Respiratory Assessment• Thoracic cage bony conical shape with

narrow at top• Defined by sternum, 12 pairs ribs and 12

thoracic vertebrae• Rib 1-7 attached to sternum via costal

cartilages• Rib 8,9,10 attached to costal cartilage• Rib 11,12 “floating” with free palpable tips

• Anterior thoracic Landmarks;– Suprasternal notch, “U” shaped

– Sternum-”breastbone” has three parts:• The body• The xiphoid• The Manubrium

– Manubriosternal Angle- “Angle of Louis”-is articulation of the manubrium and the body of the sternum; continuous with the 2ed rib; marks site of the tracheal bifurcation into the R & L bronchi

– Costal Angle- R & L costal margins form angle where meet at xiphoid process

• Posterior thoracic Landmarks– Vertebra Prominens– Spinous Processes– Interior Boarder of Scapula– 12th Rib

• Anterior Chest• Midsternal Line• Midclavicular Line- bisects the center of

each clavicle at point halfway between the palpated sternoclavicular and acromioclavicular joint, near nipple line

• Posterior Chest• vertebral Line- midspinal• Scapular line- extends through inferior

angle of scapula• Lateral Chest- Lift arms 90* & divide by 3

lines• Anterior axillary- down from anterior

axillary fold to where the pectoralis major muscle inserts

• Posterior anillary down from posterior axillary fold to where latissimus dorsi muscle inserts

• Midaxillary line-down from apex of axilla, lies between and parallel to other two

• Thoracic cavity– Mediastinum- middle section of thoracic

cavity contains esophagus, trachea, heart and great vessels; and the Left & Right pleural cavities

– Lung Borders- anterior • Apex 9 highest point of lungs 3-4 cm

above inner 3rd of clavicles• Base- lower border, rest on diaphragm

about 6th rib in midclavicular line

– Lungs Border- posterior• C7-Apex of lung tissue

• Lungs- 2 pair• Anterior

– Right lung shorter because of underlying liver; has 3 lobes• Anterior Right Upper Lobe (RUL)• Right Middle Lobe (RML)• Right Lower Lobe (RLL)

- Left Lung- narrower because heart bulges to left; has 2 lobes

• Anterior Left Upper Lobe (LUL)• Anterior Left Lower Lobe (LLL)

• Posterior – Right Upper Lobe (RUL) and Left Upper

Lobe (LUL)- from apices at T1 down to T3– Right Lower Lobe (RLL) and Left Lower

Lobe (LLL)- from the above border to T10 on expiration and to T12 on inspiration.

• Pleurae- thin slippery which forms an envelope between lungs and chest wall.

• Visceral Pleura- lines outside of lungs down into fissures

• Parietal Pleura- lining inside the chest wall and diaphragm.

• Trachea- lies anterior to esophagus; is 10– 11 cm long in adult; starts at cricoid cartilage bifurcates below sternal angle into R and L bronchi; posterior bifurcates at T4 or T5;R bronchus shorter wider;

L bronchus vertical than L main

• Function of Trachea and bronchi- transport gases between environment and lung parenchyma.– Bronchial tree- protect alveoli from small

particulate matter in the inhaled air– Bronchi lined- goblet cells which secrete

mucus that entraps particles– Bronchi line with cilia- which sweeps

particles upward swallowed or expelled– Acinus- functional respiratory unit consist

of bronchioles, alveolar ducts, alveolar sac and alveoli

• Alveolar duct & Alveolar-gaseous exchange takes place

• Major function of Respiratory System-1. Supply oxygen to body for energy

production

2. Remove CO 2 as waste product for energy reaction

3. Maintaining homeostasis (acid-base balance) of arterial blood

4. Maintaining heat exchange (less important to humans)

• Control of Respirations– Involuntary control mediated in respiratory

center in brain stem (pons & medulla)– Change in carbon dioxide and oxygen

levels in blood– Hypercapnia- Increase of carbon dioxide-

stimulus to breathe– Hypoxemia ) decrease in oxygen in blood

can cause increase in respirations but less effective

– Hypoventilation – slow, shallow breathing causes carbon dioxide to build in blood

-With age less surface area available for gas exchange

Increases older person risk for postoperative pulmonary complications due to decreased ability to cough

• Assessment ( need to note normal from abnormal)

A. Subjective Data: questions to ask-what client tells you

1. Cough - cold in particular to children; how frequent, when, time of day, contributing factors; what kind of cough (hacking, dry, with blood), what makes it worse or better

2. SOB- older adults on exercise

3. Chest pain with breathing

4. History of respiratory infections- chronic

allergies, history of asthma, TB.

Pulmonary disease in older adults

5. Environmental exposure- where did you or do you work, do you smoke, do you live or work near pollutants

6. Self care behavior- chest x-ray, TB testing, etc.

7. Allergies in family- particularly in children

ObjectiveA. Inspection (what you see)

1. Shape and Configuration of chest wall.a. Thorax symmetric, elliptical shape with

downward sloping ribsb. Any signs tumors, lumps, bruising on

chest– Check shape for:

» Scoliosis (“s” shape)» Kyphosis (humpback)» Barrel chest

Skin color and condition»Person’s position»Level of consciousness (LOC)

B. Palpation

a.Symmetric expansion- place hands of posterolateral chest wall with thumbs at level of T9 or T10; Slide hands medially to pinch up a small fold of skin between thumb; have person take a deep breath

your thumbs should move apart symmetrically

b. Tactile Fremitus- palpable vibrations- with palmar base ( the ball) of fingers or ulna edge of one hand touch person’s chest and have then repeat “ninety-nine” or “blue moon” should feel vibration; varies among people but symmetry most important

Affecting normal intensity of Tactile Fremitus:

-Relative location of bronchi to chest wall

- Thickness of chest wall

- Pitch and intensityCheck for:

Decreased fremitus Increased fremitus

Rhonchal fremitusPleural friction fremitusCrepitus

C Percuss• Tapping on client’s skin with short sharp

strokes to assess underlying structure

• Strokes yield palpable vibrations and characteristics sounds that depict location, size, density of underlying organ pg.163

• Two methods-– Direct- striking hand direct contact with

body wall. Used in infant’s thorax and adult sinus areas

– Indirect- use both hands. Striking hand

contacts stationary hand fixed on client’s skin

Avoid striking client’s ribs & scapulae, always a dull sound & yields no data

Lung Field• Start at apices at top of both shoulders• Percuss interspaces comparing side to

side going down lung region–Hyperresonance- too much air

present –Resonance-voice heard through

stethoscope; is muffled nondistinct

-Dull- abnormal density in lung

c. Diaphragmatic Excursion- mapping out lower lung border at expiration & inspiration; somewhat higher due to liver

C. Auscultation-with the diaphragm of stethoscope from apex to base, from side to side.

a. Evaluate the presence and quality of normal breath sounds.b. With flat diaphragm of stethoscope listen at

least one full respiration in each locationc. Compare side to side and top to bottom ( Go from left to right and then down or from right

to left and then downd. analyze breath soundse. detect any abnormal soundsf. examine sounds produced by spoken wordg. pulse oximeter-noninvasive method of assessing arterial oxygen saturation (SpO2)

h Listening to own breathingStethoscope tubing bumpingPatient shiveringPatient has hairy chestRustling of paper gownMusic or talking in background

i. Normal breathing Sounds- for adultsa. Bronchial (tracheal) –loud, high pitched, over

trachea and larynxb. Bronchovesicular-moderate, moderate pitch,

over major bronchi posterior between scapular especially right anterior upper sternum at 1st and 2ed intercostal spaces

c. Vesicular- Soft, low pitch, rustling sound of wind through trees; over peripheral lung fieldI. Decreased Sounds• Obstruction- by

secretion, mucus plug or foreign body• Loss of Elasticity- in lung fiber &

decreased force of inspired air

• Something obstructs transmissionof sound between lung

andstethoscope

2. No breath sounds- no air moving; ominous sign

3. Increased breath sounds-bronchial

sounds are abnormal when heard

over abnormal location

i. Adventitious Sounds- sounds not normally heard in the lungs; if present are superimposed on breath sounds

1. Crackles- rales

2. Wheeze – rhonchi

3. Atelectatic crackles-short, popping, crackling sounds like fine crackles

j. Voice Sounds- Vocal Resonance ; soft muffled indistinct, heard through stethoscope

1. Bronchophony-repeat “99”- soft,muffled, indistinct heard through stethescope cannot distinguish. 2.Egophony- auscultate chest person phonates long “ee-ee-ee-ee-” through stethoscope

3. Whispered pectoriloquy- perslecton whispers phrase “one-two-

three”; response faint, muffled and almost inaudible

• Normal Adult Respiration Patterns– Rate- 10 to 20 breaths/minute– Depth- 500 ml to 800 mo– Pattern- even– Ratio to Respiration- fairly constant 4:1– Depth- air moving in & out each respiration– Sigh- occasional normal pattern; purposeful

to expand alveoli

• Respiration Patterns:• Tachypnea- rapid shallow breathing;

increased to >24

– Bradypnea- Slow breathing decrease but regular; < 10/minute

– Cheyne-Stokes- breathing periods last 30 to 45 seconds, with periods of apnea (20 seconds); alternating the cycle

– Hyperventilation- Increase both in rate and depth

– Hypoventilation- irregular shallow pattern– Biot’s Respiration- similar to Cheyne-Stokes

except pattern is irregular– Orthopnea- difficulty breathing when supine– Paroxysmal nocturnal dyspnea-is

awakening from sleep with SOB & needs to be upright to achieve comfort

- Hyperventilation- rapid, deep breathing causes carbon dioxide to be blown off

• Chest size changes-– Inspiration- lung size increases; diaphragm

descends and flattens; negative pressure air rushes in

– Expiration- chest size recoils; diaphragm decreases in chest size and relaxes; positive pressure air flows out

• Abnormal Tactile Fremitus– Increased tactile Fremitus-increased density

of lung tissue, thereby making a better conducting medium for vibration

– Decreased Tactile Fremitus- anything obstructs transmission of vibration.

– Rhonchal Fremitus- vibration felt when inhaled air passes through thick secretions in larger bronchi

– Pleural Friction Fremitus- inflammation of the parietal or visceral pleura causes a decrease

in normal lubricating fluid

• Adventitious Lung Sounds:• Discontinuous Sounds- are discrete crackling

sounds– Crackles-fine; formerly called rales, high-

pitched, short crackling, popping sounds heard during inspiration cannot be cleared by coughing

– Crackles-coarse; loud, low-pitched, bubbling & gurgling sounds that start in early inspiration and may be present in expiration; sound like Velcro fastener opening

– Atelectatic crackles; sound like fine crackles, but do not last and are not pathologic

– Pleural friction rub- is coarse & low pitch has, Sounds is inspiratory and expiratory

• Continuous Sounds are musical sounds– Wheeze- high pitched- musical sound that

sound polyphonic; predominately in expiration but may occur in inspiration & expiration

– Wheeze- low pitched- rhonchi; monophonic single note; musical snoring; moaning sound; more prominent on expiration; may be cleared by coughing

– Stridor- high pitched- monophonic, crowing sound, heard on inspiration

• Common Respiratory Conditions:– Atelectasis-collapsed shrunken section of

alveoli or entire lung due to:• Airway obstruction, Compression on

lung, Lack of surfactant • Pt. exhibits-cough, increased pulse &

respiration, possible cyanosis• None if bronchus obstructed; occasional

fine crackles is bronchus patent– Lobar Pneumonia- Consolidation;

• alveoli consolidated with fluid, bacteria, RBC’s & WBC’s

• Crackles, fine to medium

– Bronchitis-proliferation of mucous glands in passageway• Bronchial inflammation and copious

secretions• Deflated alveoli beyond obstruction• Crackle over deflated area; may have

wheeze• Pt. exhibits hacking rasping productive

cough– Emphysema-destruction of pulmonary

connective tissue• Over distended alveoli with destruction of

• septa; permanent enlargement of air sacs distal to terminal bronchioles

• Pt. exhibits barrel chest, uses accessory muscles to aid respiration, SOB, tachy-pnea,

• Adventitious Sounds- usually none; occasionally wheeze

– Asthma- allergic hypersensitivity to certain inhaled allergens• Bronchospasm

• Edema of bronchial mucosa• Thick mucus• Pt exhibit-SOB with audible wheeze,

retraction of intercostal spaces, use of accessory muscles,cyanosis

– Pleural Effusion- excess fluid in the intrapleural space with compression of overlying lung tissue• Effusion maybe; Transudative (watery

capillary fluid), Exudatative ( protein),

Empyemic (purulent matter)

Hemothorax (blood),Chylothorax (Milky lymphatic fluid)

• Presence of fluid subdues lung sounds• No adventitious sounds• Pt. exhibits-increased respirations, dyspnea

dry cough, abdominal distention, cyanosis– Heart Failure- pump failure increasing

pressure of cardiac overload causes pulmonary congestion• Bronchial mucosa may be swollen• Dependent airways deflated• Engorged capillaries

• Adventitious Sounds-crackles at lung base

• SOB, increased respiratory rate, PND, nocturia, ankle edema

– Tuberculosis (TB) Tuberculosis-inhale tubercle bacilli into alveolar wall• Initial complex is acute inflammatory• Rust colored sputum• Night sweats• Low grade afternoon fever• High incidence of Asian immigrant

– Initial complex is acute inflammatory• Scar tissue forms, lesion calcifies• Reactivation of previously healed lesion• Extensive destruction as lesion erodes

into bronchus• Adventitious sounds, crackles over

upper lobes, persist following full expiration and cough

– Pneumocystis carinii Pneumonia• Virulent form of pneumonia associated

with AIDS• Cysts containing organism & macro-

phages form in alveolar space; alveolar walls thicken

• Adventitious sounds-crackles may be present but often absent

– Pulmonary Embolism-undissolved material originating in legs or pelvis, detach

and travels and lodges to occlude pulmonary vessels• Sometimes occluded medium pulmonary

branches• Client exhibits chest pain, worse on

inspiration, dyspnea, anxious, apprehensive, Crackles and wheezes

• Adventitious Sounds- Crackles, Wheezes

– Acute Respiratory Distress Syndrome (ARDS)• Acute pulmonary insult, damages alveolar

capillary membrane, increased permeability of pulmonary capillaries, alveolar epithelium, to pulmonary edema

• Adventitious Sounds- crackles, rhonchi• Pt. exhibit-acute dyspnea, apprehension,

shallow rapid breathing, thin frothy sputum,retraction of intercostal spaces

• Measurement of Pulmonary Function Status-– Forced expiratory time-number of seconds it

takes for person to exhale from total lung capacity to residual volume

– Pulse Oximeter- noninvasive method to assess arterial oxygen saturation (Spo2) Sensor attaches to client’s finger detector measures amount of light absorbed by oxyhemoglobin (HbO2) and unoxygenated (reduced) hemoglobin (Hb); ratio of light emitted to light absorbed con converts to % of oxygen saturation; Healthy person no lung disease or anemia has a Spo2 of 97% to 98 %.

– 12 minute distance (12MD) walk, clinical measure of functional status of clients with COPD; used as outcome measure for

people in pulmonary rehabilitation

• Infants and children• Inspect and then listen to lung sounds of

infants sleeping, can concentrate on breath sounds

• May sit in parents lap and play with stethoscope reduces fear

• Older children like to listen to their own lungs

A. Inspection• Infants has rounded thorax with equal

anteroposterior-to-transverse chest diameter

• Infants and Children• Respiratory system develops in utero• Respiratory system doesn’t function till

birth• At birth when cord cut blood gushes to

pulmonary circulation, the foramen oval in heart closes, the ductus arteriosus contracts and closes some hrs. later and the pulmonary circulation functions

• In childhood-respiratory development continues, increases in diameter and length in size and number of alveoli

• Chest wall thin with little musculature; ribs & xiphoid are prominent; thoracic cage soft & flexible

• Newborn first respiratory assessment is part of Apgar scoring system to measure successful transition to extrauterine lifescored at 1 minute and at 5 minutes after birth; 1 minute score of 7 to 10 very good condition, needs only suction of nose and mouth

• Age 6 thorax ratio is 1:2 (anteroposterior-to-transverse diameter) pg 464; Count respiratory rate for 1 full minute; normal rate is 30 to 40 breaths/minute; may go to 60/minute; get count when infant asleep

– Breathe through nose rather than mouth– Intercostal muscles not well developed– Abdominal bulges with each inspiration but

see little thoracic expansion

B. Other observations

Evidence of Infection, Cough, Wheezes,

Cyanosis, Chest Pain, Sputum, Bad

breath

C. Palpation encircle infant’s thorax with both hands;

should be no lumps, masses or crepitus; may feel costochondral junctions.

D. Percussion-limited, fingers of adult too large in relation to tiny chest.; note hypper- resonance occurs normally in infants and young child due to thin chest wall

E. Auscultation-normally bronchovesicular breath sounds in infants up to 5-6 year old; breath sounds are louder and harsher-fine crackles commonly heard

immediate

in newborns

-Cackles in upper lung field occur with cystic fibrosis

-Expiratory wheezing occurs in lower airway obstruction e.g., asthma, bronchiolitis

-Stridor- high pitched inspiratory crowing with upper arway obstruction, e.g., croup, foreign body aspiration, acute epiglottitis

– Depth of respirations-• Hyperpnea- too deep• Hypopnea- too shallow

– -Retraction- sinking in of soft tissue relative to the cartilaginous and bony thorax; in severe airway obstruction- retraction extreme.

– Nasal flaring- sign of respiratory distress– Head bobbing- in sleeping or exhausted

infant sign of dyspnea

– Noisy breathing- “snoring” obstruction, polyps or foreign body in nasal passages

– Grunting- sign of chest pain- acute pneumonia/ pleural involvement

– Chest pain-older children maybe pulmonary and or nonpulmonary

– Clubbing- proliferation of tissue about the terminal phalanges, associated with chronic hypoxia, chronic pulmonary disease or primarily cardiac defect

– Cough- maybe associated with respiratory disease; is protective mechanism

F. Tests- – Pulse oximetry- similar to adults however

can position around foot, toe, earlobe– Transcutaneous Oxygen Monitor –Tc Po2

measures O2 diffusion across skinG. Oxygen Therapy

– Delivered by mask, nasal cannula, tent, hood, face tent, or ventilator

– Oxygen mask- various sizes, delivers higher O2 concentration than cannula; can cause skin irritation

– Nasal Cannula-low-moderate O2

– concentration; can talk ad eat; must have patent nasal passages

• Oxygen Tent-lower O2 concentrations; can increase concentration while eating; fit around bed to prevent leakage; cool & wet environment; poor access to child

• Oxygen hood, face tent- high O2 concen-tration; free access to child’s chest; high humidity; need to be removed for feeding & care; humidified O2 not blown directly on infants/child face

• Masks not well tolerated by child

• Pregnancy– Thoracic cage wider; costal angle feels

wider; respirations deeper; although this can be quantified only with pulmonary function test

– Pregnancy induces small degree of hyperventilation as tidal volume increases steadily throughout pregnancy

– Diaphragm elevated and subcostal angle increased due to enlarging uterus

– Lung disease maybe aggravated by pregnancy

• Pregnancy– As uterus increases elevates diaphragm

which decreases the vertical diameter of thoracic cage but is compensated by increase in horizontal diameter.

– As fetus grows there is increase in oxygen demand on mother’s body; increasing tidal volume( deep breathing)

• Aging Adults– Costal cartilages calcifies, less mobile

thorax– Respiratory muscles strength declines after

50 and continues to do so till 70– Decrease in elastic properties of lungs,

becomes harder to inflate– Decrease in Vital Capacity- maximum

amount of air that a person can expel from lungs after first filling lungs to maximum

– Increase in Residual Volume- amount of air remaining in lungs even after most forceful expiration

– With age less surface area available for gas exchange

-Chest cage increases anteroposterior diameter; looks barrel shape and outward

curvature of thoracic spine; compensates holding head extended and tilted back

-Chest expansion decreases though still symmetric

-cartilages becomes calcified

-Older adults fatigue easily, make sure do not hyperventilate and become dizzy-Allow brief periods of rest-If feeling faint, holding breath for few seconds will restore equipibrium