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Assessment of the Respiratory System
Irene Owens MSN, FNP-BC
Anatomy and Physiology Review
Upper respiratory tractLower respiratory tractLungs Accessory muscles of respirationRespiratory changes associated
with aging
Assessment TechniquesCollect history of client data on
family, personal, smoking, drug use, allergies, travel, place of residence, dietary history, occupational history, and socioeconomic level.
Assess current health problems such as cough, sputum production, chest pain, and dyspnea.
Physical AssessmentAssessment of the nose and
sinusesAssessment of the pharynx,
trachea, and larynxAssessment of the lungs and
thorax–Inspection–Palpation, check fremitus–Percussion–Auscultation
Breath SoundsNormal breath sounds include
bronchial, bronchovesicular, and vesicular.
Adventitious breath sounds include:–Crackle–Wheeze–Rhonchus–Pleural friction rub
Other AssessmentsVoice soundsBronchophonyWhispered pectoriloquyEgophonySkin and mucous membranesGeneral appearanceEndurance
Psychosocial AssessmentSome respiratory problems may be
worsened by stress.Chronic respiratory disease may
cause changes in family roles, social isolation, and financial problems due to unemployment or disability.
Discuss coping mechanisms and offer access to support systems.
Laboratory Tests
Blood testsSputum testsRadiographic examinations
including standard chest x-rays, digital chest radiography, CT
Ventilation and perfusion scanningPulse oximetry
Pulmonary Function Testing
These tests evaluate lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation.
Client preparationProcedure for performing tests at
the bedside
Other Testing and Follow-Up Care
Exercise testingSkin testing
Other Invasive Diagnostic TestsEndoscopic examinationsThoracentesis: aspiration of pleural
fluid or air from the pleural space–Client preparation for stinging sensation and feeling of pressure
–Correct position–Motionless client–Follow-up assessment for complications
Lung Biopsy
Performed to obtain tissue for histologic analysis, culture, or cytologic examination
Client preparationMay be performed in client’s room
(Continued)
Lung Biopsy (Continued)
Follow-up care:–Assess vital signs and breath sounds at least every 4 hours for 24 hours.
–Assess for respiratory distress.–Report reduced or absent breath sounds immediately.
–Monitor for hemoptysis.
Interventions for Clients Requiring Oxygen Therapy
Oxygen Therapy
Hypoxemia: low levels of oxygen in the blood
Hypoxia: decreased tissue oxygenation
Goal of oxygen therapy: to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects
Hazards and Complications of Oxygen Therapy
CombustionOxygen-induced hypoventilationOxygen toxicityAbsorption atelectasisDrying of mucous membranesInfection
Low-Flow Oxygen Delivery Systems
Nasal cannulaSimple face maskPartial rebreather maskNon-rebreather mask
High-Flow Oxygen Delivery Systems
Venturi maskFace tentAerosol maskTracheostomy collarT-piece
Noninvasive Positive-Pressure Ventilation
BiPAP cycling machine delivers a set inspiratory positive airway pressure each time the client begins to inspire. At exhalation, it delivers a lower set end-expiratory pressure. Together the two pressures improve tidal volume.
Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation.
Continuous Nasal Positive Airway Pressure
Technique delivers a set positive airway pressure throughout each cycle of inhalation and exhalation.
Effect is to open collapsed alveoli.Clients who may benefit include
those with atelectasis after surgery or cardiac-induced pulmonary edema; it may be used for sleep apnea.
Transtracheal Oxygen Delivery
Used for long-term delivery of oxygen directly into the lungs
Avoids the irritation that nasal prongs cause and is more comfortable
Flow rate prescribed for rest and for activity
Home Oxygen Therapy
Criteria for home oxygen therapy equipment
Client education for use–Compressed gas in a tank or cylinder
–Liquid oxygen in a reservoir–Oxygen concentrator
Interventions for Clients with
Noninfectious Problems of the
Upper Respiratory Tract
Fracture of the NoseDisplacement of either the bone or
cartilage of the nose can cause airway obstruction or cosmetic deformity and is a potential source of infection.
Cerebrospinal fluid could indicate skull fracture.
Interventions:–Rhinoplasty–Nasoseptoplasty
Epistaxis Nosebleed is a common problem.Interventions if nosebleed does not
respond to emergency care:–Affected capillaries are cauterized with silver nitrate or electrocautery and the nose is packed.
–Posterior nasal bleeding is an emergency.
(Continued)
Epistaxis (Continued)
–Assess for respiratory distress and for tolerance of packing or tubes.
–Administer humidification, oxygen, bedrest, antibiotics, pain medications.
Nasal Polyps
Benign, grapelike clusters of mucous membranes and connective tissue
May obstruct nasal breathing, change character of nasal discharge, and change speech quality
Surgery: treatment of choice
Cancer of the Nose and SinusesCancer of the nose and sinuses is
rare and can be benign or malignant.
Onset is slow and manifestations resemble sinusitis.
Local lymph enlargement often occurs on the side with tumor mass.
Radiation therapy is the main treatment; surgery is also used.
Facial Trauma
Le Fort I nasoethmoid complex fracture
Le Fort II maxillary and nasoethmoid complex fracture
Le Fort III combination of I and II plus an orbital-zygoma fracture, often called craniofacial disjunction
First assessment: airway
http://en.wikipedia.org/wiki/Le_Fort_fracture_of_skull
Facial Trauma Interventions
Anticipate the need for emergency intubation, tracheotomy, and cricothyroidotomy.
Control hemorrhage.Assess for extent of injury.Treat shock.Stabilize the fracture segment.
Obstructive Sleep ApneaBreathing disruption during sleep
that lasts at least 10 seconds and occurs a minimum of five times in an hour
Excessive daytime sleepiness, inability to concentrate, and irritability
Nonsurgical management and change of sleep position
Surgical management: uvulopalatopharyngoplasty
Disorders of the Larynx
Vocal cord paralysisVocal cord nodules and polypsLaryngeal trauma
Interventions for Clients with
Noninfectious Problems of the
Lower Respiratory Tract
Chronic Airflow Limitation
Chronic lung diseases of chronic airflow limitation include:–Asthma–Chronic bronchitis–Pulmonary emphysema
Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis characterized by bronchospasm and dyspnea.
Asthma
Intermittent and reversible airflow obstruction affects only the airways, not the alveoli.
Airway obstruction occurs due to inflammation and airway hyperresponsiveness.
Aspirin and Other NonsteroidalAnti-Inflammatory Drugs
Incidence of asthma symptoms after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)
However, response not a true allergy
Results from increased production of leukotriene when other inflammatory pathways are suppressed
Collaborative ManagementAssessmentHistoryPhysical assessment and clinical
manifestations:–No manifestations between attacks
–Audible wheeze and increased respiratory rate
–Use of accessory muscles–“Barrel chest” from air trapping
Laboratory Assessment
Assess arterial blood gas level.Arterial oxygen level may decrease
in acute asthma attack.Arterial carbon dioxide level may
decrease early in the attack and increase later indicating poor gas exchange.
(Continued)
Laboratory Assessment (Continued)
Atopic asthma with elevated serum eosinophil count and immunoglobulin E levels
Sputum with eosinophils and mucous plugs with shed epithelial cells
Pulmonary Function Tests
The most accurate measures for asthma are pulmonary function tests using spirometry including:–Forced vital capacity (FVC)–Forced expiratory volume in the first second (FEV1)
–Peak expiratory rate flow (PERF)–Chest x-rays to rule out other causes
Interventions
Client education: asthma is often an intermittent disease; with guided self-care, clients can co-manage this disease, increasing symptom-free periods and decreasing the number and severity of attacks.
Peak flow meter can be used twice daily by client.
Drug therapy plan is specific.
Drug Therapy
Pharmacologic management of asthma can involve the use of:
BronchodilatorsBeta2 agonistsShort-acting beta2 agonistsLong-acting beta2 agonistsCholinergic antagonists
(Continued)
Drug Therapy (Continued)
MethylxanthinesAnti-inflammatory agentsCorticosteroidsInhaled anti-inflammatory agentsMast cell stabilizersMonoclonal antibodiesLeukotriene agonists
Other Treatments for Asthma
Exercise and activity is a recommended therapy that promotes ventilation and perfusion.
Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack.
Emphysema In pulmonary emphysema, loss of
lung elasticity and hyperinflation of the lung
Dyspnea and the need for an increased respiratory rate
Air trapping, loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles)
Classification of Emphysema
Panlobular: destruction of the entire alveolus
Centrilobular: openings occurring in the bronchioles that allow spaces to develop as tissue walls break down
Paraseptal: confined to the alveolar ducts and alveolar sacs
Chronic Bronchitis
Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke
Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm
Affects only the airways, not the alveoli
Production of large amounts of thick mucus
Complications
Chronic bronchitisHypoxemia and acidosis Respiratory infectionsCardiac failure, especially cor
pulmonaleCardiac dysrhythmias
Physical Assessment and Clinical Manifestations
Unplanned weight loss; loss of muscle mass in the extremities; enlarged neck muscles; slow moving, slightly stooped posture; sits with forward-bend
Respiratory changesCardiac changes
Laboratory Assessment
Status of arterial blood gas values for abnormal oxygenation, ventilation, and acid-base status
Sputum samplesHemoglobin and hematocrit blood
testsSerum alpha1-antitrypsin levels
drawnChest x-rayPulmonary function test
Impaired Gas Exchange
Interventions for chronic obstructive pulmonary disease:–Airway management–Monitoring client at least every 2 hours
–Oxygen therapy–Energy management
Drug Therapy
Beta-adrenergic agentsCholinergic antagonistsMethylxanthinesCorticosteroidsCromolyn sodium/nedocromilLeukotriene modifiersMucolytics
Surgical Management
Lung transplantation for end-stage clients
Preoperative care and testingOperative procedure through a
large midline incision or a transverse anterior thoracotomy
Postoperative care and close monitoring for complications
Ineffective Breathing PatternInterventions for the chronic
obstructive pulmonary disease client:–Assessment of client–Assessment of respiratory infection
–Pulmonary rehabilitation therapy–Specific breathing techniques–Positioning to help alleviate dyspnea
–Exercise conditioning–Energy conservation
Ineffective Airway ClearanceAssessment of breath sounds
before and after interventions Interventions for compromised
breathing:–Careful use of drugs–Controlled coughing–Suctioning –Hydration via beverage and humidifier
(Continued)
Ineffective Airway Clearance (Continued)
–Postural drainage in sitting position when possible
–Tracheostomy
Imbalanced NutritionInterventions to achieve and
maintain body weight:–Prevent protein-calorie malnutrition through dietary consultation.
–Monitor weight, skin condition, and serum prealbumin levels.
–Address food intolerance, nausea, early satiety, loss of appetite, and meal-related dyspnea
Anxiety
Interventions for increased anxiety:–Important to have client understand that anxiety will worsen symptoms
–Plan ways to deal with anxiety
Health Teaching
Instruct the client:–Pursed-lip and diaphragmatic breathing
–Support of family and friends–Relaxation therapy–Professional counseling access–Complementary and alternative therapy
Activity Intolerance
Interventions to increase activity level:–Encourage client to pace activities and promote self-care.
–Do not rush through morning activities.
–Gradually increase activity.–Use supplemental oxygen therapy.
Potential for Pneumonia or Other Respiratory Infections
Risk is greater for older clients Interventions include:
–Avoidance of large crowds–Pneumonia vaccination–Yearly influenza vaccine
Sarcoidosis
Granulomatous disorder of unknown cause that can affect any organ, but the lung is involved most often
Autoimmune responses in which the normally protective T-lymphocytes increase and damage lung tissue
Interventions (corticosteroids): lessen symptoms and prevent fibrosis
Occupational Pulmonary Disease
Can be caused by exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens
Worsened by cigarette smokeInterventions: special respirators
that ensure adequate ventilation See page 640 Iggy
BOOP
Patho: inflammatory process that allows connective tissue plugs to form in the lower airways and in the tissue between the alveoli. Inflammation triggers WBC’s with connective cell growth that occludes and obliterates these airways and leads to restricted lung volume with decreased VC. Not a true pneumonia. No known cause
BOOP cont Triggers Infectious organisims, drugs
antiseizure medications cocaine, RA, SLE, also related to chest radiation therapy for cancer. Solid organ transplant patients
Usually S?S present for months and do not improve with standard ABX.
CT will suggest BOOP not confirm it Biopsy needed to confirm BOOP Treatment Corticosteroids
Interventions for Clients with Infectious
Problems of the Respiratory Tract
RhinitisInflammation of the nasal mucosaOften called “hay fever” or
“allergies”Interventions include:
–Drug therapy: antihistamines and decongestants, antipyretics, antibiotics
–Complementary and alternative therapy
–Supportive therapy
Sinusitis
Inflammation of the mucous membranes of the sinuses
(Continued)
Sinusitis (Continued)
Nonsurgical management–Broad-spectrum antibiotics–Analgesics–Decongestants–Steam humidification–Hot and wet packs over the sinus area
–Nasal saline irrigations
Surgical Management
Antral irrigationCaldwell-Luc procedureNasal antral window procedureEndoscopic sinus surgery
Pharyngitis
Sore throat is common inflammation of the mucous membranes of the pharynx.
Assess for odynophagia, dysphagia, fever, and hyperemia.
Strep throat can lead to serious medical complications.
Epiglottitis is a rare complication of pharyngitis.
Tonsillitis
Inflammation and infection of the tonsils and lymphatic tissues located on each side of the throat
Contagious airborne infection, usually bacterial
AntibioticsSurgical intervention
Peritonsillar Abscess
Complication of acute tonsillitisPus behind the tonsil, causing one-
sided swelling with deviation of the uvula
Trismus and difficulty breathingPercutaneous needle aspiration of
the abscessCompletion of antibiotic regimen
Laryngitis
Inflammation of the mucous membranes lining the larynx, possibly including edema of the vocal cords
Acute hoarseness, dry cough, difficulty swallowing, temporary voice loss (aphonia)
Voice rest, steam inhalation, increased fluid intake, throat lozenges
Therapy: relief and prevention
Influenza
“Flu” is a highly contagious acute viral respiratory infection.
Manifestations include severe headache, muscle ache, fever, chills, fatigue, weakness, and anorexia.
Vaccination is advisable.Antiviral agents may be effective.
Pneumonia Excess of fluid in the lungs
resulting from an inflammatory process
Inflammation triggered by infectious organisms and inhalation of irritants
Community-acquired infectious pneumonia
Nosocomial or hospital-acquiredAtelectasisHypoxemia
Laboratory Assessment
Gram stain, culture, and sensitivity testing of sputum
Complete blood countArterial blood gas levelSerum blood, urea nitrogen levelElectrolytesCreatinine
Impaired Gas Exchange
Interventions include:–Cough enhancement–Oxygen therapy–Respiratory monitoring
Ineffective Airway Clearance
Interventions include:–Help client to cough and deep breathe at least every 2 hours.
–Administer incentive spirometer—chest physiotherapy if complicated.
–Prevent dehydration.
(Continued)
Ineffective Airway Clearance (Continued)
–Monitor intake and output of fluids.
–Use bronchodilators, especially beta2 agonists.
–Inhaled steroids are rarely used.
Potential for SepsisPrimary intervention is
prescription of anti-infectives for eradication of organism causing the infection.
Drug resistance is a problem, especially among older people.
Interventions for aspiration pneumonia aimed at preventing lung damage and treating infection.