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The Respiratory System

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The Respiratory System

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    1. The Respiratory System Thorax and Lungs Rachel S. Natividad, RN, MSN, NP

    2. Lobes and Landmarks

    3. Performing the Assessment: Subjective Data ROS -Ask about dyspnea, cough, chest pain (PQRST format) Short interview sessions if resp. distress / tiring easily

    4. Assessment begins. Inspection Always first!!! The moment you see the patient. What position is most comfortable for him? Does he appear relaxed, anxious, uncomfortable? Is he having any trouble breathing?

    5. Focused Assessment Inspection-cont. Color, Size and shape & symmetry of chest, any lesions or scars Anterior Lateral Posterior

    6. Altered size/shape: Barrel Chest Increased Anteroposterior:Transverse Diameter

    7. Barrel Chest

    8. Asymmetrical chest Fractured ribs/ flail chest Pneumothorax atelectasis paralysis of the diaphragm Spinal deformity

    9. Intercostal Spaces and Muscles

    10. Focused Assessment Cont Resp. rate (per min.) and depth (shallow, even, deep) Normal pattern of respiration regular rhythm

    11. Relating to other systems Skin: cyanosis, pallor Nails: Clubbing Spongy nail matrix and nail angle of greater than 160 degrees

    12. Focused Assessment Cont.: Palpation Check for tenderness (normally nontender) Crepitus SQ air pockets Tactile fremitus increased with fluid accumulation Abnormal if tumor, fractured ribs, chest tubes, wound site, fluid

    13. Focused Assessment: Auscultation

    15. Normal Breath Sounds

    16. Adventitious/Abnormal Breath Sounds (T 11-2) p.132 Continuous sounds Wheezes Sibilant Sonorous (Rhonchi) Discontinuous sounds Crackles (Rales) Fine Course *Atelectic crackles Stridor Pleural friction rub

    17. Wheezes (Continuous) Sibililant wheeze Heard 1st in expiration high-pitched musical sounds Partial blockage in airflow Sonorous wheeze (rhonchi) Heard primarily in expiration low pitched snoring, rattling sound Air passes through large airways filled with fluid/ secretions

    18. Interpreting what you hear Is the sound is continuous or discontinuous? Is the sound occur during inhalation or exhalation, or both?

    19. Crackles (Discontinuous)

    20. Abnormal Breath Sounds Diminished breath sounds Absent breath sounds

    21. Assessment Guide: Gas Exchange Respiratory Rate: 18 resp/min Depth: deep, even, shallow Effort: labored, unlabored Breath Sounds Describe: clear, rhonchi, inspiratory/expiratory wheezes, crackles Location: all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat. Cough: present/not present Describe: productive, moist, nonproductive Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.

    22. Interventions in use: Position, Turn, Cough, Deep breathe O2 Method: nc, venti mask, rebreathing mask Flow rate: 2L/min; 3l/min Humidity: yes/no Pulse Oximeter: continuous, spot monitoring Incentive Spirometer: in use, n/a Time used: 10 am, 11 am, 1 pm, 3 pm Volume: 500 cc, 500 cc, 600 cc, 800 cc Oropharyngeal Suctioning: Describe- moderate amount thick tan secretions Med List: Albuterol inhaler, Prednisone, Theophylline

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