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Respiratory Assessment NURS 113

Respiratory Assessment NURS 113. Suzy Dalgarn RN, MSN, CNE, PMHNP. Goals. Identify Review of Systems (ROS) and Health Promotion questions pertinent to a respiratory assessment Demonstrate a focused physical assessment of the respiratory system using proper technique and organization

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Respiratory Assessment NURS 113

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  1. Respiratory AssessmentNURS 113 Suzy Dalgarn RN, MSN, CNE, PMHNP

  2. Goals • Identify Review of Systems (ROS) and Health Promotion questions pertinent to a respiratory assessment • Demonstrate a focused physical assessment of the respiratory system usingproper technique and organization • Define and use in documentation common terms to describe abnormal and normal

  3. Nursing Process • Assessment • Subjective interview • HPI • Patient complaints • Objective exam • Physical findings • Diagnosis • Planning • Implementation • Evaluation

  4. Reference Lines (Anterior)

  5. Subjective Data • Sample respiratory-related questions for focused HPI: • Feeling SOB? • Onset? Provocation? Severity? Position (Orthopnea, Paroxysmal nocturnal dyspnea)? Timing? Alleviating factors? Home oxygen? Affect on ADLs? • Cough? • Productive? Frequency? Hemoptysis? Quality? Provocation? Alleviating factors? Affect on ADLs? Timing? Worsening? • Chest pain? • Worse with breathing or cough? OPQRST? • Fever? Dizziness? Other symptoms? • History of respiratory infections? Exposure? • Smoke?

  6. Cough • Common cough descriptions: • Pneumonia/bronchitis: congested, productive • Croup: barking • Early heart failure: dry • Late heart failure: wet • Mycoplasma pneumonia: hacking, persistent (common comm.-acquired pneumonia) • Common mucus descriptions: • Clear/white: viral, colds, bronchitis • Yellow/green: bacterial • Rust: TB, pneumococcal pneumonia (sepsis) • Pink/frothy: pulmonary edema

  7. Subjective Data • Pertinent… • Past medical history • Family history • Personal or social history • Medications • Allergies • Other? • Smoking history

  8. Respiratory Screening – Every Patient • General inspection of the following: • Position? Distress? • Tripod • Work of breathing • Relaxed, labored • Accessory muscle use • Retractions, grunting, flaring, pursed lips • Skin color, temperature, moisture – cyanosis? • Speech? Full sentences? • Spontaneous respirations? • Rate, quality, pattern and depth of respirations • Tachypnea vs bradypnea, shallow vs deep, obvious adventitious LS (wheezing, crackles, stridor), regularity • JVD? • LOC and mental status • May be first sign of decline • Coughing? • Obvious airway obstruction • Any other bleeding, trauma, deformity, edema, skin abnormality, etc

  9. Further Examination • When to further examine any one particular aspect? • Abnormal finding on general inspection • Subjective data reveals symptom or other finding that necessitates further exam • Any time you feel it is indicated

  10. Detailed Exam • Inspection of: • Closer inspection of ‘general inspection’ items • Shape/diameter of chest • Barrel chest (anteroposterior:transverse diameter)? • Sign of air trapping – obstructive lung disease • Inhalation:Exhalation ratio • Exhalation normally 2x inhalation (increases in obstructive lung diseases) • Deformities • Tracheal position - shift toward unaffected side in pneumothorax & large pleural effusion; toward involved side in atelectasis

  11. Respiratory Patterns • Normal • Hypoventilation - Narcotic, anesthesia, splinting • Cheyne-Stokes – Inc. ICP, meningitis, OD, severe HF • Chronic obstructive disease Also tachypnea, bradypnea, hyperventilation, sigh

  12. Auscultation • Breathe thru mouth, Anterior and posterior • Top to bottom, Side to side

  13. Lung Sounds • Bronchial: hi pitch, loud, insp<exp, trachea • Bronchovesicular: med pitch, insp=exp, bronchi • Vesicular: lo pitch, soft, insp>exp, alveoli See table 18-1

  14. Adventitious Sounds • Crackles – fine, coarse, discontinuous, popping, bubbling; fluid, consolidation or collapsed alveoli • Pulmonary edema, Pneumonia, Restrictive disease • Atelectatic crackles – disappear after a few breaths or cough • Wheeze – high-pitch, continuous, air thru narrow passage, inspiratory and/or expiratory • Asthma, Emphysema • Ronchi (low-pitched wheeze/snoring sound) • Due to secretions – Pneumonia, etc • Stridor – high-pitch, monophonic, inspiratory, narrowing of upper airway: Croup, Epiglotittis http://www.youtube.com/watch?v=5JA6D1Mguh0&feature=related http://www.youtube.com/watch?v=5-8uTk1MfwQ&feature=related

  15. Document • Clarity - any adventitious sounds • Location • Depth of respiration • Equality • Abnormal pattern (if any)

  16. Other • Palpation: • Tactile fremitus (“Ninety-nine”) • Consolidation, obstruction • Asymmetry (symetric chest expansion) • Atelectasis, pneumonia, trauma, pneumothorax • Crepitus • Pneumothorax • Deformity, rib fx, etc

  17. Other (cont.) • Percussion • Hyperresonance • Air • Dull • Density

  18. Diagnostic Testing • Chest XR (CT, MRI, etc) • Oxygen saturation • ABG • PFT • Peak flow • Road test

  19. Special Populations • Pregnancy: Elevated diaphragm, increased oxygen demand • Geriatric: Decreased vital capacity, increased residual volume, fatigue easier • Pediatric: • Let parents hold child • Let child examine stethoscope • Normally barrel chested until ~6 y/o • Obligate nose breather until 3 months • Diaphragm major muscle of resp. until intercostals develop • Look for accessory muscle use!

  20. Sample Charting

  21. Putting It All Together Ben is a 54 y/o who presents to the ER c/o difficulty breathing and cough for the last 3 days. As the primary nurse you enter the room and find him laying back on the bed • What focused questions do you want to ask?

  22. Putting It All Together • What focused questions do you want to ask? • Are you feeling SOB? • Yes • When did it start? • 3 days ago • Does anything make it worse? • Yes, worse when I am doing stuff • How bad is it? • Pretty bad, I have never felt like this before • Does it change if you change positions or lie down? • No • Does anything make it better? • Not really • Have you been able to go to work? • No, been in bed for last 3 days

  23. Putting It All Together • What focused questions do you want to ask? • Do you have a cough? • Yes, and it gets worse each day • Did it start at the same time? • Yeah, maybe a day or so before • Are you coughing up mucus? • Yes, a lot of green-brown mucus • Any blood when you cough? • No, I don’t think so • How often are you coughing and does anything make it worse? • I’m coughing constantly, I don’t know how it could get worse • Does anything make it better? • Not really

  24. Putting It All Together • Are you having any pain in your chest? • Yes • Can you describe it for me? • It’s sharp, kind of all over • When did it start? • 2 days ago • Does it get worse when you cough? • Yes! It’s awful • How bad is it on a scale of 0-10? • 8 • Does that pain go anywhere? • No

  25. Putting It All Together • Any fever, chills, aching or sweatyness? • Yes, all of that • Any dizziness? • Maybe a little • Are you feeling fatigued? • Yeah, I have no energy • Ever have anything like this before? • No • Do you smoke? • No • Any other symptoms or anything else we didn’t mention? • I don’t think so

  26. Putting It All Together • Any other… • Recent illness? • No • Past medical history? • HTN, hypothyroid, L knee injury • Family history? • Dad = MI at 62 • Medications? • Lisinopril, synthroid • Allergies? • PCN

  27. Putting It All Together • General inspection reveals patient lying in bed, slightly pale and diaphoretic. Breathing is shallow and rapid. Occasional congested cough which causes patient to grimace and grab chest. What else do you want to look at??

  28. Putting It All Together • Supine position, rolling to side and moaning occasionally • Respirations shallow, tachypnic – no accessory muscle use • VS: HR 113, BP 101/52, RR 28, SpO2 94%RA, T 101.7 • Skin hot, pale, moist – no cyanosis • Speaking in nearly full sentences • LS diminished in bases, slight crackles/ronchi in RLL, equal, regular • A&Ox4/4, appears uncomfortable • No JVD or other abnormality noted What other tests could you do?

  29. Putting It All Together • Assess for… • Symmetric chest expansion • Tactile fremitus What tests do you want to order?

  30. Putting It All Together • Chest XR • ABG? • Road test? • CBC • Metabolic panel • BC x 2 • Sputum culture Treatment?

  31. Putting It All Together • IV • Antibiotics • Normal saline fluid bolus • Tylenol/ibuprofen for fever • Oxygen • Pain med? • Admit?

  32. A teenage patient comes to the emergency department with complaints of an inability to “breathe and a sharp pain in my left chest.” The assessment findings include the following: cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. This description is consistent with: • 1. bronchitis. • 2. a pneumothorax. • 3. acute pneumonia. • 4. an asthmatic attack.

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