.

مدرس التمريض الباطني والجراحي مدرس التمريض الباطني والجراحي

والحاالت الحرجةوالحاالت الحرجة

– جامعة طنطا – جامعة طنطاكلية التمريضكلية التمريض

Respiratory systemRespiratory system

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Respiratory ASSessmentRespiratory ASSessmentيوالحكيمعبدجيهاند

نس

• Assessment of Respiratory SystemOutline• part I : assessment of respiratory function:

– history– physical examination:

• inspection• percussion• palpation• auscultation

– laboratory tests:• pulmonary function studies• arterial blood gases• sputum studies• pleural fluid analysis

• part II: assessment of respiratory structure:• pulse oximetry• chest –x- ray• computed tomography for chest• magnetic resonrnce imaging• bronchoscopy

Respiratory System Functions

1. supplies the body with oxygen and disposes of carbon dioxide

2. filters inspired air3. produces sound4. contains receptors for smell5. rids the body of some excess water and

heat6. helps regulate blood pH7. Gase exchange

Respiration

• Respiration – four distinct processes must happen– Pulmonary ventilation – moving air into and

out of the lungs

– External respiration – gas exchange between the lungs and the blood

– Transport – transport of oxygen and carbon dioxide between the lungs and tissues

– Internal respiration – gas exchange between systemic blood vessels and tissues

Anatomy and physiology • The respiratory tract extends from the nose

to the alveoli and includes not only the air-conducting passages also but the blood supply

• The primary purpose of the respiratory system is gas exchange, which involves the transfer of oxygen and carbon dioxide between the atmosphere and the blood.

• The respiratory system is divided into two parts: the upper respiratory tract and the lower respiratory tract

Components of the Upper Respiratory Tract

Figure 10.2

• The nose • pharynx• adenoids• tonsils• epiglottis• larynx,• and trachea.

The upper respiratory tract includes

Passageway for respiration Receptors for smell Filters incoming air to filter larger

foreign material Moistens and warms incoming air

Upper Respiratory Tract Functions

Components of the Lower Respiratory Tract

Figure 10.3

The lower respiratory tract consists of

• the bronchi,• Bronchioles• alveolar ducts• and alveoli• all lower airway structures are

contained within the lungs.

Functions: Larynx: maintains an open airway, routes food and air appropriately, assists in sound production

Trachea: transports air to and from lungs

Bronchi: branch into lungs Lungs: transport air to alveoli for gas exchange

Lower Respiratory Tract

lung

• The right lung is divided into three lobes (upper, middle, and lower)

• the left lung into two lobes (upper and lower)

• The structures of the chest wall

• (ribs, pleura, muscles of respiration) are also essential

Physiology of Respiration• Ventilation. Ventilation involves inspiration (movement

ofair into the lungs) and expiration (movement of air

out of the lungs). Air moves in and out of the lungs

because intrathoracic pressure changes in relation to

pressure at the airway opening.

• Contraction of the diaphragm and intercostal muscles

increases chest dimensions, thereby decreasing

intrathoracic pressure. Gas flows from an area of

higher pressure (atmospheric) to one of lower pressure

(intrathoracic)

Assessment of respiratoryPart I: Assessment of respiratory function

[1] history:

1) medical history:

Is there pt's history of lung disease

Cardiac or neuromuscular disease.

2) Surgical history of any operation:

- is there a history for any surgical operation?

3) Past medical history: -

Is there past pulmonary diseases?

History of heart problem?

Childhood illness exposure to TB,?

Diabetes? kidney disease, liver disease? Or

hypertension

cancer or T.B?

4) Family history: is there a History of lung disease, COPD, cardiac

disease ,diabetes, kidney disease, liver disease,

hypertension, cancer, T.B, or Others ?

5) Smoking History: Is there smoking history? If there is smoking

history ? is it current or in the past?

environmental exposure to dust, chemicals,

asbestos, air pollution

6 present complaint:

Chest pain

Cough

dyspnea

Cough

• Type – dry, productive

• Onset • Duration • Pattern

– activities, time of day, weather

• Severity – effect on ADLs

• Wheezing • Associated symptoms • Treatment and effectiveness

sputum

• amount

• color

• presence of blood  (hemoptysis)

• odor

• consistency

]2 [Physical Examination:

[1] Posterior Chest: Inspect, Palpate, Percuss, and Auscultate

• Preparation before procedure:

Position/Lighting/Draping• Position –• patient should sit upright on the examination table.

• The patient's hands should remain at their sides.

• When the back is examined the patient is usually asked to

move their arms forward (hug themself position)

• Lighting - adjusted so that it is ideal.

• Draping - the chest should be fully exposed. Exposure

time should be minimized.

Surface markings of the lobes of the lung:(a) anterior, (b) posterior, (c) right lateral and (d) left lateral.(UL, upper lobe; ML, middle lobe; LL, lower lobe).

Ulml

a

b ll

ul

ll

ul

llml

1) Inspiction:

1. Inspect posterior thorax:

1. Assess shape and symmetry. Note rate and rhythm of

respiration, movement of chest wall with deep

inspiration and full expiration, and signs of distress.

2. Estimate the anteroposterior diameter.

Respirations are quiet, effortless, and regular, 12–20

breaths per minute. Thorax rises and falls with

respiratory cycle.

Ribs slope across and down, without movement or

bulging in the intercostals spaces

3.Observe for abnormalities

II. Palpation. place thumbs close to client’s spine

and spread hands over thorax. Note

divergence of thumbs, feel for range

and symmetry of movement during

deep inhalation and full exhalation.

Place ulnar aspect of your open

hand at right apex of lung and place

the hand at each location .

Instruct client to say “99” and

palpate for tactile fremitus (vibrations

created by sound waves). Note areas

of increased or decreased fremitus.

Palpation

•Tactile fremitus is vibration felt by palpation. Place your open palms

against the upper portion of the anterior chest, making sure that the fingers do not touch the chest. Ask the patient to repeat the phrase “ninety-nine” or another resonant phrase while you systematically move your palms over the chest from the central airways to each lung’s periphery.You should feel vibration of equally intensity on both sides of the chest. Examine the posterior thorax in a similar manner. The fremitus should be felt more strongly in the upper chest with little or no fremitus being felt in the lower chest

• Move hands from side to side, from right to left, with client

repeating the words with the same intensity every time you

place your hands on the back.

• Thumbs should separate an equal distance (3–5 cm) and in

the same direction during thoracic expansion and meet in the

midline on expiration. Posterior thorax is free from

tenderness, lesions, and pulsations.

• Fremitus is equal on both sides of thorax, strongest at the

level of trachea.

• Examine the body part that may be tender or painful

Note the following characteristics:

Pulsations, Temperature of the tissue

Presence of lumps or tumors,Swelling

Texture of the skin

Moisture or dryness of the skin

Tenderness or pain, Distensions

If a lump, nodule, or tumor is located: Feel for the size,

shape, and consistency; attempt to move it with the

Fingers.

(III) Using Percussion:

Start at lung apices. Move

hands from side to side

across the top of each

shoulder.

Note sound produced from

each percussion strike .

Continue downward and

posterolateral every other

intercostal space.

Note intensity, pitch, duration

-Air-filled lungs create a resonant sound.

Identify contralateral sound; bones (e.g., ribs

or spine, create a flat sound).

- Thorax is more resonant in children and

thin adults.

Note these sounds:

Flat: Soft intensity, high pitch, short duration

Dull: Medium intensity, medium pitch, medium

duration

Dull sound is created in solid or fluid-filled

structures (e.g., pneumonia, pleural effusion,

or tumors). Pleural fluid sinks to lowest part of

pleural space (posteriorly in a supine client).

Resonant: Loud intensity, low pitch, long

duration

Hyperresonant: very loud intensity, lower

pitched; longer duration

Hyperresonance in adults occurs in

pneumothorax, emphysema, or asthma.

Tympany: Loud intensity, lower pitched with

musical quality, longer duration

(IV) Auscultation: - Auscultate posterior and lateral surfaces.

Place diaphragm of stethoscope on right lung apex.

Instruct client to inhale and exhale deeply and

slowly when the stethoscope is felt on the back.

Repeat on left lung apex.

Move downward every other intercostal space and

auscultate, placing stethoscope in the same

position on both sides.

Auscultation

• To assess breath sounds, ask the patient to breathe in and out slowly and deeply through the mouth.

• Begin at the apex of each lung and downward between intercostal spaces . Listen with the diaphragm portion of the stethoscope.

• Normal breath sounds

Observe:

• Pitch

• Intensity

• Quality

• Duration

Auscultate the lateral aspect by placing the

stethoscope directly below the right axilla,

instructing the client to breathe only through the

mouth and to inhale and exhale deeply and

slowly. Proceed downward, every other

intercostal space on the same side.

Repeat on left side. Posterior sounds:

bronchovesicular and vesicular sounds; lateral:

vesicular sounds.

Normal Breath Sounds

• Bronchial: Heard over the trachea and mainstem bronchi (2nd-4th

intercostal spaces either side of the sternum anteriorly and 3rd-6th

intercostal spaces along the vertebrae posteriorly). The sounds are

described as tubular and harsh. Also known as tracheal breath sounds.

• Bronchovesicular: Heard over the major bronchi below the clavicles in the

upper of the chest anteriorly. Bronchovesicular sounds heard over the

peripheral lung denote pathology. The sounds are described as medium-

pitched and continuous throughout inspiration and expiration.

• Vesicular: Heard over the peripheral lung. Described as soft and low-

pitched. Best heard on inspiration.

• Diminished: Heard with shallow breathing; normal in obese patients with

excessive adipose tissue and during pregnancy. Can also indicate an

obstructed airway, partial or total lung collapse, or chronic lung disease.

Normal auscultatory sound

Anterior Chest: Inspect, Palpate, Percuss, and

Auscultate

(I) inspection

Place client in a sitting or supine position.

Instruct client to inhale deeply and exhale fully. Inspect

anterior thorax for:

a. Symmetry and depth of movement

b. Rhythm of respirations

c. Slope of ribs and musculoskeletal deformities Scapula at same

height. Thorax rises and falls in unison with respiratory cycle

(II). Palpation: Place finger pads on right apex, above

the clavicle. Proceed downward to

each rib and intercostal space and

note tenderness, pulsation, masses,

and crepitance. Repeat on left side.

Palpate for tactile

Note that fremitus is usually decreased

or absent over the precordium.

Assessing chest expansion in expiration (left) and inspiration (right).

Direct percussion of the clavicles for disease in the lung apices

Percussion over the anterior chest.

(III) percussion: Symmetrically percuss anterior

surface

Percuss 2–3 strikes along right

lung apex, repeat on left lung

apex.

Proceed downward, percussing

in every other intercostal space

going from right to left in same

position on both sides. Displace

breast tissue as necessary.

Assess in each thoracic area:

Resonant-lung field

Cardiac dullness: third to fifth intercostal spaces

left of sternum.

Liver dullness: place your pleximeter finger parallel

to upper border of expected liver dullness in right

midclavicular line; percuss downward. - Gastric air

bubble: repeat procedure performed for liver

dullness on left side. Resonant sound over lung

tissue (hyperresonance in children and thin adults).

(IV) Auscultate anterior surface:

• -Note about sounds:

• Their presence and location.

• Type of sounds

• Pulses, heart sounds, lung sounds, and bowel sounds)

• Duration and intervals between sounds

NormalSound

Duration of soundIntensity ofExpiratory

sound

Pitch of expirator

ysound

Location

1-vesicular sound

Inspiratory sound lasts longer

than expiratory one

softRelatively

lowOver the lung (both

lung)

2-bronchvesicul

ar sound

Inspiratory & expiratory sounds are

equal

intermediate intermediate

In the 1s1 & 2nd intercostals

space anterior & between

scapula

3- Bronchial sound

Expiratory sound lasts longer

than Inspiratory one

loudRelatively

highOver manubrium

4- tracheal sound

Inspiratory & expiratory

sound are about equal

very loudRelatively

highOver the trachea

in the neck.

1-Crackles Soft, high pitched discontinuous popping sounds

occur during inspiration

Secondary to fluid in the air ways, or alveoli or to opening or collapse

of alveoli

2-Crackles in early

inspiration

Same as above Associated with obstructive; pulmonary disease;fine crackles

associated with bronchitis, or Pneumonia

3-Crackles in late

Inspiration

Same as above Associated with restrictive Pulmonary disease

4-Wheezing or bronchi

Deep, low, pitched rumbling sound during

expiration

Caused by air moving through narrowed trachio bronchial passage

may be from secretion or tumor

5-Sibilant wheezes

Continues, musical, high-pitched whistle like sound during inspiration & expiration

Caused by narrow bronchioles & associated with broncho spasm , asthma, build up of secretion.

6- Pleural friction rub

Harsh, crackling sound likes two pieces of leather rubber together.

Heard during inspiration alone or during both inspiration &

expiration may subside when patient Holds breath.

Secondary to inflammation & loss of lubricating pleural fluid

[3] laboratory tests:

pulmonary function studies:

Pulmonary function studies provide

information about the volume, pattern, and

rates of air flow involved in respiratory

function.

to determine the need for mechanical

ventilation.

Uses:

Pulmonary function tests are used to

diagnose specific types of lung abnormalities

and to assess the risk of respiratory

complications. They are also used to monitor

the course of pulmonary diseases

Evaluate the effectiveness of prescribed

medications, and

Arterial blood gas analysis: - ABGs analysis is an essential test in diagnosing &

monitoring patient with respiratory disorder, because it

gives direct information about ventilatory function.

Blood gas results are reported in millimeters of

mercury(mmHg).

Arterial blood gas studies aid in assessing the ability of

the lungs to provide adequate oxygen and remove carbon

dioxide and the ability of the kidneys to reabsorb or

excrete bicarbonate ions to maintain normal body pH

Normal ABG ranges are:

PaO2 (partial pressure of O2 in arterial blood) is 80-l00 mmHg.

PaCO2 (partial pressure of CO2 in arterial blood) is 35-45

mmHg.

The arterial oxygen tension (PaO2) indicates the degree of

oxygenation of the blood, and the arterial carbon dioxide

tension (PaCO2) indicates the adequacy of alveolar ventilation.

SaO2 saturation of O2 in arterial blood is greater than 94 % or

95 %.

pH → Hydrogen ion concentration or degree of acid base

balance 7.35-7.45

•Pleural fluid analysis:

Part II assessment of respiratory structure

• (1) pulse oximetery Pulse oximetrey is a

noninvasive method of

continuously monitoring the

oxygen saturation of

hemoglobin (SpO2 or SaO2).

A probe or sensor is

attached to the fingertip ,

forehead, earlobe, or bridge

of the nose.

(2) Chest X-Ray

Chest radiography, is one of the most frequently performed

radiologic diagnostic studies. This study yields information about the

pulmonary, cardiac, and skeletal systems.

X-rays penetrate air easily; areas filled with air appear dark or black

on x-ray film.

Bones appear near-white on the film because x-rays cannot

penetrate them to reach the film.

Organs and tissues appear as shades of gray because they absorb

more x-ray than air but less than bone. A routine chest x-ray includes a posteroanterior and lateral view.

Films may be taken on full inspiration and on full expiration to detect a pneumothorax.

Chest films can indicate the following alterations and diseases:

Lesions (tumors, cysts, masses) in the lung tissue, chest wall, bony

thorax or heart

Inflammation of lung tissue (pneumonia, atelectasis, abscesses,

tuberculosis); pleura (pleuritis); and pericardium (pericarditis)

Fluid accumulation in the lung tissue (pulmonary edema, hemothorax);

(pleural effusion); and (pericardial effusion)

Bone deformities and fractures of the rib and sternum

Air accumulation in the lungs (chronic obstructive

pulmonary disease, emphysema), and pleura

(pneumothorax)

Diaphragmatic hernia

(3) Computed Tomography for thorax:

• - CT of the thorax is an imaging method in which the

lungs are scanned in successive layers by a narrow-beam

x-ray.

• CT may be used to define pulmonary nodules and small

tumors adjacent to pleural surfaces that are not visible on

routine chest x-ray, and to demonstrate mediastinal

abnormalities and hilar adenopathy, which are difficult to

visualize with other techniques. Contrast agents are

useful when evaluating the mediastinum and its contents.

• (4) Magnetic Resonance Imaging

- MRIs are similar to CT scans except that magnetic

fields and radiofrequency signals are used instead

of a narrow-beam x-ray.

• MRI uses a magnet and radio waves to produce an

energy field that can be displayed as an image.

- Chest MRI scanning is performed to assist in

diagnosing abnormalities of cardiovascular and

pulmonary structures.

• (5) Bronchoscopy

- This procedure provides direct visualization of the

larynx, trachea, and bronchial tree by means of

either a rigid or a flexible bronchoscope.

- The purpose of the procedure is both diagnostic and

therapeutic. The rigid bronchoscope allows

visualization of the larger airways, including the

lobar, segmental, and subsegmental bronchi, while

maintaining effective gas exchange.