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L5 Respiratory System.docx

17 Pages

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NURS 2200
Cynthia Barkhouse Mckeen

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NURS 2240: Review A&P of respiratory system Objetives:  Identify landmarks used in assessment of respiratory system  Complete a focused history in the lab using specific examples of respiratory problems  Demonstrate physical assessment of the respiratory system using inspection, palpation, auscultation  Differentiate normal from abnormal findings  Describe developmental, psychosocial, cultural, & environmental findings in physical assessment of the respiratory system  Describe signs & symptoms (S&S) of COPD (differentiate bronchitis & emphysema)  Describe S&S of asthma  Describe S&S of pneumonia  Use critical thinking in selected simulations related to focused history & physical assessment of the respiratory system Structures of Respiratory System Respiratory System Primary function: Exchange of gases in the body- O2 & CO2 Physiology of Respirations Mechanical Process: Pulmonary ventilation- inspiration & expiration- exchange of air between lungs & atmosphere Physiological Process: External- exchange between alveoli & blood Internal- exchange between systemic capillaries and tissue Cellular- exchange within the cell Oxygen Exchange Respiratory Cycle Eupnea: Regular, even, rhythmic pattern of breathing Dyspnea: Change in pattern producing shortness of breath or difficulty breathing Orthopnea: difficulty breathing lying flat Paroxysmal nocturnal dyspnea: waking at night with sudden shortness of breath Health History  History of respiratory disease e.g. COPD, asthma  Presence of respiratory symptoms e.g. cough, sputum, shortness of breath  Identification of risk factors e.g. smoking, family history Specific Respiratory Hx Includes:  Is there a pattern?  Is there a trigger?  Current medications  Client’s management strategy/treatment plan  Family supports  Length of time since diagnosis  Client’s attitude toward illness and management Bony Landmarks - Provide exact location for assessment & documentation of findings Anterior Thorax, Lt Lateral view Posterior Thorax Lines of the Anterior Thorax Lines of the Lateral Thorax Lines of the Posterior Thorax Lobes of the Lungs- Posterior View Lobes of the Lungs- Lt. Lateral View Lobes of the Lungs- Rt. Lateral View Physical Assessment Approach: *Vital signs*, O2 sat, consider pain, inspection, palpation, percussion & auscultation Position: Sitting Assessment tools: gown, drape, stethoscope If client can not lie down, then a semi-fowler’s or fowler’s or side lying position may have to be used. Use a systematic approach and proceed from apex to the base, comparing one side to the other Vital Signs: Elevated temperature: infection, pulmonary embolism Respirations: rate, depth & rhythm can be affected by cardiac, metabolic neurological, emotional disorders and medications (see text p 466-467) Oxygen saturation: pulse oximetry, blood gases Rate: Tachypnea (increased rate): hypoxia, metabolic acidosis, anxiety, fear, pain, sepsis, fever, neurological control Bradypnea (decreased rate): sedation, hypercapnea, compromised neurological control & metabolic alkalosis Depth & Rhythm: Shallow respirations: habit; fatigue; metabolic alkalosis; ascites; restrictive lung disease; chest, abdominal or pleuritic pain; neurological disorders Increased depth: anxiety, neurological or metabolic disorders Abnormal Patterns: Hyperventilation: rapid, deep respirations; can be with fear or exertion; associated with metabolic acidosis (Kussmaul’s respirations: with diabetic ketoacidosis or lactic acidosis); CO2 is “blown off”, causing alkalosis Cheyne Stokes: rapid deep inspirations followed by gradual ceasing & apnea (drug induced, heart or renal failure, brain damage or impending death) Biot’s:  irregular in rate & depth  alternates with irregular periods of apnea  seen in respiratory depression, damage to medullary respiratory centre or head injury (indicating increased ICP) Explain procedure Inspection  Observation of skin colour  Respiratory rate  Inspect anterior & posterior thorax for:  Prolonged expiration phase (indicates  Symmetry airway narrowing e.g. asthma)  Configuration Palpate Anterior Chest Palpation of Posterior Thorax Palpate for Fremitus Fremitus: vibration on chest wall when client speaks  Strongest over trachea, diminishes over bronchi, nonexistent over alveoli in lungs  Place hands while asking client to repeat 99 in clear loud voice  Use palmar or ulnar surfaces , one or both hands Palpate for Fremitus Diminished Fremitus: Can be caused by thick chest wall or soft voice – normal finding  Fluid or air trapped outside the lung  Excess air trapped in lungs  Emphysema  Pneumothorax (on affected side)  Asthma  Pleural effusion (on affected side) Increased Fremitus  Fluid inside the lungs, called consolidation  Infection (e.g. pneumonia)  Tumour Palpate for Tactile Fremitus Palpate for Chest Expansion Palpate for Crepitus Crepitus is a coarse, crackling sensation palpable over the skin surface, “crunchy feeling”, caused by air leaking from the lung into subcutaneous tissue Percussion –used to gather information about abnormal findings *Not commonly used in RN practice Auscultating Posterior Thorax Normal Breath Sounds: Bronchial: high-pitch; loud; inspiration < expiration (inspiration sounds shorter time than expiration) than ; heard over trachea & larynx; harsh, hollow tubular Bronchovesicular: moderate pitch & amplitude, inspiration = expiration, heard over main bronchi Vesicular: low-pitched, soft, inspiration > expiration, sounds like rustling of wind in trees, heard over most of lung fields p. 453 text Auscultation of voice sounds – findings in absence of respiratory problems Bronchophony: auscultating while client says “99”, sound is muffled; abnormal if clearly heard Egophony: auscultating while client says “E”- sounds like “eeee”; abnormal if sound changes to “aaaaa” Whispered pectoriloquy: auscultate while client whispers “1, 2, 3”- sounds should be indistinguishable; abnormal if distinguishable Auscultation of voice sounds – findings if patient has respiratory problems Bronchophony, egophony & whispered pectoriloquy are found with increased consolidation or compression as with lobar pneumonia, atelectasis or tumour Assessed if patient has other findings such as increased breath sounds over the lung fields (advanced assessment techniques) Auscultate Anterior Chest Auscultate Posterior Chest Normal & Abnormal Breath Sounds Adventitious Sounds p. 469 text Crackles (rales):  Discontinuous, high pitched sounds heard during inspiration, or loud low-pitched bubbling and gurgling sounds that start in early inspiration not cleared by coughing  Air bubbling through secretions in alveoli or from collapsed alveoli “popping” open  Sound is similar to that of rolling a strand of hair between your fingers near you ear or moistening your thumb and index finger and separati
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