RESPIRATORY ASSESSMENT (SIGNIFICANCE)

80,000 die each yr in USA from chronic lung disease 5 million have serious lung problems Cancer of lungs is the leading cause of death from cancer in the US. There are about 150,000 new cases each year.

Total surface area of alveoli comprises area larger than a tennis court

Lung lobes: on left: upper & lower on right: upper & middle & lower

WHAT CCs WARRANT AN Upper and/or lower RESPIRATORY ASSESSMENT?

SOB, DOE, cough, -If patient has hx of allergy, hx of asthma ask separately about wheeze hx or any resp problems -edema -headache, especially child sore throat hoarseness earache smoker with other presenting --S&S child with abdominal pain child with vomiting (HA, abd pain and vomiting all assoc. with strep pharyngitis) -chest pain or other abnormal chest sensation (pressure, etc) recent surgery (increased chance of emboli) -fever -infant with diarrhea (sometimes the only obvious symptom of otitis media or pneumonia which can be secondary to a URI) Infant: "breathing funny", noisy breathing, breathing too fast, not eating Note: neonates (very young infants) tend to run SUBNORMAL temps when they have an infection

Child:

any of above plus not playing, or sleeping only for short periods

SUBJECTIVE DATA (What do you want to know)

Example cc: Cough

(HPI) Onset? Productive? Color of sputum? Fever? How much? Nasal drainage? What color? Ear pain? Night sweats (common in TB, cancer, AIDS, lung abscess)? Precipitating factors, worse any time of day or night? Relieving factors, better any time of day or night? Tx tried & results? Associated symptoms? Any swelling? Dyspnea, DOE--how bad is it? "2 block dyspnea" ORTHOPNEA --how bad is it? "2 pillow ORTHOPNEA" Symptoms of GERD? Hx of allergies or asthma (put info here and/or med hx)? Ever had anything like this before? How often? (VERY important in differentiating allergies from URIs) Anyone else sick? What do you think it is? Smoker (pack index: # packs per day x # of years smoked, could go in social hx) Last TB skin test and results (could go in med hx) Last CXR and results (could go in med hx) Pets? (could go in social hx) Work & hobbies (social hx) (health care workers at risk for TB-some jobs Exposure to toxic fumes - even housekeeper) Any recent illness (put in HPI or med hx) Immunizations up to date? (either here or in med hx) (Allergies) list (Current meds) ask specifically about oral contraceptive pills (OCPs) (increase risk of pulmonary emboli) Use of allergy or asthma drugs supply hx info sometimes when pt

denies allergies, HTN drugs (ACE inhibitors) Ask specifically if they have already taken any antibiotics

(Med hx) see some items above, childhood illnesses , exposure to TB, asbestos, recent surgery ( increased risk of emboli - hemoptysis may be sign but not diagnostic) military hx, travel hx (could go in social) Ask specifically about FHV status (100 times more prone to TB) When was last TB test and what were results Immunization status (Surg hx) (Family hx) specifically ask about allergies and cancer and HTN, heart and stroke (Social hx) marital status, type dwelling and who lives in household. Type utilities, whether smoke detector used, natural gas in home? CO detector? Seat belt use? Self breast exam ? (some of these questions are because many women never have an annual exam ... so ask risk related question often when seeing women for unrelated concerns) (ROS) any recent illness? (Could go in med hx) What systems to include in ROS? Ears - pain, drainage, problems hearing nose - drainage? Stuffy? throat- sore? sinus - any PND or facial pain lymph nodes - any swollen glands musculoskeletal- joint or muscle pain (seen with flu, AIDS) derrn: any recent rashes (infectious diseases-pharyngitis: look at chest in child) GI: general & vague symptoms with flu and other viruses, diarrhea may go with AIDS, abd pain and vomiting with strep pharyngitis Reproductive: LMP (could she be pregnant-why do you need to know? Type birth control- OCPs will increase risk of pulmonary emboli) Known exposure to STDS, any vaginal symptoms, or abd pain -sometimes cc is just the ticket to get in the door, new sexual partner) Neuro: HA

common with strep and viral syndromes Ask: Has anything else been bothering you?

Objective Data Physical exam: General: Vital signs, ht and wt (if this is a child, you will need wt to calculate any meds you may order Some hints r/t vitals: Normally, Resp: pulse rate - about 1:4 If temp is up but heart rate is not, fever may be factitious (malingerer) If the systolic BP is down and diastolic up pt may be in heart failure (stroke volume decreases systolic but compensatory vasoconstriction maintains diastolic); you will see decreased pulse pressure INSPECT (LOOK): Look for signs of air hunger or respiratory distress: tachypnea (rapid) bradypnea (slow) kids in severe trouble will slow rate look for prolonged expiratory phase (seen in obstructive conditions: Like COPD or asthma) dyspnea (labored respirations anxious facial expression restlessness (esp in child - cardinal sign of air hunger) breathing with mouth open (may just be stopped up nose) drooling in child may indicate epiglotittis ( a medical emergency) nasal flaring head bobbing (an example of using accessory muscles to breath) splinting - pain usually from the parietal pleura ( a membrane that enfolds the lungs). The pain is usually sharp and stabbing

position of comfort - tripod common hypoxia inducing illnesses such as CBF and COPD, cystic fibrosis or acute asthma or epiglotittis

(People with ORTHOPNEA can't breathe lying down)

Assess skin -may see petechiae over chest with pulmonary emboli ( perfusion, look for cyanosis or pallor), ck nail beds and mucous membranes esp in dark skinned people

cyanosis: central cyanosis is found in lips, tongue, & face and is caused by hypoxia. 02 sat has to be below 80 for this to occur. Peripheral cyanosis (in extremities) without central cyanosis suggests cold-induced vasoconstriction. If hands are warm & nail beds cyanotic, the cyanosis is probably central in origin Tip: ANEMIA can prevent cyanosis and prevent decreased SaO2 measurement because cyanosis is result of deoxygenated hgb Rash over chest may indicate scarlet fever or "scarlatina" Assess ears and pharynx for any type resp exam -impacted ears can be the sole cause of cough, likewise postnasal drip can be the cause; may see 46 cobblestone appearance of posterior pharynx Assess nasal mucosa -red and irritated appearing for infections and pale or bluish and "'boggy" for allergic process. Assess color of mucus. Clear with allergy or virus and purulent (yellow or green) with bacterial infection Assess facial sinuses -can palpate, percuss and transilluminate Assess symmetry of trachea ; Trach deviated toward atelectasis if collapsed area is large Atelectasis may result from tumor, foreign body, or mucous plug

Trachea usually goes to opposite side during exhalation with Pneumothorax and toward the side of the pneumothorax during inspiration Pneumothorax is air in pleural space; may be caused by rupture in lung wall or leak in chest wall. Tachypnea also present Assess symmetry of upper torso: when there is atelectasis ( impaired expansion), the chest will lag on affected side *Observe for use of accessory muscles: Retractions in child, Head bobbing Observe spinal alignment: pt should stand if possible: kyphosis (humpback) will restrict respiratory movements lordosis (swayback) expected in toddler and pregnant female scoliosis (lateral curve) -have pt bend at waist to R/O functional curve (structural is true curve) *Observe costal angle (just below the sternum) : normal = 90 or less (this means that sharper is OK) increased angle (wider) means more flattened out - seen in obstructive diseases like COPD *Observe angle of rib slope: should be about 45 ; more horizontal ribs seen in obstructive diseases *Observe AP:lateral ratio (how does front to back compare to side to side measurement of chest?): 1:2 to 5:7 in adult, second # decreased (when the second number is decreased it's called an increased ratio). This is also seen in COPD, bronchiolitis, or any condition in which air is trapped in alveoli (Obstructive diseases) *Observe respiratory pattern: men and children are abdominal breathers, women are chest breathers LISTEN: (some books call this part of observation - not auscultation) Do you hear: expiratory grunt (HMB or RDS in NB or pneumonia in adult - this is an attempt to

keep alveoli open - pt gives himself PEEP) inspiratory stridor (croup) wheezing asthma, bronchiolitis or foreign body aspiration rattling (usually hear rhonchi with auscultation) cough - wet or productive sounding (indicates loose secretions and Possibly improving condition - ask pt to turn head and Cough while you listen Dry or nonproductive (usually earlier in an inflammatory Type condition) Always ASK the pt to cough several times so you can listen (Hint: stand behind him before asking him to cough-good to be behind when auscultating also)

Smell breath: foul breath may indicate sinus or lung infection always ck bum patient for smoky smell ER patient with altered consciousness and unknown dx: diabetic coma - fruit or sweet odor to breath drug or alcohol poisoning bloody odor Before beginning other assessment techniques - think about where the lung tissue is located and where it can be assessed. see pictures in Seidel and know which lobes mostly accessible in what areas (anterior, posterior, under right axilla) Palpation - touch *palpate for masses and tenderness : keep fingers together and use circular motion of hand (chest wall tenderness with costochondritis - at sternum - rib attachment) *palpate for crepitation, esp if pt in ER, on mechanical ventilation or has known respiratory problems ( may also occur with spontaneous pneumothorax - air in pleural cavity) TIP - FOR POSTERIOR EXAM, LET PATIENT LEAN 0VER BEDSIDE TABLE *tactile fremitus, use flat hand or ulnar aspect of hand. Bronchus must be open to feel tactile fremitus; fremitus is increased over consolidation (pneumonia) unless

bronchus is blocked Fremitus is decreased with pneumothorax (where there is air between you and the lung tissue) Fremitus can be assessed anterior and posterior *Assess chest expansion -(respiratory excursion, not to be confused with diaphragmatic excursion) place hands near costal angle on anterior chest and over lower rib cage on posterior chest - remember that males are abd breathers there will be a unilateral lag with atelectasis post op patients may guard and intentionally restrict excursion PERCUSSION: Not very useful in muscular or obese patient *normal sound is resonance over most of lung area dullness over heart dullness over lung tissue indicates lack of air (consolidation) flatness heard over scapula *Diaphragmatic excursion: 3-5 cm; can ck anterior or posterior, usually checked posterior only

AUSCULTATION: Note where chest is auscultated: anatomic landmarks note pitch of sound note length of expiration compared to inspiration *Adventitious sounds wheeze=musical rale=sibilant rhonchi Indicates fluid in large airways as seen in severe heart failure or bronchospasm of asthma or bronchiolitis rale=crackle (sounds like when you rub hair between fingers near your ear) Indicates presence of fluid, mucus, or pus in smaller airways. Often with pneumonia rhonchi=coarse rale (a wet sound produced in the large airways) Usually disappears when patient coughs-adventitious sounds frequently progress from rale to rhonchi when the patient's condition improves, even though a rhonchi is much louder and sounds worse than a rale. Rhonchi cause by turbulent air passing thru secretions in large air ways. Often with pneumonia pleural friction rub--loud, creaking or grating sound caused by inflamed surfaces rubbing together. Heard best in lateral anterior thorax because there's a lot of movement in this area with respirations - heard best at end of inspiration and a little at beginning of expiration

*Auscultate for vocal fremitus or resonance -decreased or increased in same conditions that cause decrease or increase in tactile fremitus Fremitus increases with increased lung density because dense tissue transmits sound better-pneumonia Fremitus decreased when there is more air in an area than there sound be --COPD or pneumothorax Technique: Bronchophony--have pt say 99 Egophonye sounds like aaa or like a bleating goat Whispered pectoriloquy--this is abnormal, the words seem to clearly come from the area being auscultated-heard over consolidation Be familiar with info at end of Seidel chapter on abnormal conditions
Bholloway, FNP, DNSc