History
• Physical problems• Function problems• Life style• Smoking• Family Hx• Occupation hx• Allergens / environment• Recreational exposure• Anxiety• S&S
• The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
A. Low birth weightB. Large for gestational ageC. Preterm birth, but appropriate size for gestationD.Growth retardation in weight and length
Inspection
• Normal chest– Slight retraction of
intercostal spaces– 2x as wide as deep– Anterior/posterior
diameter• 1:2
Inspection
• Funnel chest– Depression of the
lower portion of the sternum
– Complications• Heart damage• Cardiac output
– Nrs management• Murmurs
Inspection
• Scoliosis– Lateral curvature of
thoracic spine– Assessment
• Shoulders elevated?
– Complications• Lung & heart damage• Back problems• Body image
Quiz?
• How many hours a day should a child wear a brace for treating scoliosis?
A. 8 hrB. 12 hrC. 23 hrD. 24 hr
Inspection
• Uniform expansion of the chest– Pneumonia– Pleural effusion– Pneumothorax
• Bulging intercostal spaces– Obstruction– Emphysema
Inspection
• Marked retraction of intercostal spaces– Blockage
• Shoulder rise• Accessory muscles• Posture
Inspection: Breathing patterns
Rate• Eupnea– Normal– 12-20 / min
• Tachypnea– rate– Pnuemonia, pulm edema, acidosis, septicemia, pain
• Bradypnea– rate– ICP, drug OD
Inspection: Breathing patterns
Depth• Hyperpnea– depth
• Hyperventilation– depth & rate
• Hypoventilation– depth & rate
Inspection: Breathing patterns
Depth• Kussmaul's– rate & depth– Assoc. with sever acidosis
• Apneustic– Prolonged gasping I following by short
Inspection: Breathing patterns
Rhythm• Apnea– Not breathing
• Cheyne-stokes– Varying depth f/b apnea– Death rattles– Death rales
Inspection:
• Trachea– ? Deviation
• Pleural effusion• Tension pneumothorax• Atelectasis
• Color• LOC• Emotional state
Palpation
• TML– Tenderness (T)– Masses (M)– Lesions (L)
• Sinuses– Palpate below eyebrow &
Cheekbone• Crepitus
– Subcutaneous emphysema– Air leaks into the sub-q tissue
Percussion
Rational• To determine if underlying
tissue is filled with air or solid material
Procedure• Pt sitting• Tap starting at shoulder• compare rt to lf
Percussion: results
• Resonance – drum like– Normal
• Hyper-resonance– Too much air– Emphysema
• Flatness / dull– Fluid or solid– Pleural effusion– Pneumonia– Tumor
Auscultation
Purpose• Asses air flow through
bronchial treeProcedure• Diaphragm of
stethoscope• Superior inferior• Compare rt to lf
Auscultation: Results
Normal• Vesicular
– Lung field– Soft and low
• Bronchial– Trachea & bronchi– Hollow
• Bronchovesicular– Mixed– Between scapulae– Side of sternum– 1st & 2nd intercostal space
Auscultation: Results
Adventitious• Crackles– Rales– air bronchi with
secretions
• Fine crackles– Air suddenly
reinflated
• Course Crackles– Moist
Auscultation: Results
• Wheezes– Sonorous wheezes
• Deep low pitched• Snoring• > E• Caused by air
narrowed passages• D/t secretions
– Sibilant Wheezes• High pitched• Whistle-like• I & E• Caused by air
narrowed passages• D/t constriction
– Asthma
Auscultation: Results
• Pleural friction rub– D/t inflammation of
pleural membranes– Grating, creaking– I & E– Best heard
• Anterior, Lower, lateral area
Quiz?
• A child with difficulty breathing and a “barking” cough id displaying signs associated with which condition?
A. AsthmaB. CroupC. Cystic fibrosisD. Epiglottitis
Quiz?
• When assessing the lung sounds of a child with asthma, which sound are you most likely to hear?
A. MurmursB. Sonorous WheezingC. Sibilant WheezingD. CracklesE. Pleural friction rub
Early & late signs of hypoxia
• Anxiety• Bradycardia• Cyanosis• Depressed respirations• Diaphoresis• Disorientation• Dyspnea
• Restlessness• Headache• Agitation• Poor judgment• Retraction• Tachycardia• Tachypnea
The nurse recognizes which of the following as an early sign of hypoxia?
A. Restlessness, yawning & tachycardiaB. Dyspnea, confusion & bradycardiaC. Bradycardia, hypotension dyspneaD. Dyspnea, restlessness, hypotension
Dyspnea
• Significance– Common with cardiac & resp. disease– Sudden onset – healthy person • Pneumothorax
– Sudden onset ill, post-op or injury • Pulmonary emboli
Dyspnea
• Right ventricle– If chronic airway resistance – pressure – Rt ventricle work – Rt. Vent damage
Cough
• Significance– Infection– Irritants– Protective mechanism– Dry, irritating• URT
– Cough + chest pain• Pleural or musculoskeletal
Cough
• Nrs management– Assess– Describe – Directed – Pain control• Splinting
– Infection control– Suppressants / Anti-tussives
Sputum Production
Definition• Matter discharged
from resp. track that contains mucus and pus, blood, fibrin, or bacteria
Sputum Production
Significance• Purulent– Thick, yellow/green – Bacteria
• Rusty – Strep or staph
• Thin, mucous – Viral
Sputum Production
• Pink-tinged– Lung CA– TB
• Pink tinged, profuse, frothy– Pulmonary edema
• Malodorous– Lung abscess
Sputum Production
Nrs Management• Thick– Hydrate
• water• Nebulizer• Humidifier
• TCDB• No smoking• Oral care• Appetite
Do You Know?????
What breath sound would you expect to hear on a patient with increased sputum production?
A. VesicularB. CracklesC. Sonorous wheezesD. Sibilant wheezes
Obtaining a sputum specimen
• Explain– From lungs
• Sterile cup• Deep breath x 3 • Cough deeply• Expectorate • Best time for
specimen collection?– AM
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Whichaction should the nurse take first?
A. Ask client to cough sputum into containerB. Have the client take several deep breathsC. Provide a appropriate specimen containerD.Assist with oral hygiene
What?????
What breath sound would you expect to hear on a patient suffering from pleurisy?
A. CracklesB. Sonorous wheezesC. Sibilant wheezesD. Pleural Friction Rub
Clubbed fingers
Definition• Sponginess of the nail
bed • Loss of the nail bed
angle• Finger tip is round and
bulbous
Mr. Caveman:
Mr. Caveman enters the ER unconscious following an Automobile accident. The paramedics report that his O2 sats are 86%. You note that Mr. Caveman has clubbed fingers. What does this tell you?
Hemoptysis
Significance• Pulm or cardiac• Common causes– Pulm infection– CA of lungs– Pulm. Emboli– Pulm. Infarction– TB
Hemoptysis
• Hemoptysis– Definition?
• Coughed up blood
– From?• Pulm hemorrhage
– Description• Pink, red, mixed with
sputum
– Blood pH• Alkaline blood
• Hematemesis– Definition?
• Vomited blood
– From?• Stomach / GI
– Description• “Coffee ground”
– Blood ph• Acidic blood
Cyanosis
Significance• Very late indicator of
hypoxia• Appears when O2 sats
< 85%• NOT a reliable sign of
hypoxia– Esp. with anemia
Cyanosis
• NormalBreath 100 O2 molecules 98 cross into blood
Blood: 100 Hgb• O2 SATS– 98%– No cyanosis
Cyanosis
• HypoxiaBreath 100 O2 molecules 75 cross into blood
Blood: 100 Hgb• O2 SATS– 75%– Cyanosis
Cyanosis
• Anemic and hypoxicBreath 100 O2 molecules 75 cross into blood
Blood: 75 Hgb• O2 SATS– 100% – No Cyanosis