Health Assessment Lecture: Respiratory System B

Good assessment skill is paramount in providing quality nursing care. There is the reason why Assessment is the first step in the nursing process and is incorporated in every phase. In assessment nurses can gather pertinent information from the patient's health status so as to have a good overview of the patient's condition to be able to formulate a nursing diagnosis and even help doctors to come up with their medical diagnosis- much more it help the whole health care team.

PHYSICAL ASSESSMENT OF THE LOWER RESPIRATORY STRUCTURES AND BREATHING

Thorax

Inspection of the thorax provides information about the musculoskeletal structure, the patient’s nutritional status, and the respiratory system. The nurse observes the skin over the thorax for color and turgor and for evidence of loss of subcutaneous tissue. It is important to note asymmetry, if present. When findings are

recorded or reported, anatomic landmarks are used as points of reference

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CHEST CONFIGURATION

Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1 2. However, there are four main deformities of the chest associated with respiratory disease that alter this relationship: barrel chest, funnel chest (pectus excavatum), pigeon chest (pectus carinatum), and kyphoscoliosis.

Barrel Chest. Barrel chest occurs as a result of overinflation of the lungs. There is an increase in the anteroposterior diameter of the thorax. In a patient with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration. The appearance of the patient with advanced emphysema is thus quite characteristic and often allows the observer to detect its presence easily, even from a distance.

Funnel Chest (Pectus Excavatum). Funnel chest occurs when there is a depression in the lower portion of the sternum. This may compress the heart and great vessels, resulting in murmurs. Funnel chest may occur with rickets or Marfan’s syndrome.

Pigeon Chest (Pectus Carinatum). A pigeon chest occurs as a result of displacement of the sternum. There is an increase in the anteroposterior diameter. This may occur with rickets, Marfan’s syndrome, or severe kyphoscoliosis.

Kyphoscoliosis. A kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax. It may occur with osteoporosis and other skeletal disorders that affect the thorax.

BREATHING PATTERNS AND RESPIRATORY RATES

Observing the rate and depth of respiration is a simple but important aspect of assessment. The normal adult who is resting comfortably takes 12 to 18 breaths per minute. Except for occasional sighs, respirations are regular in depth and rhythm. This normal pattern is described as eupnea. 

Bradypnea, also called slow breathing, is associated with increased intracranial pressure, brain injury, and drug overdose. Tachypnea, or rapid breathing, is commonly seen in patients with pneumonia, pulmonary edema, metabolic acidosis, septicemia, severe pain, and rib fracture.  Shallow, irregular breathing is referred to as hypoventilation. An increase in depth of respirations is called hyperpnea. 

An increase in both rate and depth that results in a lowered arterial PCO2 level is referred to as hyperventilation. With rapid breathing, inspiration and expiration are nearly equal in duration. Hyperventilation that is marked by an increase in rate and depth, associated with severe acidosis of diabetic or renal origin, is called Kussmaul’s respiration.

Apnea describes varying periods of cessation of breathing. If sustained, apnea is life-threatening.

Cheyne-Stokes respiration is characterized by alternating episodes of apnea (cessation of breathing) and periods of deep breathing. Deep respirations become increasingly shallow, followed by apnea that may last approximately 20 seconds. The cycle repeats after each apneic period. The duration of the period of apnea may vary and may progressively lengthen; therefore, it is timed and reported. Cheyne-Stokes respiration is usually associated with heart failure and damage to the respiratory center (drug-induced, tumor, trauma).

Biot’s respirations, or cluster breathing, are cycles of breaths that vary in depth and have varying periods of apnea. Biot’s respirations are seen with some central nervous system disorders.

Certain patterns of respiration are characteristic of specific disease states. Respiratory rhythms and their deviation from normal are important observations that the nurse reports and documents. The rate and depth of different patterns of respiration are presented

In thin people, it is quite normal to note a slight retraction of the intercostal spaces during quiet breathing. Bulging during expiration implies obstruction of expiratory airflow, as in emphysema. Marked retraction on inspiration, particularly if asymmetric, implies blockage of a branch of the respiratory tree. Asymmetric bulging of the intercostal spaces, on one side or the other, is created by an increase in pressure within the hemithorax. This may be a result of air trapped under pressure within the pleural cavity where it does not normally appear (pneumothorax) or the pressure of fluid within the pleural space (pleural effusion).

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