Pulmonary assessment and disorders ch 33 34 35 36 osborn 2012
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Transcript of Pulmonary assessment and disorders ch 33 34 35 36 osborn 2012
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Complete Assessment
• History– Biographic and demographic data– Chief complaint– Past medical history– Family history– Risk factors– Social history
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Complete Assessment
• Components of Physical Exam – Inspection– Auscultation– Percussion– Pain– Genetic and gerontological considerations
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Social History
• Patients’ lifestyles and habits and • Risk for developing pulmonary disease• Current and previous work settings• Home environment• Social settings
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Gerontological Considerations
• aging decreases respiratory function• lower arterial oxygen values, • increase risk of pneumonia• Risk of aspiration may increase with aging• Aging may affect patient comfort needs
during the examination
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Genetic Considerations
• Cystic fibrosis (CF): genetic disorder, typically diagnosed in childhood
• CF has serious pulmonary complications – thick mucus builds up in lungs
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Initial assessment activity• General appearance:
– Posture, facial expression and movements – Changes in mental status – Respiratory rates shallow breathing, irregular
patterns of breathing – Size and shape of the thorax, asymmetry– Diminished movement of rib cage, use of
accessory muscles
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Color and appearance of skin– Pallor may indicate decreased oxygen-
carrying capacity of the blood due to anemia– Central cyanosis, where the mouth, lips, and
mucous membranes are blue-tinged, indicates hypoxia in adults
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Inspection of the neck– Appearance of veins, trachea and
musculature may indicate chronic cardiac or pulmonary disease, pneumothorax
– Goiter or lesions may obstruct the upper airway
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Palpation of skin and extremities– Edema of lower extremities– Skin temperature and moisture – Clinical reference points – Chest excursion – Tactile fremitus – Tenderness – Crepitus
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Reference Points
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Occupational Impact on Respiratory Disease
• Exposure to airborne particles, vapors, and irritants
• Can result in acute or chronic respiratory disease in susceptible individuals
• Early recognition, diagnosis, and treatment of occupational asthma can prevent pulmonary complications
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Auscultating Breath Sounds
• Patient should be upright • Use the diaphragm of the stethoscope• Begin at C7 posteriorly and anteriorly from
above the clavicles• Move steadily from right to left upper and
lower• Compare breath sounds bilaterally• Do not auscultate over clothing
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Diaphragm - best for higher pitched sounds, like breath sounds and normal heart sounds.
Bell - is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. It is used for the detection of bruits, and for heart sounds (for a cardiac exam, listen with the diaphragm, and repeat with the bell).
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Figure 33.1 In a respiratory assessment, it is important to palpate and count ribs and interspaces to accurately record the location of lesions or adventitious breath sounds.
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Auscultating Breath Sounds
Figure 33.2 Lobes of the lung—anterior.
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Auscultating Breath Sounds
Figure 33.3 Lobes of the lung—posterior
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Tracheal Breath Sounds
• Auscultated over the trachea• Loud and high pitched• Cause: airflow through tubular trachea• Best heard over the neck and trachea• Occurs during upper airway obstruction
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Bronchial Breath Sounds
• Anterior: heard on either side of sternum, over main stems of the bronchus from 2nd to 4th intercostal spaces
• Posterior: best heard lateral to the spine between 3rd and 6th intercostal spaces
• Loud, harsh, less turbulent and lower than tracheal sounds
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Bronchial Breath Sounds
• Pause between inspiration and expiration; expiration is heard for a longer time than inspiration
• Sounds over smaller airways are low pitched and softer
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Bronchovesicular Breath Sounds
• Heard during inspiration and expiration• Midway in Pitch and loudness between
vesicular and bronchial breath sounds• Best heard in 1st and 2nd intercostal
spaces of anterior chest, between scapulae of the posterior chest
• Represent air movement in the moderate airways between the bronchi and the smaller airways
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Vesicular Breath Sounds
• Heard over most of the thorax• Soft and low pitched, rustling, from air
moving through small airways• Heard longer during expiration, which
generally lasts twice as long as inspiration
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Adventitious Breath Sounds
• Decreased or no sounds where normal sounds should occur
• Breath sounds occurring in abnormal locations
• Diminished breath sounds demonstrate decreased airflow and potentially decreased oxygen exchange
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Adventitious Breath Sounds
• Adventitious/extra sounds: – Represent pathologic conditions of heart or
lungs– Indicate disrupted airflow due to airway
spasm, fluid, or secretions – Crackles (rales-term not used as much),
Wheezes, Stridor, Friction rubs
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Crackles • Caused by fluid in the airways• Intermittent or discontinuous, nonmusical, or
popping sounds • Caused by fluid, inflammation, infection, or
secretions• Crackles are described as either fine or coarse• Occur when closed airways snap open during
inspiration• Softer, gentler sound may also be heard on
inspiration
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Wheezes • Heard equally during inspiration and expiration• High-pitched musical sounds • Caused by air flowing across strands of mucus,
swollen pulmonary tissue that narrows the airway, bronchospasm
• Rhonchi (term for secretions in airways-not used as much)
• Inspiratory/expiratory, continuous/ discontinuous, mild/moderate/severe
• Asthma, allergies, reactive airway disease
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Stridor
• Heard only during inspiration as air attempts to flow across an obstruction
• Heard without stethoscope as high-pitched, crowing sound
• With stethoscope, best heard over large airways, e.g., trachea or bronchus
• Report to the health care provider immediately • Indicates airway obstruction requiring
intervention
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pleural Friction Rubs
• Low-pitched, creaking or squeaking sounds • Occur when inflamed pleural surfaces rub
together • Heard on inspiration• Pitch usually increases with chest expansion• Have the patient hold breath to distinguish
between pleural and pericardial friction
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Adventitious Lung Sounds
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Travel and Area of Residence
• An important aspect of the history in diagnosing potential respiratory problems
• Exposure to region-specific infectious diseases
• Exposure to environmental conditions, e.g. high altitudes
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
High-Altitude Pulmonary Edema (HAPE)
• HAPE – can occur with travel to altitudes greater than 5,000 feet
• Increasing altitude → decreasing atmospheric pressure → decreasing available O2
• Rapid onset of hypoxemia may result• Compensatory increased respiratory rate
may contribute to fatigue
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
High-Altitude Pulmonary Edema (HAPE)
• This causes further respiratory insufficiency
• Initial compensatory mechanisms – pulmonary vascular vasoconstriction
• Later, inflammatory mediators cause vasodilation
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Percussion • Assess presence of air, fluid, solid mass in
underlying tissues • Normal lungs produce a resonant, low-pitched clear
sound• Hyperresonance indicates airways are hyperinflated
or air is present outside of lung tissue• Dullness indicates that air is absent
– Pneumonia, pleural effusion, hemothorax, solid tumors
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pain
• Pain during respiration may decrease tidal volumes
• Pain management enables participation in rehabilitative activities
• Also promotes deep breathing to prevent pneumonia and atelectasis
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Standard of Care
• For patients with cardiac and respiratory illness, standard is:– Continuous or intermittent observation of the
patient’s oxygen saturation – End-tidal carbon dioxide levels– Peak flow is utilized to trend treatment
effectiveness in patients with asthma
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Assessment of Arterial Oxygen Levels
• ABG’s• Pulse oximetry• Physical assessment• FiO2 will increase the PaO2 four times
(normal patient)
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Pulse Oximetry
• Measures O2 saturation of hemoglobin• Reflects light off the hemoglobin
molecules• Measures the absorption of light by
hemoglobin• Normal range is from 95% to 100%
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Factors Interfering with Pulse Oximetry
• Nail polish • Automated BP cuffs, hemodialysis fistulas,
or arterial lines interfere with blood flow • Shock and hypovolemia • Patient movement, ambient light, and
venous pulsations may also cause inaccurate readings
Copyright ©2010 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Peak Flow Meters
• Track trends in a patient’s condition, evaluate air movement to determine severity of asthma exacerbation
• Measure the peak expiratory flow rate• Normal values based on age and body
size• Severity scale: Utilizes red, yellow, and
green zones to determine the severity of decrease in peak flow
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Arterial Blood Gas Studies (ABG)
• Provide information on arterial oxygen and carbon dioxide levels
• Oxygen saturation, bicarbonate, and blood pH are also calculated
• CO2 is major determinant of respiratory alkalosis/acidosis
• Bicarbonate level is determinant of metabolic acidosis/alkalosis
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Capnography
• Measurement of exhaled CO2
• Some utilize paper treated to detect the presence of acid such as CO2
• Others use spectrography, generate waveform readings
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Capnography
• Useful in determining ventilatory status, readiness for extubation
• Also used to determine pulmonary vessel perfusion in patients with pulmonary embolus
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Capnography Monitor
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Medical Surgical NursingPreparation for Practice
CHAPTER
Caring for the Patient with Upper Airway Disorders
34
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Facial Bones
• Mandible • Maxilla• Zygoma• Temporal bones • Frontal bone
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Mandible
• U-shaped bone • Together with the maxilla, largest and
strongest bone of the face• Forms lower jaw, holds the lower teeth in
place• Articulates with temporal bones at the
temporomandibular joint• Only mobile bone of the facial skeleton;
motion is essential for mastication
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management for Mandibular Fractures
• Determine patient’s nutritional requirements and knowledge deficits
• Oral nutrition with high-protein liquid diet and calories is essential
• Avoid weight loss if possible to ensure nutritional adequacy for healing
• Nasogastric or oral gastric tube supports nutrition if patient has extensive facial swelling
• Observe for nausea and vomiting, intervene to prevent aspiration
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Maxilla
• Largest component of the middle third of the facial skeleton
• Attaches laterally to the zygomatic bones • Key bone in the midface, provides
structural support • Fractures less frequently than mandible or
nose due to strong structural support
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Classification System of Maxillary Fractures
• Le Fort I Fracture (horizontal)• Le Fort II Fracture (pyramidal)• Le Fort III Fracture (transverse)
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Zygoma
• A paired bone, commonly called the cheekbone
• Articulates with maxilla, temporal, sphenoid, and frontal bones
• Forms prominence of the cheek• The masseter muscle is suspended from
the zygomatic arch
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Temporal Bone
• Situated at the sides and base of the skull• Houses cochlear and vestibular end
organs, facial nerve, carotid artery, jugular vein
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Nursing Management for Temporal Bone Fractures
• Care is conservative• Assess for nerve damage and hearing loss• Test for otorrhea; may indicate a CSF leak• Monitor lumbar drain if inserted • If facial nerve injury is present, provide eye
care • Institute CSF leak precautions – HOB 30o , no
straining, bending or lifting
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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Frontal Bone
• Makes up the forehead, upper edge and roof of the orbit
• Forms the anterior portion of the cranium• Frontal sinus – air-filled cavity between
lamina of the frontal bone• Serves as a mechanical barrier to protect
the brain