Diagnostic Reasoning for Advanced Nursing Practice
431
Respiratory Assessment
Respiratory
System - History
§
First,
assess for signs of acute respiratory distress:
l restlessness
l anxiety
l inability to follow
conversation
l noisy or labored
respirations
§
If
so, treat or obtain help.
§
When
breathing comfortably, proceed with full health history.
History
§
Chief
complaint
§
Patient
profile (recent travel, work, home)
§
HPI
§
PMH
§
FH
§
ROS
Respiratory System - History
§
Shortness
of breath? (pattern, how relieved)
§
Position,
time, activity affect breathing?
§
How
many stairs, block before feel SOB?
§
Cough?
(analyze)
§
Sputum?
(analyze)
§
Chest
pain? (analyze)
§
Hx.
of resp. illness/surgery/dx. Study
§
How
many pillows to sleep on?
§
Seasonal
allergies? (cause, sx., tx.)
§
Smoke
tobacco? (how long, how much)
§
Use
OTC nasal sprays or inhalers?
§
Use
nebulizer or other breathing tx.?
§
Use
oxygen at home?
§
Vaccinated
against flu/pneumonia?
§
Family
hx: emphysema, asthma, allergies, TB?
§
In
last 1-2 months: fever, chills,
fatigue, or night sweats?
§
Anemia?
§
Sinus
problems?
History: Peds Particulars
§
Respiratory
problems at birth? (treatment?)
§
Frequent
congestion, runny nose, colds?
§
Does
SOB interfere with taking bottle?
§
Cough
at night? Does child awaken?
§
Does
cough/SOB interfere with childs play or school activities?
History: Elderly Elements
§
Aware
of any changes in breathing patterns?
§
Easily
fatigued when climbing stairs
§
Trouble
breathing when lying flat?
§
Seem
to have more colds that last longer?
Health Promotion Questions
§
Last
CXR? Last TB test?
§
Home
remedies used for resp. problems
§
Need
assistance for activities? $ for meds?
§
Any
hobbies with respiratory irritants?
§
3
large meals or several small meals?
§
Does
work/home stress affect breathing?
§
Home:
others, pets, heating,
Examination of the Chest
General Approach: Position
§
Sitting
upright
§
Recumbent
if too ill
§
Good
lighting
§
Undressed
to waist
Proceed in orderly fashion
§
Inspection,
palpation, percussion, auscultation
§
Compare
one side with other
§
Work
from above-down
§
Begin
with posterior chest
§
Try
to visualize underlying tissue
Observation (Inspection)
§
THORACIC
CAGE
§
Shape
l deformities of thorax
l shape of ribs
§
Retraction
of interspaces on inspiration
§
Bulging
interspaces
§
RESPIRATORY
MOVEMENT
§
Rate/rhythm
§
Depth
§
Use
of accessory muscles
§
Symmetry
and expansion
Palpation
§
Areas
of tenderness
l Check costochondral
junctions
§
Abnormalities
such as masses
§
Respiratory
excursion (range, symmetry)
l thumbs at level of 10th ribs
l grasp rib cage laterally;
deep inhalation
§
Check
supra/infraclavicular nodes
§
Crepitation: subcutaneous emphysema
Palpation: Tactile fremitus
§
Definition: palpable vibrations transmitted to chest
wall when patient speaks
§
Use
ball of hand (side of hand in child)
§
99
or 1,2,3
§
Can
do both sides at once
§
Increased
Tactile Fremitus:
l consolidation due to pneumonia - especially close to
surface
l large patent bronchus
§
Decreased
Tactile Fremitus:
l obstructed bronchus
l fluid in pleural space
l air in pleural space (pneumothorax)
l normal finding (dull over heart)
l COPD, fibrosis, tumor
l thick chest wall
l soft voice
Percussion: Sounds
§
Resonance - normal lung
§
Hyperresonance - increased air volume
§
Tympany - gastric air bubble
§
Dullness - consolidation in lung; normal over liver and heart
§ Flatness - large fluid mass, pleural
effusion, normal over thigh
Percussion: Procedure
§
Percuss
symmetrical areas at 5 cm intervals (< 5 cm in child) down posterior chest
and sides of chest
§
Note: Anteriorly:
dull at 5th right rib due to liver
Percussion: Diaphragmatic excursion
§
Diaphragmatic
excursion: note distance between levels
on full expiration and full inspiration
§
Normal
= 5-7 cm. Difference
§
Exhalation
- 10th rib
§
Inhalation
- 12th rib
Auscultation
§
Listen
to lungs as patient breathes through his mouth, more deeply than normal
§
Listen
to one full breath at each location on posterior, lateral,and
anterior chest
Normal Breath Sounds
§
Vesicular: Most of lungs
l Inspiration > Expiration
(I > E)
l Low pitch, soft intensity
§
Bronchovesicular: Near main bronchi
l I = E, medium pitch and
intensity
§
Bronchial
(tracheal): Over trachea
l E > I, high pitch, low
intensity
Adventitious (Additional) Sounds
§
Discontinuous
sounds: Crackles (rales)
l Fine
l Coarse
§
Continuous
sounds:
l Wheezes
l Rhonchi
§
Clearing
of adventitious sounds by cough suggested secretions caused them (as in
bronchitis or atelectasis)
Fine Crackles
§
Fluid
in alveoli
§
End
of inspiration
§
Like
rolling a strand of hair between fingers next to ear
§
Occurs
with CHF, pneumonia, atelectasis, bronchitis, pulmonary fibrosis
Coarse Crackles
§
Exudate
in larger bronchi and smaller bronchioles
§
Early
to mid inspiration and expiration
§
Loud
- gurgling, bubbling
Wheezes
§
Partial
obstruction to airflow in smaller bronchi and bronchiole
§
Frequently
heard on expiration
§
Wheezes
may be on both inspiration and expiration due to narrowing of bronchioles by
spasm or obstruction
§
NO
wheezes in asthmatic may mean complete obstruction!!!
Rhonchi
§
Partial
obstruction to airflow in large rhonchi and trachea - usually from mucous
collection
§
Prominent
on expiration though may be heard in both
§
Lower
pitch than wheeze - Snoring
§
Coughing
may clear
Auscultation
§
If
breath sounds are decreased, or you suspect but cannot hear signs of
obstructive breathing, ask patient to breath hard and fast
§
If
abnormality present, check spoken and whispered voice sounds
Voice Sounds
§
Normal
voice transmission
l not loud or clear
l syllables are not
distinguishable
§
Abnormal
voice sounds
l often associated with
consolidation
Abnormal Voice Sounds
§
Bronchophony - loud only, cannot distinguish words/syllables
§
Whispered pectoriloquy - whispered syllable; can distinguish what
is whispered; occurs even when process too small to produce bronchial breathing
§ Egophony - letter E sounds like
A
Stridor
§
Upper
airway obstruction
§
Prominent
on inspiration
§
Crowing
sound
§
Narrowing
of trachea
§
Example: acute glossitis
Pleural Friction Rub
§
Pleural
irritation without fluid
§
Heard
on inspiration and expiration but is frequently heard at the end of inspiration
§
Grating,
leathery quality, noncontinuous
§
Auscultatory
site: usually anterior lateral wall
§
Found
in pulmonary embolus, pleurisy, pneumonia
Sample
Documentation
§
Height
56, Wt. 124#, T 99.2, HR 104/regular, BP 168/96, RR 36 labored with use of
accessory muscles, pursed lip breathing.
Thin, barrel-chested male appearing older than stated age of 56. Complexion with bluish cast. Chest expansion symmetrical/minimal
movement. Crepitus over LLL.
Hyperresonance over all chest walls. Decreased breath sounds over LLL with
prolonged expiration.
Other Objective Findings
To add to the O of the
SOAP format
Diagnostic
Testing
§
ABGs
§
CBC
(esp. RBCs, Hgb)
l Compensatory polycythemia in
COPD
§
CXR
§
V/Q
scans
§
Pulse
oximetry
§
Peak
flow meter