Download Respiratory system

Respiratory system
Upon completion of this chapter, you will be able to:
Identify the anatomy and physiology of the respiratory system.
Distinguish landmarks that guide assessment of the respiratory system.
Develop questions to be used when completing the focused interview.
Explain client preparation for assessment of the respiratory system.
Describe the techniques required for assessment of the respiratory system.
Differentiate normal from abnormal findings in physical assessment.
Describe developmental, psychosocial, cultural, and environmental variations in
assessment techniques and findings.
Discuss the focus areas related to the overall health of the respiratory system as
presented in Healthy People 2010.
Apply critical thinking in selected simulations related to physical assessment of the
respiratory system.
Key Concepts
Overview
 The primary responsibility of the respiratory system is the exchange of gases in
the body.
 The intake of oxygen and release of carbon dioxide take place with each
respiratory cycle.
 The central nervous system regulates the rate and depth of each respiratory cycle.
 The respiratory system helps maintain acid-base balance, helps maintain body
fluids, and assists with speech.
Anatomy and physiology review
 The thorax is a closed cavity containing the structures needed for respiration.
 The thorax extends from the base of the neck to the diaphragm and is surrounded
by muscles and ribs.
 The thorax is divided into the mediastinum in which the heart, trachea, esophagus,
and major blood vessels are located, and the right and left pleural cavities.
 External respiration refers to the exchange of oxygen and carbon dioxide at the
alveolar level of the lung.
 Internal respiration refers to the exchange of oxygen and carbon dioxide at the
cellular level.
 The upper respiratory tract consists of the nose, mouth, sinuses, pharynx, larynx,
and part of the trachea.
 The lower respiratory tract includes the distal trachea, bronchi and lungs, the
pleural membranes, muscles of respiration, and the mediastinum.
 The lungs are elastic, spongy, cone-shaped, and air-filled structures on the left and
right of the mediastinum.
 The left lung has two lobes and the right lung has three lobes.
 The intercostal muscles and diaphragm are muscles that assist the breathing
process.
 The respiratory cycle consists of the active process of inhalation and the passive
process of exhalation.
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Landmarks
 Landmarks for assessment of the thorax include bony structures, horizontal and
vertical lines, and the division of the thorax.
 The thorax is divided into anterior and posterior sections or anterior, posterior, and
lateral sections.
 The sternum, the first bony landmark, is the flat line in the midline of the thoracic
cavity.
 The angle of Louis is a bony ridge of the location where the manubrium and the
body of the sternum join.
 The clavicles are long, slender bones that articulate with the manubrium medially
and laterally form the acromion of the shoulder joint.
 The 12 pairs of ribs form horizontal reference points.
 The vertebral column is located at the midline of the posterior thoracic cage.
 Five imaginary vertical lines are identified on the anterior thorax. These are the
sternal, midclavicular, and anterior axillary lines.
 The posterior aspect of the thorax contains the following imaginary vertical lines:
the vertebral, scapular, and posterior axillary lines.
 The landmarks serve as reference points for internal structures of the respiratory
system.
Special considerations
 During fetal development, breathing movements occur that strengthen muscles for
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respiration after birth, but gas exchange occurs at the placenta. At birth, gas
exchange becomes an extrauterine function as fluid in the lungs is absorbed by
the pulmonary capillary bed and lymphatic system, is expelled or suctioned from
the trachea, and is replaced with air.
During infancy and early childhood, breathing involves the use of abdominal
muscles.
Pregnancy produces changes in the respiratory system. The muscles and cartilage
of the ribs relax, allowing an increase in tidal volume. Inspiratory capacity
increases, but expiratory reserve volume is decreased. The total lung capacity
remains the same. The mild respiratory alkalosis that occurs is necessary for
placental gas exchange.
Stress, anxiety, fatigue, and pain may exacerbate respiratory problems.
Race, ethnicity, and socioeconomic status are significant factors in respiratory
health. The incidence of respiratory diseases such as asthma, tuberculosis,
chronic obstructive pulmonary disease, and obstructive sleep apnea is greater in
non-Caucasians, in poor rural populations, and in recent immigrant groups.
Geography and environment influence respiratory health.
Gathering the data
 Respiratory health assessment includes gathering subjective and objective data.
 Subjective data is gathered during the client interview and includes data about
illness, symptoms, family history, treatment, developmental considerations,
behaviors, and the environment.
 The focused interview guides physical assessment of the respiratory system.
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Physical assessment
 Age, gender, and culture must be considered when preparing for physical
assessment of the respiratory system.
 Equipment required for physical assessment of the respiratory system includes an
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examination gown and drape, examination gloves, an examination light, a
stethoscope, a skin marker, a metric ruler, tissues, and a face mask.
Physical assessment of the respiratory system includes the techniques of
inspection, palpation, percussion, and auscultation.
Physical assessment of the respiratory system proceeds in an organized fashion. It
begins with a client survey, followed by inspection of the anterior thorax. The
entire assessment of the posterior thorax follows. The assessment is completed
with palpation, percussion, and auscultation of the anterior thorax.
Skin color is assessed to determine the client's oxygenation status.
The nurse visualizes landmarks prior to assessment of the thorax to form reference
points for underlying structures.
Auscultation of lung sounds includes classification according to intensity, location,
pitch, duration, and characteristics.
Four normal breath sounds are tracheal, bronchial, bronchovesicular, and
vesicular.
Abnormal Findings
 Eupnea is normal adult breathing characterized by a regular pattern of respirations
of even depth.
 Inspiration equals expiration, and sighs are occasionally interspersed.
 Abnormal breathing patterns include tachypnea (rapid shallow breathing),
bradypnea (slow regular respirations), hyperventilation, hypoventilation, CheyneStokes, Biot’s, frequent sighs, and obstructive breathing.
 The normal chest configuration for the adult is elliptical with a lateral diameter
twice as large as the anteroposterior diameter.
 Abnormalities in chest configuration include barrel chest, pectus excavatum, and
pectus carinatum. Kyphosis and scoliosis are alterations in spinal alignment that
impact chest configuration.
 Respiratory disorders include asthma, atelectasis, bronchitis, emphysema,
pneumonia, pleural effusion, pneumothorax, and congestive heart failure.
Glossary
adventitious sounds Added sounds superimposed on normal breath sounds and often
indicative of underlying airway problems or diseases of the cardiovascular or
respiratory systems.
angle of Louis (Sternal angle) A horizontal ridge formed at the point where the
manubrium joins the body of the sternum.
bronchial sounds Loud, high-pitched sounds heard next to the trachea and are longer
on exhalation.
bronchophony Auscultation of voice sounds, patient says "ninety-nine" and normal
lung sound will be muffled.
bronchovesicular sounds Sounds that are medium in loudness and pitch, heard
between the scapula, posteriorly and next to the sternum, and anteriorly upon
inhalation and exhalation.
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dullness The level of the diaphragm during quiet respiration.
dyspnea A change in normal breathing pattern, producing shortness of breath or
difficulty in breathing.
egophony Ausculation of voice sounds, patient says "E", normal lungs sound like
"eeeeee".
eupnea The regular, even-depth, rhythmic pattern of inspiration and expiration;
normal breathing.
fremitus The palpable vibration on the chest wall when the client speaks.
landmarks Thoracic reference points and specific anatomical structures used to help
provide an exact location for the assessment findings and an accurate orientation for
documentation of findings.
manubrium The superior portion of the sternum.
mediastinum Part of the thorax, or thoracic cavity, that contains the heart, trachea,
esophagus, and major blood vessels of the body.
rales/crackles Discontinuous sounds which are intermittent, nonmusical, and brief.
resonance The usual sound in the thorax, a long, low-pitched hollow sound.
respiratory cycle Consists of an inspiratory phase and an expiratory phase of
breathing.
rhonchi (Sonorous Wheezes) Sounds that are low-pitched with a snoring quality.
tracheal sounds Harsh, high-pitched sounds heard over the trachea when the client
inhales and exhales.
vesicular sounds Sounds are soft and low-pitched and heard over the remainder of
the lungs, longer on inhalation than exhalation.
wheezes
(Sibilant) Sounds that are high-pitched with a shrill quality.
whispered pectoriloquy Auscultation of voice sounds, patient whispers "one, two,
three", normal lung sounds will be faint, almost indistinquishable.
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Case study
Tanisha Robinson, a 14-year-old female, has been seen regularly in the clinic for chronic asthma.
Today, Tanisha's mother has accompanied her for a checkup. Tanisha has required two visits to the
emergency room (ER) for severe wheezing in the month since her last clinic visit. The physical
assessment revealed that the client was in no distress and breath sounds were clear. Her vital signs
were BP 126/82 P 84 RR 20.Her skin was warm, dry, and pink in color. Tanisha could speak clearly and
seemed relaxed. During the interview the nurse learned that the client has been following her
prescribed treatments and has done well except for the two ER visits.
The nurse learned that each ER visit occurred after school hours. The client experienced severe
shortness of breath and wheezing that was unrelieved by rest or use of her inhalers. ER treatment
consisted of injection of epinephrine and administration of oxygen, IV fluids, Benadryl, and steroids.
Each ER visit lasted approximately 6 hours. The client's breathing was restored to nearly normal at
discharge and she was given a prescription for a course of prednisone.
When asked if she could identify any precipitating factors, Tanisha replied, "I know they happened on
days that we had gym, but I don't usually have a problem with that." The nurse asked if she had any
changes in her routines, activities, or environments. She said, "No, not that I can think of." Her
mother stated, "We're so upset. She's been out twice this month." The client then added, "Yes, I hate
to have to miss school and get behind. Now my friend and I have to work twice as hard as before to
get our project done."
The nurse asked about the project and the client said, "We are working on an art project--collecting
materials and doinga thing on textures. It's pretty cool. We collected old clothes from the Salvation
Army and a garage sale and we've been cutting them up sort of in a collage." The nurse asked if the
work on the project coincided with her recent attacks. The client said, "Gee, I don't know. I never
thought about it." Her mother stated, "Oh, we never even thought about that, but on both days, she
had been working on the project after school with her friend and really got bad as the evening wore
on."
Complete Documentation
The following is a sample documentation from assessment of Tanisha Robinson.
SUBJECTIVE DATA: Visit to clinic for a checkup, 14-year-old female asthmatic. Required two ER visits
for severe wheezing in month since last clinic visit. Following prescribed treatments. Doing well
except ER visits. ER visits occurred on school days when client had gym, but usually no problem with
physical activity. ER visits associated with work on art project-a textile collage from old clothes.
Wheezing started after work on project and increased in severity requiring epinephrine, IV, Benadryl,
and steroids. Client is discharged with course of oral steroids after each visit. Resumed normal
treatment and activity after episodes.
OBJECTIVE DATA: Breath sounds clear. Skin warm, dry, and pink. Clear speech, relaxed. VS: BP
126/82 P 84 RR 20.
With this information and the guidance from the textbook, complete the following application
exercises
Part 1: Critical Thinking
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Several questions are provided to challenge your thinking about this case. Answer each question
and compare your answers to the experts.
Describe the nurse's thoughts
and actions as the nurse
applies the steps of the
critical thinking process in
this situation.
In interpreting the data, how
would it be clustered?
What are the options that
could be developed for the
14-year-old and her mother?
Expert Response
Part 1: Critical Thinking
Several questions are provided to challenge your thinking about this case. Answer each question
and compare your answers to the experts.
Describe the nurse's
thoughts and actions as the
nurse applies the steps of
the critical thinking process
in this situation.
The nurse recognizes she must apply critical thinking to the situation.
The first part of critical thinking is to collect information in an
organized manner. Then the nurse will determine the reliability and
relevance of the information, and look for inconsistencies in the data.
The data in the case study were collected in an organized manner.
Once the nurse determined the client was in no distress, she
proceeded with collection of data as follows.
SUBJECTIVE:
History of chronic asthma
Following prescribed treatments
Two emergency room visits in the past month with severe SOB and
wheezing, unrelieved by rest or inhalers.
Treatment was epinephrine, steroids, O2, IV fluids, Benadryl
Precipitating factors - occurred on days for gym - usually, no problem
Reports no change in routines, activities or environments
Working on art project - old clothes and garage sale items used to
make collage
Both ER visits were required after work on project
OBJECTIVE:
Breath sounds clear
Skin warm, dry, pink
Speech clear, relaxed
VS B/P 126/82 P 84 RR 20
The sources of information are reliable. The information is relevant to
the situation because the nurse is attempting to identify triggers for
recent acute asthmatic episodes. Inconsistencies are not present.
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Once data has been collected, the nurse will analyze the situation to
distinguish normal from abnormal data, cluster data, identify patterns
within the data and identify missing information.
The Physical Findings at the time of the visit are normal. The
symptoms experienced during the ER visits are abnormal.
The data will be clustered according to:
History
Physical Findings
Impact on Function
Precipitating Factors
Patterns will examine similarities, differences, and commonalities in
data or data sets. Follow up questions by the nurse yielded missing
information about activities in relation to episodic acute asthma
events. The nurse will then generate alternatives by identifying
options and priorities for this client. Alternatives will be selected and
the nurse will evaluate the outcomes.
In interpreting the data,
how would it be clustered?
The data is clustered as follows:
History
History of chronic asthma
Following prescribed treatments
Two emergency room visits in past month with severe SOB and
wheezing, unrelieved by rest or inhalers
Treatment was epinephrine, steroids, O2, IV fluids, Benadryl
Precipitating factors - occurred on days for gym - usually, no problem
Reports no change in routines, activities or environments
Working on art project - old clothes and garage sale items used to
make collage
Both ER visits were required after work on project
Current Physical Findings
Breath sounds clear
Skin warm, dry, pink
Speech clear, relaxed
VS B/P 126/82 P 84 RR 20
Impact on Function
Upset about missing school and getting behind on projects
Precipitating Factors
Days for Gym
Textile exposure - "old clothes"
What are the options that
Options
could be developed for the Priority is reducing the number of acute episodes
14-year-old and her mother? Alternatives are:
Discontinue work on project
Select other textiles for project
Use protective equipment (masks, gloves) when working on project
Identify allergens - testing
Education regarding strategies to reduce exposure to allergens
Part 2: Applying Nursing Diagnoses
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Review the case study again and answer the questions related to Nursing Diagnoses. When
finished, compare your answers to the experts.
Identify two nursing
diagnoses that could be
derived from the data in this
case study.
Is the data in the case study
supportive of the diagnosis
ineffective breathing
pattern? Provide examples of
the definition, defining
characteristics, and risks or
related factors of the
diagnoses.
Expert Response
Part 2: Applying Nursing Diagnoses
Review the case study again and answer the questions related to Nursing Diagnoses. When
finished, compare your answers to the experts.
Identify two nursing diagnoses that could be derived from Diagnoses derived from data in case
the data in this case study.
study:
Knowledge deficit related to the need to
develop strategies to reduce exposure to
allergens
Self esteem, risk for situational low
related to breakthrough episodes of
acute asthma or inability to manage
chronic disease
s the data in the case study supportive of the diagnosis
ineffective breathing pattern? Provide examples of the
definition, defining characteristics, and risks or related
factors of the diagnoses.
The data regarding the ER visits is
supportive of the NANDA diagnosis
Ineffective Breathing Pattern.
Definition: Ineffective breathing pattern
is inspiration or expiration that does not
provide adequate ventilation
Defining Characteristics include: severe
shortness of breath
Risks and Related Factors include:
Chronic asthma, exposure to allergens
Part 3: Documentation Challenge
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Consider this case with the following information changed. Once you consider the information
below, use the blank chart provided with this exercise to document your findings.
New
Information
About this
Case
Tanisha arrives at the clinic in respiratory distress. She is hunched forward and says
she cannot get her breath. She is holding her inhaler but says it is empty. She is crying
softly and says she does not want to be admitted to the hospital again.
Tanisha tells you that her attack started about 2 hours ago. She used her inhaler 6
times, but it does not seem to help.
As you assess her, she is wheezing and in some distress. When she tries to take a
breath, she coughs. Her oxygen saturation is 92%.
Documentation Form
Reason for
Visit
History
Assessment
Vital Signs
Skin
Lungs
Affect
Speech
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Expert Response
Part 3: Documentation Challenge
Consider this case with the following information changed. Once you consider the information
below, use the blank chart provided with this exercise to document your findings.
Tanisha arrives at the clinic in respiratory distress. She is hunched forward and
says she cannot get her breath. She is holding her inhaler but says it is empty. She
is crying softly and says she does not want to be admitted to the hospital again.
New Information
Tanisha tells you that her attack started about 2 hours ago. She used her inhaler
About this Case
6 times, but it does not seem to help.
As you assess her, she is wheezing and in some distress. When she tries to take a
breath, she coughs. Her oxygen saturation is 92%.
Documentation Form
Reason for Visit
Shortness of breath/unable to get enough air starting approximately 2 hours ago.
History
History of chronic asthma. The current episode started approximately 2 hours
ago. Unknown participating factor. During past 2 hours has used inhaler 6 times
without relief. No other medications today.
Assessment
Client in obvious distress. Sitting on examination table and posturing forward to
get more air. Slight nasal flaring. Mouth breathing with mouth slightly open.
Vital Signs
T: 98.2 F
P: 122 R: 28 with distress
BP: 112/62
Skin
Pale and slightly moist skin. Nailbeds pale. Capillary refill < 2 seconds.
Lungs
Wheeze and crackles heard throughout lung fields.
Affect
Alert but in acute distress
Speech Speaking in short sentences. Obvious difficulty speaking due to shortness of
breath.
Part 4: Prepare the Teaching Plan
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LEARNING NEED: Data reveals two episodes of respiratory distress following the construction of a
textile collage for a school project. Tanisha needs to learn more about environmental allergens as
causing her respiratory distress.
Listed below is the Teaching Plan goal and objectives for this case. The textbook has shown how
one of the objectives may be completed. Your challenge is to create the Teaching Plan for the
remaining objectives.
GOAL: Tanisha will decrease the number of acute respiratory distress episodes.
OBJECTIVES: At the end of the lesson, Tanisha will be able to:
1. Identify locations of known allergens in her environment.
2. Identify strategies to decrease her exposure to allergens.
Content
Teaching Strategy
Evaluation
Expert Response
Part 4: Prepare the Teaching Plan
LEARNING NEED: Data reveals two episodes of respiratory distress following the construction of a
textile collage for a school project. Tanisha needs to learn more about environmental allergens as
causing her respiratory distress.
Listed below is the Teaching Plan goal and objectives for this case. The textbook has shown how
one of the objectives may be completed. Your challenge is to create the Teaching Plan for the
remaining objectives.
GOAL: Tanisha will decrease the number of acute respiratory distress episodes.
OBJECTIVES: At the end of the lesson, Tanisha will be able to:
1. Identify locations of known allergens in her environment.
2. Identify strategies to decrease her exposure to allergens.
Content
Teaching Strategy
Content
One-to-one discussion
It is important for you to review your to provide recall and
known allergens and where you will reinforcement of
Evaluation
Match the allergens in Column A with
environmental factors of Column B.
A
B
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find them. This will then help you
to avoid contact.
Location
Allergen
air, surface, cloth
Dust
Mold
Cat dander
Feathers
Tree nuts
Petroleum
derivatives
air - damp, dark,
moist places - cellar,
attics, gardens
where cats are or
have been
where birds have
been or are present,
pillows, mattress
learner's knowledge.
Printed material to
provide review and
reinforcement of
material.
____ 1. Mold
a. paint
____ 2. dust
b. attics
____ 3. feathers
c. cloth
____ 4. petroleum
d. pillows
Identify strategies to decrease her
exposure to allergens. (cognitive)
Content
You have been able to recall your
allergens and have identified
environmental placement. Now you
need to look for alternatives to prevent
future exposure and distress.
Alternative strategies could include:
• Work in a well ventilated area.
• Plan all activities to decrease
exposure to allergens.
• use clean and dry materials
• select other substances for texture wood, stone, plastic
• wash material before handling
Read all labels to be sure allergens are
not in the product being used.
includes all in food
except peanuts
gasoline, kerosene,
paint, paint removal
products and
cleaning products
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