin scale. The patient is asked to self rate - Tactile fremitus- Place your open palms the difficulty of breathing is accusing on both sides of the client’s back him or her at present time, with 0 without touching his back with your corresponding to no difficulty at all to fingers. ask the patient to repeat the 10 corresponding to maximal level of phrase ninety nine loud enough to difficulty in breathing. produce palpable vibration - Symmetry and expansion 2. COUGH Is a reflex that protects the lungs form Chest Percussion tones- when lungs are filled the accumulation of secretions or the with air, fluid or solid material inhalation of foreign bodies 1. Resonant Its presence or absence can be a heard over normal lung tissue, bronchitis diagnostic clue because some disorders Long, loud, low pitch cause coughing and some supress it. 2. Hyper resonant Coughing reflex may be impaired by abnormal sound heard during percussion weakness or paralysis in adults The nurse should inquire: Very loud lower pitch sound Onset and duration (When did first Hyperinflated lung/air trapping such in notice a change in your cough?) COPD. 3. Flat heard between the scapulae and lateral heard over airless tissue to the sternum at the first and second Short, soft, high pitch, extremely dull ICS Atelectasis, and extensive pleural effusion ADVENTITIOUS Breath Sounds 4. Dull Crackles/rales (Fine) Medium in intensity and pitch caused by collapse or fluid filled alveoli occur over dense lung tissue such as popping sounds tumor and consolidation. Usually don’t clear with coughing Lobar pneumonia Classified by fine or coarse Fine- intermittent, non-musical, soft, 5.Tympanic high pitch, short crackling popping Loud, high pitch, moderate length, sounds, heard during inspiration musical drum like sound Coarse- Intermittent, loud, low pitch, Gastric air bubble, air in the intestine bubbling or gurgling sounds heard indicates large tension pneumothorax during inspiration at bases of lower lung lobes Chest Auscultation air passing through fluid or mucus in Normal Breath Sounds any air passage. Vesicular Asthma, Bronchitis, CHF low pitch sound and heard all over the chest and heard best in the bases of Crackles/ Rales (Coarse) lungs loud and low pitch, bubbling and best heard on (prolong) inspiration and gurgling sounds. shortened during expiration Commonly heard in the bases of lower Tracheal lung lobes. Harsh, high pitch sound Heard when patient inhale or exhales Pleural friction rub Above supraclavicular notch, over the Cause by rubbing of inflamed pleural trachea surfaces Bronchial High pitch and loud sounds created by WHEEZE air moving through the trachea continuous, high pitched musical squeak Heard loudest when patient exhales, or whistling sound occurring on discontinuous EXPIRATION and inspiration when air Just above the clavicles on each side of moves through a narrowed or partially the sternum, over the manubrium obstructed airway Broncho vesicular Don’t change with coughing Moderate pitch with moderate amplitude Asthma, bronchitis and CROUP. created by air moving through larger airway Gurgling/rhonchi Heard when pt inhales or exhales, continues, low pitch, snoring quality continuous best heard on expiration, but could be heard in both inspiration and expiration Cause: air passes through a narrow Can occur during or after excersize or passages due to swelling and result from pain, anxiety or metabolic secretion/blocks the large airways acidosis Indicate hypoxia or hypocalcemia in a Chest Wall Abnormalities coma patinet Cheyne-stokes breathing BARREL CHEST marked rhythmic, waxing and waning Unusually round and bulging chest with respirations from very deep and very a greater than normal front to back shallow breathing and temporary apnea. Seein heart failure, kidney failure or diameter CNS damage Caused by COPD, indicating that lungs Kussmaul’s breathing have lost their elasticity and the Deep rapid breathing. RR is greater diaphragm is flattened than 20 and labored breath sounds FUNNEL CHEST/PECTUS EXCAVATUM Metabolic acidosis or DKA A funnel shape depression on all or part Hypoventilation of the sternum very slow respiration May interfere with respiratory and Biot’s breathing shallow breaths interrupted by apnea cardiac function irregular PIGEON CHEST An ominous sign of severe CNS damage Displaced sternum that protrudes in Apneustic Breathing front of the abdomen that increases the prolonged, gasping inspiration followed front to back diameter of the chest by a very short and inefficient expiration THORACIC KYPHOSCOLIOSIS Normal Findings Characterized by spinal curvature to one 1. General appearance Breathing is quiet and easy without side and rotate vertebra apparent effort It cause difficulty in assessing 2. Breathing Pattern respiratory status because of the rotation Smooth and regular, breathing is quiet distorts the lung tissue and passive with symmetric chest Altered Breathing Patterns expansion. TACHYPNEA 3. Respiratory rate 12-20/ minute/ 20-40/minute Shallow breathing with a respiratory rate 4. Skin greater than 20 breath/minute Pink, no cyanosis or pallor present Seen in patients with restrictive lung Palpation of chest wall reveals smooth disease, pain, fever, obesity or anxiety skin and stable chest wall, no crepitus, BRADYPNEA masses and painful areas. Decrease RR usually below 5. Nails- no clubbing 10breath/min 6. Chest wall configuration symmetric, bilateral muscle development CNS depression caused by sedation, tissue damage or Diabetic coma 7. Vocal and Tactile Fremitus APNEA -the sensation of sound vibrations Absence of breathing produced when the patients speaks. HYPERPNEA place the extended hand gently on the Deep rapid breathing chest wall instruct the patient to say 1, 2, 3…as Cytologic exam- to assess for presence these words are spoken, the examiner of CA. feels the for the vibrations. AFB staining- Abnormal Responses - to detect PTB Increase Fremitus Nursing considerations - Increase in vibration is felt due to Collect sputum early in the consolidation of the lung caused by MORNING. Sputum usually fluid-filled or solid structures. accumulates in the lungs during sleep - Pneumonia and tumor of the lungs and can easily be coughed in the morning Decrease fremitus Advise the patient to rinse mouth with plain water. Do not used mouthwash Diagnostic Procedure/ Examination that may destroy microorganisms Non Invasive Sterile container should be used. To prevent contamination 1. Skin Test/Mantoux Test Sputum specimen for C and S is PPD is used collected before the first dose of Route: ID antibiotic. 48-72 hrs For AFB- collect sputum for 3 POSITIVE- 10mm or more consecutives morning HIV patients- 5mm is POSITIVE + Mantoux test signifies exposure to Pulmonary Function Test Mycobacterium Tubercle Bacilli - A procedure to determine the Mantoux Test will be positive for clients capacity of the lungs to exchange O2 who have received BCG and CO2 CHEST X-RAY Instruct the client to hold his breath and Incentive Spirometry not to do breathing To prevent and treat atelectasis Remove metals from the chest. Semi fowlers position Done to enhance deep inhalation PULSE OXIMETRY Instruct the client to take in a slow, easy To determine o2 saturation in the blood deep breath from the mouthpiece. Can detect hypoxemia or hypoxia 95-100% ABG analysis The pulse oximeter sensor is place in the to assess ventilation and acid base index finger or earlobe. balance The sensor should be covered with It helps to monitor patients response to opaque material. The result is affected therapy by sunlight. Radial Artery is the common site for withdrawal of specimen Sputum exam To determine the appearance of the Allen’s Test is done to assess for sputum adequacy of collateral circulation of the Rusty sputum- pneumococcal hand. May be used to find out if the pneumonia blood flow to your hand is normal. Greenish sputum- Pseudomonas The health professional drawing infection your blood will apply pressure to the Blood tinged- PTB arteries in your wrist for several Culture and Sensitivity- to detect the seconds. This will stop the blood actual microorganisms causing flow to your hand, and your hand will respiratory infection become cool and pale Use 10 ml heparinized syringed to draw Check for expectoration of blood. Notify the blood specimen. To prevent blood the doctor. Indicates trauma to the lung clotting. Monitor for complications: Place the specimen in a container with Shock, Pneumothorax, and Respiratory ice. To prevent hemolysis. If hemolysis, arrest OXYGEN and CO2 are release and cannot be measure accurately. Bronchoscopy Direct inspection and observation of AVOID INACCURATE ABG VALUES the larynx, trachea, and bronchi using Be sure to use proper technique bronchoscope. Avoid delays in getting the sample to USES: the laboratory To collect secretions Don’t draw blood for ABG ANALYSIS To determine pathologic process and within 15-20 minutes of a procedure collect specimen for biopsy such as suctioning or administering To remove aspirated foreign object and respiratory treatment excise small lesions. Remove air bubbles from the syringe because they could affect the oxygen Nursing Intervention before the Procedure level in the blood Informed consent. Invasive procedure Don’t get venous blood in the syringe Atropine sulphate and valium as ordered because it could affect the CO2 and O2 Topical anesthesia sprayed in the throat levels and pH followed by local anesthesia in the larynx INVASIVE Procedure NPO 6-8 hrs. To prevent aspiration. Remove dentures prostheses and contact THORACENTESIS lenses. To prevent airway obstruction. Aspiration of fluid or air from the Nursing intervention after Procedure pleural space Side lying position- to promote drainage of secretions from the mouth Nursing Interventions Before the procedure Check for cough and gag reflex before Secure written consent- invasive giving fluid. To prevent aspiration Take V/S- aspiration of air/fluid from Prepare suction device at the bedside the pleural space cause Hypovolemic Watch for cyanosis, hypotension, shock tachycardia, arrhythmias, dyspnea and Position: upright, leaning on the over hemoptysis. And notify the physician. bed table/Sitting position These are signs of perforation of Topical anesthesia is used at the site of bronchial tree needle insertion Pressure sensation is felt on insertion LUNG SCAN site Following injection of radioisotope, scans are taken with a scintillation Nursing interventions Post Procedure camera. Apply pressure to the puncture site Measures the blood perfusion through Turn the client on the unaffected side. the lungs To prevent leakage of fluid in the Confirms pulmonary embolism and thoracic cavity other blood flow abnormalities Bed rest. To prevent postural Instruct the client to remain still during hypotension the procedure BIOPSY OF THE LUNG expansion of the lungs, strengthen Transbronchoscopic biopsy- done respiratory muscles, and eliminate during bronchoscopy secretions from the respiratory system. Chest physical therapy includes postural Percutaneous needle biopsy- done drainage, chest percussion, chest with the use of aspiration needle vibration, turning, deep breathing exercises, and coughing. Open lung biopsy- done during Turning- Turning from side to side surgery permits lung expansion. The child may LYMP node BIOPSY- to assess metastatic turn on his or her own, or be turned by a CA caregiver. Turning should be done at a minimum of every two hours if the child COMMON RESPIRATORY is bedridden. The head of the bed can INTERVENTIONS also be elevated in order to promote OXYGEN THERAPY drainage. Asses signs of hypoxemia. An indication Coughing- helps to break up secretions of the need for oxygen therapy in the lungs so that the mucus can be Check for doctor order expectorated or suctioned out if Place pt in Semi fowlers. To enhance necessary. Patients sit upright and inhale lung expansion deeply through the nose. They then Regulate oxygen flow accurately. exhale in short puffs or coughs. This Excessive administration of O2 can procedure is repeated several times a cause oxygen narcotics/ respiratory day. alkalosis Deep breathing helps expand the lungs Place a “NO SMOKING” sign at the and forces an improved distribution of bedside. O2 geratly accelerates the air into all sections of the lungs. combustion and can cause fire from The patient either sits in a chair or sits small spark upright in bed and inhales then pushes Avoid use of oil, greases, alcohol and the abdomen out to force maximum ether near the client O2. These further amounts of air into the lung. The support combustion abdomen is then contracted, and the Check electrical appliances that generate patient exhales. Deep breathing static electricity. Small sparks can cause exercises are done several times each fire if there is leakage of oxygen day for short periods. HUMIDIFY OXYGEN. Place sterile water into the oxygen humidifier. To POSTURAL DRAINAGE prevent irritation and dryness of mucous uses the force of gravity to assist in membrane effectively draining secretions from the Provide oronasal hygiene. To revent smaller airways into the central airway dryness and irritation of mucous where they can either be coughed up or membrane suctioned out. The child is placed in a Lubricate nares with water soluble head- or chest-down position and is kept lubricant to soothe the mucous in this position for up to 15 minutes. membrane Postural Drainage and Percussion (PD Assess effectiveness of O2 therapy. & P), also known as chest Check RR, quality of respiration, ABG, physical therapy (CPT), is a way to O2 saturation. help people with cystic fibrosis (CF) breathe with less difficulty and stay CHEST PHYSIOTHERAPY healthy. PD & P uses gravity A group of treatments designed to and percussion to loosen the thick, improve respiratory efficiency, promote sticky mucus in the lungs so it can be Place pt in each position for 10 -15 removed by coughing minutes. A total of 30 minutes for each treatment Percussion and Vibration are done to loosen secretions Change position gradually to prevent postural hypotension Percussion Done before meal to avoid vomiting or Involves striking the chest wall with early in the morning and at bedtime cupped hands. Provide oral care after the procedure. It is also called cupping or clapping. To remove unpalatable taste of The purpose of percussion is to break up secretions. thick secretions in the lungs so they can more easily be removed. TRACHEOBRONCHIAL SUCTIONING It is performed on each lung segment Semi fowlers or High for one to two minutes at a time. Sterile Technique. Use sterile gloves, Mechanical percussors are available and and suction catheter. To prevent may be suitable for children over two infection years of age. The percussor is moved Hyperventilate the client with 100% O2 over one lobe of the lung for before and after suctioning. To prevent approximately five minutes, while the hypoxia patient is encouraged to performing Insert catheter with glove hand 3-5 coughing and deep breathing techniques. inches length of catheter. The trachea is This process is repeated until each 4-5 inches length segment of the lung is percussed. Apply suction during withdrawal of the catheter. To prevent trauma of the mucous membrane and bleeding Vibration When withdrawing catheter rotate the The purpose of vibration is to help break catheter while applying intermittent up lung secretions. suction Vibration can be either mechanical or Suctioning should take only 5-10 sec manual. (maximum of 15 sec) to prevent It is performed as the patient breathes hypoxia, vagal stimulation and bleeding. deeply. Vagal stimulation can cause When done manually, the person g=hypotension and bradycardia performing the vibration places his or Evaluate breath sounds and auscultation her hands against the patient's chest and of the chest creates vibrations by quickly contracting and relaxing arm and shoulder muscles CLOSED CHEST DRAINAGE/ while the patient exhales. Thoracostomy Tube Repeated several times each day for To remove air or fluids from the pleural about five exhalations. space To re-establish negative pressure and re- NURSING INTERVENTIONS IN CPT expand the lungs Verify doctors TYPES of CCD Assess areas of accumulation of mucous 1. One Bottle system secretions The bottle serve as drainage bottle and Position to allow expectoration of water seal bottle mucus membrane by gravity Immerse tip of the tube in 2-3 cm of DO CPT with upper lobes before lower sterile water NSS to create water seal lobes Keep bottle at least 2-3 feet below the level of the chest to allow fluid to drain from the pleural cavity NEVER raise the bottle above the level of the chest to prevent reflux of the air or fluid Observe the patency of the device - Observe fluctuation of fluid along the tube - Observe for intermittent bubbling of fluid; continuous bubbling means presence of air leak - In the absence of fluctuation. Suspect for obstruction of the device. Check for kinks along tubings - No obstruction consider lung re expansion - Air vent should be open to air