Health Assessment - Respiratory

General Survey - 5

• position

• breathing

• facials

• speech

• LOC

Skin Objective Data - 3

• color

• scars/lesions

• nail beds

Thorax Configuration Objective Data - 3

• symmetry

• retractions

• RR

Objective Data

• general survey

• thorax configuration

• skin

• pulse ox

• auscultate

Teaching Opportunities - 5

• smoking cessation

• educate asthma pt

• chronic diseases: asthma, COPD, and emphysema

• lifestyles: allergy management, exercise

• second hand smoking

Common Complaints - 6

• chest pain;dyspnea

• orthopnea

• paroxysmal nocturnal dyspnea

• cough

• wheezing

• functional abilities

Orthopnea

can’t breathe lying down

Vesicular (Normal Breath Sounds) - 2

• soft and low

• peripheral

Bronchovesicular (Normal Breath Sounds) - 2

• intermediate and intense

• over central bronchi area

Bronchiole (Normal Breath Sounds) - 2

• harsh

• directly over trachea and pharynx

Vesicular (Abnormal) - 1

uncharacteristic sounds

Bronchovesicular (Abnormal) - 1

decreased and diminished sounds

Bronchiole (Abnormal) - 1

absent

Crackles (Adventitious Sounds) - 3

Fine: hair rolled between fingers

Course: velcro

In Alveoli and airways

Wheezing (Adventitious Sounds) - 3

• musical

• heard on inspiration and expiration

• constricted airways

Rhonchi (Adventitious Sounds) - 4

• may clear with cough

• moan

• low

• larger airways

Pleural Run (Adventitious Sounds) - 3

• harsh

• grating door opening sound

• friction between pleura

Stridor (Adventitious Sounds) - 3

• high pitched with inspiration

• happens when lungs are inflamed or there’s a foreign body

• airway obstruction

Elderly - 5

• respiratory strength declines

• chest more rounded

• immobility

• increased cough and gag reflex

• needs resting periods

Infants and Children - 3

• chest more flexible

• head and chest round

• RR fast and counted for 1 min.

Pregnant - 2

• costal angle increase

• rib fractures

Race - 3

• white ppl have larger chest

• Black and Hispanics have asthma and TB

• Asians and Pacific Islanders have most incidence for TB!

Oxygenation (signs and treatment) - 3,2

deep breaths

bronchodilators

O2 administration

cyanosis

SOB

Infection (signs and treatment) - 6,3

cough

deep breaths

increase fluids

therapy

antibiotics

reduce fever

cough

SOB

breath sounds

Acid/Base Balance (signs and treatment) - 2, 1

O2 administration

effective breathing patterns

abnormal arterial blood gases

Left Lobe - 2

• two lobes

• narrower

Right Lobe - 1

three lobes

Gas Exchange - 1

necessary for metabolism, mobility, tissue integrity, sleep, and nutrition

Examination - 9

• hand hygiene

• inspect posture and breathing effort

• count RR

• measure O2 saturation

• inspect nails, skin, and lips

• inspect posterior thorax

• auscultate the posterior and lateral thorax for breath sounds

• Inspect anterior thorax

• ausculate anterior thorax for breath sounds