respiratory assessment
TRANSCRIPT
Assessment of the Chest and Lungs
Functions of the Respiratory System
Ventilation Diffusion and Perfusion Control of Breathing
Functions
Ventilation Movement of air into and out of the lungs Inspiratory phase Expiratory phase
Functions
Hypoventilation Slow, shallow breathing Causes CO2 to build up in the blood
Acidosis
Hyperventilation Rapid, deep breathing Causes CO2 to be blown off
Alkalosis
Functions
Diffusion and Perfusion Gas exchange across the alveolar-
pulmonary capillary membranes Control of breathing
Influenced by neural and chemical factors Pons, medulla, chemoreceptors in the
carotid body Stimulus for breathing
Increased carbon dioxide - PRIMARY
Anatomical Structures
Reference points for pinpointing findings from the physical examination Topographical Landmarks Reference Lines
Topographical Landmarks
Nipples Manubriosternal junction (Angle of Louis)
Point at which the 2nd rib articulates with the sternum
Suprasternal notch Costal Angle
Usually no more than 90 degrees Ribs insert at approximately 45 degree angles
Clavicles
Manubrium
Manubriosternal junction
(Angle of Louis)
Nipple
Costal Angle
Reference Lines
Anterior Chest Midsternal line Anterior axillary lines Midclavicular lines
Posterior Chest Vertebral line Midscapular lines
Axilla Anterior axillary lines Midaxillary lines Posterior axillary lines
Anterior Chest
Posterior Chest
Axilla
Anatomy
Anatomy Points to Remember
Lungs are symmetric Lungs are divided into lobes
Right lung = 3 lobes Left lung = 2 lobes
Primary muscles of respiration Diaphragm – divides chest from abdomen External intercostal muscles Accessory muscles
Anatomy Points to Remember
Upper Airway Nose, pharynx, larynx, intrathoracic
trachea Functions in respiration
Conduct air to lower airway Filter to protect lower airway Warm and humidify inspired air
Anatomy Points to Remember
Lower Airway Trachea, bronchi, bronchioles
Functions in respiration Conduct air to alveoli Clear mucociliary structures
Alveoli Functional unit
Gas exchange Production of surfactant
Anatomy Points to Remember
Lower Airway Trachea splits into left and right
mainstem bronchi which are further subdivided into bronchioles Right bronchus is shorted, wider and more
upright than the left Functions in respiration
Conduct air to alveoli Clear mucociliary structures
Chest Anatomy
Web Anatomy: http://www.gen.umn.edu/faculty_staff/jensen/1135/webanatomy/
History
Chief Complaint and HPI Cough Shortness of breath/Dyspnea
Cough
Onset – sudden, gradual Duration Nature – dry, moist, hacking, barking Sputum – amount, color, odor Severity – disrupts activities Associated symptoms – sneezing, dyspnea, fever,
chills, congestion, gagging What brings it on? – anxiety, talking, activity What makes it better? What has been tried? – medications, treatments Anything similar in the past?
Shortness of Breath (SOB) / Dyspnea
Onset – sudden, gradual Duration Severity – disrupts activities Associated symptoms – night sweats, pain, chest
pressure, discomfort, ankle edema, diaphoresis, cyanosis
What brings it on? – position, time of day, exercise, allergens, emotions
What makes it better? What has been tried? – medications, inhalers, oxygen Anything similar in the past?
History
Past Health History Lung disease or breathing problems
Frequent severe colds, asthma, emphysema, bronchitis, pneumonia, tuberculosis
Last PPD and/or chest x-ray Allergies Medication use
Family History
History
Personal and Social History Tobacco Alcohol Drugs Home environment Occupational environment Travel
Health Promotional Activities
Physical Examination
Equipment and Techniques
Equipment Stethoscope
Techniques Inspection Palpation Percussion Auscultation
Inspection
General Appearance Posturing Breathing effort Trachea position
Midline
Inspection
Chest Wall Configuration Form Symmetry Muscle development Anterior-Posterior (AP) diameter
Approximately ½ the transverse diameter Transverse: Anterior-Posterior = 2:1
Costal angle 90 degrees or less
Inspection
Oxygenation: cyanosis Nails Skin Lips
Respiratory Effort Respiratory rate and depth Breathing pattern Chest expansion
Palpation
Trachea – for position Chest wall – for symmetry
Palpation
Thoracic Expansion (Excursion) Place both thumbs at about 7th rib
posteriorly along the spinal process Extend the fingers of both hands
outward over the posterior chest wall
Have the person take a deep breath and observe for bilateral outward movement of thumbs
Normal: bilateral, symmetric expansion
Abnormal: unilateral or unequal
Click on the pictures to view video
Palpation
Vocal (Tactile) Fremitus Use palmar or ulnar surfaces of hands Systematically position hands over both sides
of posterior chest Have person repeat “1 – 2 – 3” or “99” as you
move from the apices to the bases Normal: bilaterally symmetrical vibrations Decreased or absent: obstruction of
transmission 0bronchitis, emphysema) Increased: consolidation (compression) of lung
tissue (pneumonia)
Auscultation
Auscultate in a systematic manner Compare one side to the other Listen one full respiration at each spot Displace breast tissue to listen directly
over chest wall DO NOTDO NOT listen through gowns, clothes,
etc. Place your stethoscope over bare skin
Auscultation
Evaluate posterior, lateral, and anterior chest
Instruct person to sit upright and breathe in and out slowly through the mouth This makes it easier to hear the air
movement Use the diaphragm of the stethoscope Move from the apices to the bases
Auscultation
Evaluate for normal sounds
Sound Pitch Intensity
Quality I:E Location
Bronchial High Loud Blowing/ hollow
I < E Trachea
Bronchovesicular
Moderate
Moderate Combination I = E Between scapulae,1st & 2nd ICS lateral to sternum
Vesicular Low Soft Gentle rustling/ breezy
I > E Peripheral lung
Auscultation
Evaluate for adventitious soundsSound Intensity/
PitchI/E Quality Clear with
Cough Crackles/ Rales
Soft (fine)/ HighLoud (coarse)/ Low
I Discontinuous, nonmusical, brief
Possibly
Wheeze High E Continuous musical sounds
Possibly
Ronchi Low E Continuous snoring sounds
Possibly
Pleural Friction Rub
I & E Continuous or discontinuous creaking or brushing sounds
Never
Stridor I Continuous, crowing Never
Auscultation
Copy this URL into your Web browser to hear normal and abnormal lung sounds : http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm
Developmental Variations
Neonates Measure the chest circumference
Usually 2-3 cm smaller than head circumference Chest is round (i.e. AP diameter = transverse)
Obligate nose breathers Periodic breathing is common
Sequence of vigorous breathing followed by apnea for 10-15 seconds
Only concern if it is prolonged or baby becomes cyanotic
Developmental Variations
Neonates Breathing is diaphragmatic and
abdominal Signs of compromise
Stridor (“crowing”) Grunting Central cyanosis Flaring nares
Developmental Variations
Infants and Young Children Roundness of the chest persist for first 2
years Chest walls are thinner than the adult’s
Breath sounds may sound louder, and more bronchial than the adult Bronchovesicular sounds may be heard
throughout the chest
Developmental Variations
Pregnancy Costal angle increases to about 105
degrees in the third trimester Dyspnea and orthopnea are common Breathes more deeply
Developmental Variations
Older Adult Chest expansion is often decreased Bony prominences are marked AP diameter is increased with respect to
transverse (but not 1:1)
Videos of Thorax and Lung Assessment
Copy these URLs into your Web browser http://www.conntutorials.com/chapter5.h
tmlOR
http://medinfo.ufl.edu/other/opeta/chest/CH_main.html