Health Assessment Lecture: Respiratory System D

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.

Thoracic Percussion

Percussion sets the chest wall and underlying structures in motion, producing audible and tactile vibrations. The nurse uses percussion to determine whether underlying tissues are filled with air, fluid, or solid material. Percussion also is used to estimate the size and location of certain structures within the thorax (eg, diaphragm, heart, liver).

Percussion usually begins with the posterior thorax. Ideally, the patient is in a sitting position with the head flexed forward and the arms crossed on the lap. This position separates the scapulae widely and exposes more lung area for assessment. The nurse percusses across each shoulder top, locating the 5-cm width

of resonance overlying the lung apices. Then the nurse proceeds down the posterior thorax, percussing symmetric areas at 5- to 6-cm (2- to 2.5-inch) intervals. The middle finger is positioned parallel to the ribs in the intercostal space; the finger is placed firmly against the chest wall before striking it with the middle finger of the opposite hand. Bony structures (scapulae or ribs) are not percussed.

Percussion over the anterior chest is performed with the patient in an upright position with shoulders arched backward and arms at the side. The nurse begins in the supraclavicular area and proceeds downward, from one intercostal space to the next. In the female patient, it may be necessary to displace the breasts for an adequate examination. Dullness noted to the left of the sternum between the third and fifth intercostal spaces is a normal finding because it is the location of the heart. Similarly, there is a normal span of liver dullness in the right thorax from the fifth intercostal space to the right costal margin at the midclavicular line. The anterior and lateral thorax is examined with the patient in a supine position. If the patient cannot sit up, percussion of the posterior thorax is performed with the patient positioned on the side. Dullness over the lung occurs when air-filled lung tissue is replaced by fluid or solid tissue. 

DIAPHRAGMATIC EXCURSION

The normal resonance of the lung stops at the diaphragm. The position of the diaphragm is different during inspiration than during expiration. To assess the position and motion of the diaphragm, the nurse instructs the patient to take a deep breath and hold it while the maximal descent of the diaphragm is percussed. The point at which the percussion note at the midscapular line changes from resonance to dullness is marked with a pen. The patient is then instructed to exhale fully and hold it while the nurse again percusses downward to the dullness of the diaphragm. This point is also marked. The distance between the two markings indicates

the range of motion of the diaphragm. Maximal excursion of the diaphragm may be as much as 8 to 10 cm (3 to 4 inches) in healthy, tall young men, but for most people it is usually 5 to 7 cm (2 to 2.75 inches). 

Normally, the diaphragm is about 2 cm (0.75 inches) higher on the right because of the position of the heart and the liver above and below the left and right segments of the diaphragm, respectively. Decreased diaphragmatic excursion may occur with pleural effusion and emphysema. An increase in intra-abdominal pressure, as in pregnancy or ascites, may account for a diaphragm that is positioned high in the thorax.

Health Assessment Lecture: Respiratory System C

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.

Thoracic Palpation

The nurse palpates the thorax for tenderness, masses, lesions, respiratory excursion, and vocal fremitus. If the patient has reported an area of pain or if lesions are apparent, the nurse performs direct palpation with the fingertips (for skin lesions and subcutaneous masses) or with the ball of the hand (for deeper masses or

generalized flank or rib discomfort).

RESPIRATORY EXCURSION

Respiratory excursion is an estimation of thoracic expansion and may disclose significant information about thoracic movement during breathing. The nurse assesses the patient for range and symmetry of excursion. The patient is instructed to inhale deeply while the movement of the nurse’s thumbs (placed along the costal margin on the anterior chest wall) during inspiration and expiration is observed. This movement is normally symmetric. 

Posterior assessment is performed by placing the thumbs adjacent to the spinal column at the level of the tenth rib. The hands lightly grasp the lateral rib cage. Sliding the thumbs medially about 2.5 cm (1 inch) raises a small skinfold between the thumbs. The patient is instructed to take a full inspiration and to exhale fully. The nurse observes for normal flattening of the skinfold and feels the symmetric movement of the thorax.

Decreased chest excursion may be due to chronic fibrotic disease. Asymmetric excursion may be due to splinting secondary to pleurisy, fractured ribs, trauma, or unilateral bronchial obstruction.

TACTILE FREMITUS

Sound generated by the larynx travels distally along the bronchial tree to set the chest wall in resonant motion. This is especially true of consonant sounds. The detection of the resulting vibration on the chest wall by touch is called tactile fremitus.

Normal fremitus is widely varied. It is influenced by the thickness of the chest wall, especially if that thickness is muscular. However, the increase in subcutaneous tissue associated with obesity may also affect fremitus. Lower-pitched sounds travel better through the normal lung and produce greater vibration of the chest wall. Thus, fremitus is more pronounced in men than in women because of the deeper male voice. 

Normally, fremitus is most pronounced where the large bronchi are closest to the chest wall and least palpable over the distant lung fields. Therefore, it is most palpable in the upper thorax, anteriorly and posteriorly. The patient is asked to repeat “ninety-nine” or “one, two, three,” or “eee, eee, eee” as the nurse’s hands move down the patient’s thorax. The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand or hands are moved in sequence down the thorax. Corresponding areas of the thorax are compared . Bony areas are not tested.

Air does not conduct sound well but a solid substance such as tissue does, provided that it has elasticity and is not compressed. Thus, an increase in solid tissue per unit volume of lung will enhance fremitus; an increase in air per unit volume of lung will impede sound. Patients with emphysema, which results in the rupture of alveoli and trapping of air, exhibit almost no tactile fremitus. A patient with consolidation of a lobe of the lung from pneumonia will have increased tactile fremitus over that lobe. Air in the pleural space will not conduct sound.

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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Health Assessment Lecture: Respiratory System A

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.

The health history focuses on the physical and functional problems of the patient and the effect of these problems on his or her life. The reason the patient is seeking health care often is related to one of the following: dyspnea (shortness of breath), pain, accumulation of mucus, wheezing, hemoptysis (blood spit up from the respiratory tract), edema of the ankles and feet, cough, and general fatigue and weakness.

In addition to identifying the chief reason why the patient is seeking health care, the nurse tries to determine when the health problem or symptom started, how long it lasted, if it was relieved at any time, and how relief was obtained. The nurse collects information about precipitating factors, duration, severity, and associated

factors or symptoms and also assesses for risk factors and genetic factors that may contribute to the patient’s lung condition.

The nurse assesses the impact of signs and symptoms on the patient’s ability to perform activities of daily living and to participate in usual work and family activities. In addition, psychosocial factors that may affect the patient are explored. These factors include anxiety, role changes, family relationships, financial problems, employment status, and the strategies the patient uses to cope with them.

Many respiratory diseases are chronic and progressively debilitating. Therefore, ongoing assessment of the patient’s physical abilities, psychosocial supports, and quality of life is needed to plan appropriate interventions. It is important for the patient with a respiratory disorder to understand the condition and to be

familiar with necessary self-care interventions. The nurse evaluates these factors over time and provides education as needed.

Signs and Symptoms

The major signs and symptoms of respiratory disease are dyspnea, cough, sputum production, chest pain, wheezing, clubbing of the fingers, hemoptysis, and cyanosis. These clinical manifestations are related to the duration and severity of the disease.

DYSPNEA

Dyspnea (difficult or labored breathing, shortness of breath) is a symptom common to many pulmonary and cardiac disorders, particularly when there is decreased lung compliance or increased airway resistance. The right ventricle of the heart will be affected ultimately by lung disease because it must pump blood through

the lungs against greater resistance. It may also be associated with neurologic or neuromuscular disorders such as myasthenia gravis, Guillain-Barré syndrome, or muscular dystrophy.

Clinical Significance. In general, acute diseases of the lungs produce a more severe grade of dyspnea than do chronic diseases. Sudden dyspnea in a healthy person may indicate pneumothorax (air in the pleural cavity), acute respiratory obstruction, or ARDS. In immobilized patients, sudden dyspnea may denote pulmonary embolism. Orthopnea (inability to breathe easily except in an upright position) may be found in patients with heart disease and occasionally in patients with chronic obstructive pulmonary disease (COPD); dyspnea with an expiratory wheeze occurs with COPD. Noisy breathing may result from a narrowing of the airway or localized obstruction of a major bronchus by a tumor or foreign body. The presence of both inspiratory and expiratory wheezing usually signifies asthma if the patient does not have heart failure.

The circumstance that produces the dyspnea must be determined. Therefore, it is important to ask the patient the following questions:

• How much exertion triggers shortness of breath?

• Is there an associated cough?

• Is dyspnea related to other symptoms?

• Was the onset of shortness of breath sudden or gradual?

• At what time of day or night does the dyspnea occur?

• Is the shortness of breath worse when the patient is flat in bed?

• Does the shortness of breath occur at rest? With exercise? Running? Climbing stairs?

• Is the shortness of breath worse while walking? If so, when walking how far? How fast?

Relief Measures. The management of dyspnea is aimed at identifying and correcting its cause. Relief of the symptom sometimes is achieved by placing the patient at rest with the head elevated (high Fowler’s position) and, in severe cases, by administering oxygen.

COUGH

Cough results from irritation of the mucous membranes anywhere in the respiratory tract. The stimulus producing a cough may arise from an infectious process or from an airborne irritant, such as smoke, smog, dust, or a gas. The cough is the patient’s chief protection against the accumulation of secretions in the bronchi and bronchioles.

Clinical Significance. Cough may indicate serious pulmonary disease. The nurse needs to evaluate the character of the cough is it dry, hacking, brassy, wheezing, loose, or severe? A dry, irritative cough is characteristic of an upper respiratory tract infection of viral origin or may be a side effect of angiotensin-converting enzyme (ACE) inhibitor therapy. Laryngotracheitis causes an irritative, high-pitched cough. Tracheal lesions produce a brassy cough. A severe or changing cough may indicate bronchogenic carcinoma. Pleuritic chest pain accompanying coughing may indicate pleural or chest wall (musculoskeletal) involvement

The time of coughing is also noted. Coughing at night may herald the onset of left-sided heart failure or bronchial asthma. A cough in the morning with sputum production may indicate bronchitis. A cough that worsens when the patient is supine suggests postnasal drip (sinusitis). Coughing after food intake may

indicate aspiration of material into the tracheobronchial tree. A cough of recent onset is usually from an acute infection.

SPUTUM PRODUCTION

A patient who coughs long enough almost invariably produces sputum. Violent coughing causes bronchial spasm, obstruction, and further irritation of the bronchi and may result in syncope (fainting). A severe, repeated, or uncontrolled cough that is nonproductive is exhausting and potentially harmful. Sputum production is the reaction of the lungs to any constantly recurring irritant. It also may be associated with a nasal discharge.

Clinical Significance. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum probably indicates a bacterial infection. Thin, mucoid sputum frequently results from viral bronchitis. A gradual increase of sputum over time may indicate the presence of chronic bronchitis or bronchiectasis. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and bad breath point to the presence of a lung abscess, bronchiectasis, or an infection caused by fusospirochetal or other anaerobic organisms.

Relief Measures. If the sputum is too thick for the patient to expectorate, it is necessary to decrease its viscosity by increasing its water content through adequate hydration (drinking water) and inhalation of aerosolized solutions, which may be delivered by any type of nebulizer. Strategies to assist the patient to cough productively are discussed later in this chapter.

Smoking is contraindicated with excessive sputum production because it interferes with ciliary action, increases bronchial secretions, causes inflammation and hyperplasia of the mucous membranes, and reduces production of surfactant. Thus, smoking impairs bronchial drainage. When the person stops smoking,

sputum volume decreases and resistance to bronchial infections increases.

The patient’s appetite may decrease because of the odor of the sputum or the taste it leaves in the mouth. The nurse encourages adequate oral hygiene and wise selection of food, measures that will stimulate appetite. In addition, the nurse encourages the patient and family to remove sputum cups, emesis basins, and soiled

tissues before mealtime. Encouraging the patient to drink citrus juices at the beginning of the meal may increase the palatability of the rest of the meal because these juices cleanse the palate of the sputum taste.

CHEST PAIN

Chest pain or discomfort may be associated with pulmonary or cardiac disease. Chest pain associated with pulmonary conditions may be sharp, stabbing, and intermittent, or it may be dull, aching, and persistent. The pain usually is felt on the side where the pathologic process is located, but it may be referred elsewhere—for example, to the neck, back, or abdomen.

Clinical Significance. Chest pain may occur with pneumonia, pulmonary embolism with lung infarction, and pleurisy. It also may be a late symptom of bronchogenic carcinoma. In carcinoma the pain may be dull and persistent because the cancer has invaded the chest wall, mediastinum, or spine.

Lung disease does not always produce thoracic pain because the lungs and the visceral pleura lack sensory nerves and are insensitive to pain stimuli. However, the parietal pleura has a rich supply of sensory nerves that are stimulated by inflammation and stretching of the membrane. Pleuritic pain from irritation of the parietal pleura is sharp and seems to “catch” on inspiration; patients often describe it as “like the stabbing of a knife.” Patients are more comfortable when they lie on the affected side as this splints the chest wall, limits expansion and contraction of the lung, and reduces the friction between the injured or diseased pleurae on that side. Pain associated with cough may be reduced manually by splinting the rib cage.

The nurse assesses the quality, intensity, and radiation of pain and identifies and explores precipitating factors, along with their relationship to the patient’s position. Also, it is important to assess the relationship of pain to the inspiratory and expiratory phases of respiration.

Relief Measures. Analgesic medications may be effective in relieving chest pain, but care must be taken not to depress the respiratory center or a productive cough, if present. Nonsteroidal anti-inflammatory drugs (NSAIDs) achieve this goal and thus are used for pleuritic pain. A regional anesthetic block may be performed to relieve extreme pain.

WHEEZING

Wheezing is often the major finding in a patient with bronchoconstriction or airway narrowing. It is heard with or without a stethoscope, depending on its location. Wheezing is a highpitched, musical sound heard mainly on expiration. 

Relief Measures. Oral or inhalant bronchodilator medications reverse wheezing in most instances.

CLUBBING OF THE FINGERS

Clubbing of the fingers is a sign of lung disease found in patients with chronic hypoxic conditions, chronic lung infections, and malignancies of the lung. This finding may be manifested initially as sponginess of the nailbed and loss of the nailbed angle.

HEMOPTYSIS

Hemoptysis (expectoration of blood from the respiratory tract) is a symptom of both pulmonary and cardiac disorders. The onset of hemoptysis is usually sudden, and it may be intermittent or continuous. Signs, which vary from blood-stained sputum to a large, sudden hemorrhage, always merit investigation. The most common causes are:

• Pulmonary infection

• Carcinoma of the lung

• Abnormalities of the heart or blood vessels

• Pulmonary artery or vein abnormalities

• Pulmonary emboli and infarction

Diagnostic evaluation to determine the cause includes several studies: chest x-ray, chest angiography, and bronchoscopy. A careful history and physical examination are necessary to diagnose the underlying disease, irrespective of whether the bleeding involved a very small amount of blood in the sputum or a massive hemorrhage.

The amount of blood produced is not always proportional to the seriousness of the cause.

First, it is important to determine the source of the bleeding— the gums, nasopharynx, lungs, or stomach. The nurse may be the only witness to the episode. When documenting the bleeding episode, the nurse considers the following points:

• Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.

• Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the patient tends to splint the bleeding side. The term “hemoptysis” is reserved for the coughing up of blood arising from a pulmonary hemorrhage. This blood has an alkaline pH (greater than 7.0).

• If the hemorrhage is in the stomach, the blood is vomited (hematemesis) rather than coughed up. Blood that has been in contact with gastric juice is sometimes so dark that it is referred to as “coffee grounds.” This blood has an acid pH (less than 7.0).

CYANOSIS

Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. Cyanosis appears when there is 5 g/dL of unoxygenated hemoglobin. A patient with a hemoglobin level of 15 g/dL will not demonstrate cyanosis until 5 g/dL of that hemoglobin becomes unoxygenated, reducing the effective circulating hemoglobin to two thirds of the normal level. An anemic patient rarely manifests cyanosis, and a

polycythemic patient may appear cyanotic even if adequately oxygenated. Therefore, cyanosis is not a reliable sign of hypoxia. Assessment of cyanosis is affected by room lighting, the patient’s skin color, and the distance of the blood vessels from the surface of the skin. In the presence of a pulmonary condition, central cyanosis is assessed by observing the color of the tongue and lips. This indicates a decrease in oxygen tension in the blood. Peripheral cyanosis results from decreased blood flow to a certain area of the body, as in vasoconstriction of the nailbeds or earlobes from exposure to cold, and does not necessarily indicate a central systemic problem.