Download Ignatavicius: Medical-Surgical Nursing, 7th Edition

Ignatavicius: Medical-Surgical Nursing, 7th Edition
Chapter 29: Assessment of the Respiratory System
BLOCK 2 FOCUS ON LOWER AIRWAY
Key Points - Print
ANATOMY AND PHYSIOLOGY REVIEW
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The respiratory system includes the upper airways, lungs, lower airways, and alveolar air
sacs.
The respiratory system is vital in helping the body meet its need for oxygenation and tissue
perfusion.
The two purposes of breathing are to provide oxygen for tissue perfusion so that cells have
enough oxygen to take part in metabolism, and to remove carbon dioxide, the major waste
product of metabolism.
The upper airways consist of the nose, the sinuses, the pharynx, and the larynx.
The lower airways consist of the trachea; two mainstem bronchi; lobar, segmental, and
subsegmental bronchi; bronchioles; alveolar ducts; and alveoli.
The lungs are sponge-like, elastic, cone-shaped organs located in the pleural cavity in the
chest.
The apex (top) of each lung extends above the clavicle; the base of each lung lies just above
the diaphragm.
Breathing occurs through contraction and relaxation of specific chest muscles and the
diaphragm which cause changes in the size and pressure of the chest cavity. Accessory
muscles help in this process.
Tissue oxygen delivery through dissociation or unloading from hemoglobin is based on
tissues’ need for oxygen.
ASSESSMENT TECHNIQUES
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Obtaining accurate information from the patient is important for identifying the type and
severity of breathing problems and to assess the impact of pulmonary function.
Age, gender, and race can affect pulmonary function.
Many changes in older patients result from heredity and a lifetime of exposure to
environmental stimuli such as cigarette smoke, bacteria, air pollutants, and industrial fumes
and irritants.
Women have greater bronchial hyperreactivity and larger airways than men. This factor
increases the risk for a more rapid decline in lung function as an older adult, especially in
smokers.
Compared with white or light skin color, individuals with dark skin usually show lower
oxygen saturation as measured by pulse oximetry. This results from deeper coloration of the
nail bed and does not reflect true oxygen status.
Explore the home, community, and workplace for environmental factors that could cause or
worsen lung disease. Occupational lung diseases include pneumoconiosis.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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29-2
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other
controlled substances.
Ask whether the patient has any known allergies to substances such as drugs, foods, dust,
molds, pollen, bee stings, trees, grass, or animal dander and saliva.
Ask the patient to describe specific allergic responses such as wheezing, trouble breathing,
coughing, sneezing, or rhinitis.
Document any known specific allergies that have respiratory manifestations.
Obtain a family history to assess for respiratory disorders with a genetic component, such as
cystic fibrosis, some lung cancers, and alpha1-antitrypsin deficiency.
Whether the breathing problem is acute or chronic, the current health problem usually
includes cough, sputum production, chest pain, and shortness of breath at rest or on exertion.
Since chest pain can occur with other health problems as well, provide a detailed description
to determine whether the pain is pleural, musculoskeletal, cardiac, or gastrointestinal in
origin.
o Ask the patient whether the pain is continuous or made worse by coughing, deep
breathing, or swallowing.
o Ask the patient to measure the intensity of the pain on a pain scale.
Paroxysmal nocturnal dyspnea is intermittent dyspnea during sleep.
Orthopnea is shortness of breath that occurs when lying down but is relieved by sitting up.
Ask the patient about recent travel.
Ask the patient how many pillows they use when sleeping.
Assess the degree to which breathing problems interfere with the patient’s ability to perform
ADLs.
Assess the airway and breathing effectiveness for any patient who has shortness of breath or
any change in mental status.
Following the detailed history, begin the physical assessment.
 Assess the airway and breathing effectiveness for any patient who has shortness of breath or
any change in mental status.
 Inspect the patient’s external nose for deformities or tumors, and inspect the nostrils for
symmetry of size and shape. Inspect for color, swelling, drainage, and bleeding.
 Also assess nostrils for patency by closing first one nostril, then the other and asking the
patient to exhale.
 Nasal flaring may indicate increased respiratory effort.
 Inspect the internal structures of the mouth, using a tongue depressor to press down one side
of the tongue at a time to avoid stimulating the gag reflex.
 Inspect trachea to determine if there is any deviation, which is a sign of pneumothorax.
 Inspect the chest by assessing the front and back of the thorax.
 Examine the shape of the patient’s chest.
 Observe the rate, rhythm, and depth of inspirations as well as the symmetry of chest
movement.
 Observe the type of breathing, noting pursed-lip or diaphragmatic breathing and the use of
accessory muscles.
 Auscultate for normal breath sounds, adventitious sounds, and voice sounds.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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29-3
Palpate the chest after inspection to assess respiratory movement symmetry and observable
abnormalities, to identify areas of tenderness, and to check vocal or tactile fremitus.
Use percussion to assess for pulmonary resonance, the boundaries of organs, and
diaphragmatic excursion.
Breathing difficulty from any cause often induces anxiety. The patient may be anxious
because of reduced oxygen to the brain or because the sensation of not getting enough air is a
frightening experience.
Chronic respiratory disease may cause changes in family roles and relationships, social
isolation, financial problems, and unemployment or disability.
Finally, assess the degree to which breathing problems interfere with the patient’s ability to
perform activities of daily living and provide appropriate teaching.
Explain diagnostic procedures, restrictions, and follow-up care to patients scheduled for tests.
Laboratory and diagnostic testing assist in revealing the extent of pulmonary dysfunction.
 Laboratory tests may include red blood cell count for hemoglobin level and arterial blood gas
analysis to assess oxygenation and alveolar ventilation.
 Chest x-rays are used for patients with respiratory tract disorders to evaluate the status of the
chest and to provide a baseline for comparison with future changes. Standard chest x-rays are
performed from posteroanterior and left lateral views.
 Digital imaging is especially useful to assess lung and chest lesions.
 Computed tomography (CT) is useful when an x-ray reveals a suspicious lesion because
pulmonary soft tissue densities, tumors, and blood clots can be seen.
 Ventilation and perfusion scanning can identify the areas of the lung being ventilated and the
distribution of blood within the lungs.
 Pulse oximetry identifies hemoglobin saturation.
 Pulmonary function tests evaluate lung function and breathing problems and include lung
volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and
distribution of ventilation.
 Exercise testing assesses the patient’s ability to work and perform ADLs, differentiates
reasons for exercise limitation, evaluates disease influence on exercise capacity, and
determines whether supplemental oxygen is needed during exercise.
 Skin tests are used with other diagnostic data to identify various infectious diseases such as
TB, viral diseases, and fungal diseases. Allergies and the status of the immune system also
can be checked through skin testing.
 Endoscopic studies to assess breathing problems include bronchoscopy, laryngoscopy, and
mediastinoscopy.
o Assess the patient’s respiratory status every 15 minutes for at least the first 2 hours
after undergoing an endoscopic test for respiratory disorders.
 Thoracentesis is the aspiration of pleural fluid or air from the pleural space for diagnosis or
treatment.
 A lung biopsy is performed to obtain tissue for histologic analysis, culture, or cytologic
examination to make a definite diagnosis about the type of cancer, infection, inflammation,
or lung disease.
 Encourage all people to use masks and adequate ventilation when exposed to inhalation
irritants.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.