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

Inspect anterior & posterior thorax for:

Symmetry

Configuration

Respiratory rate

Prolonged expiration phase (indicates

airway narrowing e.g. asthma)

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 http://medinfo.ufl.edu/year1/bcs/clist/chest.html#FREM

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 separating them near your ear (fine crackles), or Velcro opening

(coarse crackles)

• Abnormal breath sounds are any sounds that are diminished or misplaced

• Rales/crackles result from air bubbling through moisture in alveoli or from collapsed alveoli popping open.

You tend to hear crackles at the end of inspiration, in the terminal bronchioles and alveoli

• Rhonchi/Wheezes caused by the narrowing of an airway by spasm, inflammation, mucous secretions or a

solid tumor. The pitch is determined by the relative tightness of the airway. They are most often heard

during expiration. Rhonchi can be cleared with coughing at times so it is good to ask the client to cough

before auscultating again. With infants it may be difficult to clear their chests and that is why they may

need suctioning.

Wheezes (rhonchi): Predominate in expiration; caused by narrowing of an airway by spasm,

inflammation, mucous secretions or a solid tumor. Pitch determined by relative tightness of airway. May

also be heard during inspiration. May be cleared with coughing at times, ask client to cough before

auscultating again. Described as musical, multiple or single toned.

p.470 text

Stridor: Results from an upper airway obstruction, a partial obstruction or spasm of trachea or larynx.

Usually acute respiratory distress!

Grunting: Heard during expiration and results from air in the lungs- prevents alveolar collapse This is an

emergency!

http://www.wrongdiagnosis.com/n/neonatal_respiratory_distress_syndrome/book-diseases-16b.htm

Friction rub: Occurs when pleural layers of lung rub together; coarse, low-pitched & grating • Friction rub results from the rubbing together of the parietal and visceral layers of an inflamed pleura which

produces a high-pitched grating or squeaking sound. The rub may be heard during inspiration and expiration

and is not affected by coughing

• Transmission of voice sounds through healthy lung tissue is normally muffled.

Abnormal vocal sounds:

Bronchophony: abnormal clarity of spoken word (through stethoscope), normally muffled, usually

indicative of consolidated lung

Egophony: “eee” sounds like “aay”, normally “eee” (Egophony sounds like a goat’s voice. You would ask the client to say “eee” and if the “eey” sounds like an “ay”

then they have egophony)

Whispered pectoriloquy: “1,2,3” whispered should sound indistinct, not distinct

(Whispered pectoriloquy would ask the client to whisper one, two, three and they should sound like puff, puff, puff

if they are clear then they have pectoriloquy)

These 3 often occur due to consolidated lung tissue, pulmonary edema or pulmonary hemorrhage

Assess for:

Increased rate, wheezing

Skin colour changes (Cyanosis, dusky,

gray)

Diaphoresis

Nare flaring

Accessory muscle use

Anxiety

Tripod positioning

Grunting

To minimize risk of progression to respiratory arrest

The nurse is the key factor here!

Common Abnormalities

Pulmonary embolus: Abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia

Pleural Effusion: Collection of fluid in pleural space; most often caused by heart failure, pneumonia,

cancer, TB and pulmonary embolism

Asthma: Reactive airway disease, resulting in inflammation & airway obstruction

• During an attack, client dyspneic with marked respiratory effort

• Nasal flaring, pursed-lip breathing, use of accessory muscles

• Cyanosis (late development)

• Auscultation reveals wheezing, particularly on expiration (absence of wheeze can be ominous –

no air movement)

• Coughing & chest tightness

Classic Presentation

• Cough

• Dyspnea

• Wheezing

Clinical Manifestations

• Dehydration

• Pulse oximetry – low Sats

• ABG’s – some degree of hypoxemia, increased CO2 in severe cases signals impending

respiratory failure

• Status asthmaticus severe, life-threatening complication

Common Abnormalities

Bronchitis: Excessive mucous production with persistent cough

Emphysema: Permanent enlargement of alveoli with destruction of alveolar wall

Critical Concept:

High flow (40-100%) oxygen can cause respiratory arrest

High level of carbon dioxide and low oxygen level is responsible for the drive for breathing

Clinical Manifestations of Bronchitis

• Productive cough, copious sputum with progression of disease

• Decreased exercise tolerance

• Shortness of breath, audible “crackles/wheezes”

• Prolonged expiration

• May have barrel chest

• Chronic hypoxemia & hypercapnia

• Pulmonary infections common

• Elevated hematocrit, polycythemia, abnormal blood gases

• Pulmonary hypertension, cor pulmonale common

• right sided ventricle enlargement with dependent edema

• Cyanosis (“blue bloaters”)

• Clubbing of fingers

Clinical Manifestations of Emphysema

• Progressive dyspnea on exertion; eventually dyspnea at rest

• Client often thin

• Loss of lung normal elastic recoil, “air trapping”

• Known as “pink puffers”, reddish complexion & hyperventilation

• Prolonged expiration, use of accessory muscles

• Anteroposterior diameter of the chest is enlarged, chest has hyperresonant sounds on percussion

• Clinical Manifestations of Emphysema

• CXR shows hyperinflation, flattened diaphragm

• Auscultation: decreased breath sounds

*Client often leans forward with arms braced on knees to support the shoulders & chest for

breathing, classic tripod position

Asthma/COPD clinical differences

Asthma

Onset <40

Not caused by smoking

Sputum rare

Allergies often

Spirometry normalizes

Exacerbations then normalizes

COPD

Onset >40

Long term smoker

Sputum frequent

Allergies rare

Spirometry never normalizes

Disease progressively worsens

Pulmonary Function Studies

Pulmonary function studies

FEV1/FVC < 70%

Ratio of forced expiratory volume in 1 sec to forced vital capacity (evaluates air flow obstruction)

http://ca.youtube.com/watch?v=oHRTiytvuow

Common Abnormalities

Pneumonia: Infection of the lung tissue

Pneumothorax: Complete or partial collapse of lung

Cancer of the larynx/lung

Clinical Manifestations of Pneumonia

Clinical Manifestations of Lung Cancer

• Insidious onset

• Cough, change in cough quality

• Starts as dry, persistent cough

• Frequently ignored

• Wheezing, dyspnea, fatigue, hoarseness

• Hemoptysis

• Repeated unresolved infections (e.g. pneumonia)

• Pain (late manifestation)

• Weakness, anorexia, wt. loss (non-specific)

Clinical Manifestations of Larynx Cancer

• Hoarseness > 2weeks

• Cough or sore throat, prolonged

• Pain/burning in throat

• esp.with hot liquid or citrus juice

• Later S&S: dysphagia, dyspnea, unilateral nasal discharge/obstruction

• Wt. loss, cervical lymphadenopathy, pain radiating to ear with metastases

Great Resources

Jarvis & Bates videos on Thorax and Lung Assessment

http://emedicine.medscape.com/article/807143-overview (COPD)

http://www.emedicinehealth.com/slideshow_asthma/article_em.htm (asthma)

facetious