Respiratory Assessment

Respiratory Assessment

"Life is pretty easy. Breathe in. Breathe out. Repeat."

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Respiratory Overview

01.

Objective Respiratory Assessment Data

02.

Oxygen Deprivation

03.

Lung Sounds

04.

Focused Respiratory Assessments

05.

Subjective Respiratory Assessment Data

06.

Nursing Alert!

Respiratory system

01.

Respiration is basic to life

Exchange of oxygen and carbon dioxide through the inspiration of air from the atomosphere and the expiration of air from the lungs.

02.

Functions of the respiratory system

• Supply for the metabolic needs of the cells
• Remove waste products of cellular metabolism

+ respiratory A&P

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Objective RespiratoryAssessment Data

Never underestimate the power of observation!

Assess EVERY time you enter the room and describe what you see!

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OXYGEN DEPRIVATION

When you think oxygen deprivation you automatically think cyanosis, but there can be many cognitive changes seen as well

LOC

Anxiety

Lethargy

Nasal flaring

Heart rate

This can look like drowsiness, disorientation, or even yawning

Can be a visual sign that they are struggling to breathe

Pt may become confused or disordented

Will increase and can become tachycardic

Can become restless

Watch

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Lung Sounds

Left Upper Lobe

Right Upper Lobe

Left Middle Lobe

Right Middle Lobe

Left Lower Lobe

Right Lower Lobe

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Lung Sounds

Normal Vesicular

Diminished

Crackles (aka Rales)

Absent

Stridor

Wheezes

Pleural friction rub

Rhonchi

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FOCUSED RESPIRATORY ASSESSMENTs

These assessments are more focused on the respiratory system and not always necessary for every patient. Click on each to learn more and see how each assessment is performed.

Whispered Pectoriloquy

Tactile Fremitus

Percussion

Egophony

Assessment of sound vibration through the chest wall

Assessment used to examine lung tissues that are filled with air, fluid, or solid tissue

Assessing loudness of whispering during auscultation

Assessment of lung consolidation

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What have we learned?

Click on each disorder to test your knowledge about what assessment findings would be found for each one!

Pneumonia

Emphysema

(Consolidation)

(Air trapping)

Pneumothorax

(Collapsed lung)

Subjective RespiratoryAssessment Data

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NURSING ALERT!

IDENTIFY CHANGES IN RESPIRATORY STATUS THROUGH FREQUENT ASSESSMENTS!

- Sputum production - Cough -Dyspnea - Tachypnea/Bradypnea - Chest pain - Adventitious breath sounds (wheezes, crakles, rhonchi, etc.) - Hymoptysis - Restlessness, anxiety, confusion

REQUIRES NURSING ACTION!

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NURSING ALERT!

NURSING INACTION WHICH THREATENS A PATIENT'S LIFE = CLASS 1 VIOLATION FOR WHICH NO PROGRESSIVE DISCIPLINE IS NECESSARY

So... What does that mean?

You MUST take action if your patient is having respiratory difficulties! If you do not this could lead to loss of job or your nursing license!

Remember your ABCs when thinking priority!

Nares & Septum

-Discharge?-Nasal flaring? Or inhaling/exhaling through both nares? This could be signs of dyspnea or air hunger! -Septal deviation?

Immunizations

When asking patient history make sure to ask if the patient is up to date on their vaccines Influenza (yearly) Pnemococcal (over age 65 or have weakened immune system) COVID-19 (CDC recommends first doses, then booster)

Trachea

Midline vs. deviated

Fatigue & Weakness

-Reduced O2 supply to tissue leads to fatigue and weakness-Breathing difficulties increase energy expenditure, causing fatigue -Chronic inflammation and stress contribue to fatigue

Occupational/Environmental History

Asking where your patient works can give you an insight onto possible issues that can affect their respiratory system -What kind of exposure do they have? Fumes, toxins, coal dust, silica, saw dust

Pain

Pleurisy - an inflammatin in the lining of the lungs and chest cavity Causes sharp chest pain seen with lung infetions or underlying conditions like penumonia or autoimmune disorders

Effort

This allows you to assess the ease or difficulty in which an individual is breathing. Labored: working hard to inhale or exhale, could indicate respiratory or other problems

This is due to the narrowing of the airway or an obstruction. This can happen on expiratory or inspiratory breaths.

Skin

What does skin tell us about someone's oxygenation status? -Check in areas of low pigmentation -Pallor: absensece of red-pink tones of oxygenated hemoglobin (takes on color of connective tissue) -Pallor can look different depending on skin color: brown skin = yellow brown, black skin = ashen/gray, dullness = not vivid, loss of luster -Cyanosis: lips, nail beds, mucous membranes -Ruddy: blue with polycythemia

Chills & Night Sweats

-These symptoms could indicate underlying respiratory condition such as pneumonia or tuberculosis-Both require further investigation and follow up assessments

Patient History

Knowing your patient's history can tell us a lot about their respiratory status/history-Sleep habits: using extra pillows to sleep? Orthopnia - difficulty breathing lying flat Sleep apnea - pauses in breathing while sleeping, can feel tired and have daytime fatigue -Conditions affecting immune system -Other history including cardiac, cancer, renal disorders -Allergies -Snoring -Chest/lung injuries -Respiratory medications/aids: allergy medications, inhalers, CPAP machine @ night

Clubbing

Nails can tell us a lot about someone's oxygenation status. Changes in status are due to oxygenation issues over a long period of time. -Increased hypoxia and increase capillary vasodilation shows in the soft tissue around the fingers increasing blood flow -The nail bed feels "spongy" or "floating"

click buttons for pictures

Vibrations felt through the chest wall with ulnar side of hands (sound transmits better through solids than air) Ask patient to say "99" while feeling chest for vibrations bilaterally Increased tactile fremitus with consolidation = pneumonia Decreased tactile fremitus with air trapping = emphysema, pneumothorax

This can sound like rattling, almost like someone is snoring. Sometimes clears after a good cough/deep breath. Something you can do after assessing and then reevaluate!

Depth

This allows us to assess how deeply the patient is breathingShallow: Might suggest respiratory distress or anxiety Deep: May suggest an increase need for oxygen

Decreased airflow in lungs. Can be seen frequently post-op because they aren't taking deep breaths or increased pain meds.

Use fingers to tap on the chest wall, which produces sound Resonance = normal, low pitch sound Hyperresonance = air trapping, ex: Emphysema, pneumothorax, Dull = consolidation, ex: Pneumonia, tumors, hemothorax

Cough

1. Frequency/timing/duration 2. Does anything precipate? Does anything make it better? 3. Productive? -COCA of sputum if yes! 4. Describe the cough: dry, hacking, hoarse, loose, wet, gurgling 5. What's causing the cough? -some medications like ACE inhibitors can cause coughs

Heard in the upper airway - trachea/throat. Very high pitched and can be heard on inspiration (obstruction). If you hear this in lower lobes it's probably wheezing!

Dyspnea

Also known as shortness of breath (SOB) Can be caused by various factors including respiratory disorders, anxiety, or physical exertion

Dyspnea Scale

0 = dyspnea with extreme exertion 4 = dyspnea with minimal exertion

Smoking History

Smoking leads to an increase risk for various respiratory issues Ask your patient if they are a smoker, how long they have smoked, and how many packs a day. Packs per day x years = pack years

2 packs/day for 30 years =

60 pack years

42 pack years

1.5 packs/day for 28 years =

This is what lung sounds should sound like in a healthy individual.

Rhythm

This shows the regularity of breathing cycles. Normal breathing should be regular and consistent. Irregular rhythm could include breathing quickly and then a few longer breaths.

Inflammation in the pleural space that causes the grating sounds when breathing. Sounds like rubbing leather together!

Ask patient to say "e" while you auscultate the lung fields Normal lungs = Hear "e" sound Consolidated areas = Changes to "e" sound to "aaaaay" sound

Characteristics

Are they using their accessory muscles to help them breathe? Are they able to finish a sentence without becoming short of breath?

Also known as Rales

Fine crackles sounds like strands of hair rubbing together Coarse very harsh, very loud

Many times there are differences between upper and lower lobes. You can hear different things in different lobes - it's important to be specific when assessing and charting!

Ask patient to whisper "1-2-3" while auscultating Normal lungs = not clear, indistinct sound Consolidation = Understandable, distinct "1-2-3" sound

Pattern

Are they breathing at a normal rate? Periods of quick breaths followed by periods of apnea?

This can occur if there has been surgery to remove all or part of the lung.

Rate

Normal respiratory rate

12-20 breaths/min