Gas Transport System

Family history & culture that affect gas transport system

History of mouth, throat, sinus, lung, or nose cancer

History of lung disease or pulmonary disorders (asthma)

Did family members smoke in your home

History of diabetes, hypertension, coronary artery disease, or elevated cholesterol

Physical assessment

Head to toe sequence

• cardiac

• Vascular

• Pulmonary

Techniques

• inspect

• Palpate

• Percuss

• Auscultate

Head inspection includes…

Face, mouth, lips, oral cavity nose, nostril air flow, internal, nasal flaring, jugular veins (neck)

Cyanosis =

Hypoxia

Ruddy to purple =

COPD or CHF due to polycythemia (excess RBC)

Circumoral pallor =

Anemia & shock

Cyanotic in mouth

Cold or hypoxic

Reddish in mouth

Carbon monoxide poisoning and COPD

Pursed lip breathing

Asthma, emphysema, COPD

Physiological response to slow expiration that attempts to keep the alveoli open longer

Tonsil enlargement

Indication of infection

Foul odor

Respiratory infection

Nose - external color & shape

Nostril airflow, impeding one side and asking pt to breathe may indicate infection or foreign object

Nasal flaring

Outward movement of nostrils with inspiration, labored breathing, hypoxia

Jugular venous pulse

Elevate HOB 45°, Pulse should not be visible visible indicates RT ventricular failure, pulmonary HTN, pulmonary emboli, or cardiac tamponade

jugular Venus pressure

Pt supine, Turn head to Left and shine light on jugular vein then @ 30, 45, 60 & 90°

Any bulging, distention or protruding may indicate RT, side heart failure, COPD, or Pericarditis

Tender sinuses =

Bacterial infection

Symmetrical inequality

Arterial constriction or occlusion

Weak pulse

Hypovolemia, shock, decreased cardiac output

Bounding pulse

Hypervolemia, increased cardiac output

Loss of elasticity

Artherosclerosis

Posterior thorax inspection, configuration

Observe the position of the scapula, shape, configuration, and appearance of the chest wall.

Scapula should be symmetric, Non-protruding, and equal horizontally.

Spinous process should appear straight, thorax is symmetrical with ribs sloping downward.

Posterior thorax expression, accessory muscle use

Observed the trapezius muscle or shoulders to see if they are being used to assist in breathing.

Pt Should primarily use the diaphragm

Posterior thorax Inspection, Positioning

Observe their posture and ability to support their weight

Pts Should be sitting up, relaxed and breathing easily with arms at their sides

Posterior thorax palpation, Tenderness and sensation

Use one or two hands to check for tenderness, warmth, pain, or other sensations

Start at midline level of left scapula, and move left to right, Compare findings

Posterior thorax palpation, crepitus

SC Emphysema, is a crackling sensation (Like hairs rubbing together), Occurs one air escapes from the lungs into the SC tissue, use fingers and follow the same sequence as when palpating for tenderness

Masses and lesions

Palpate any lesions noted during the inspection

Fremitus

Vibrations of air in the bronchial tubes transmitted to the chest wall

Chest expansion

Chest expansion, Posterior chest wall with thumbs @ T9 or T10 level, Press together a small skin fold

When the client deep breaths, observed thumb symmetry and 5-10 cm apart

Posterior thorax auscultation

Auscultation sequence

• Breath sounds

• Bronchial

• Bronchovesicular

• Vesicular

Posterior thorax auscultation; abnormal sounds

Crackles

Wheeze

Plural friction rub

Rhonchi

Stridor

Anterior thorax Inspection

Shape and configuration

Sternum position

Slope of ribs

Respiratory pattern

Intercostal spaces

Accessory muscle use

Pulsations

Apical pulse

Anterior thorax palpation

Tenderness and sensation

Masses and lesions

Crepitus and fremitus

Chest expansion

Apical impulse

Abnormal pulsations

Arm and hand inspection

Size

Edema

Lesions

Venous pattern

Color

Arm and hand palpation

Temperature

Capillary refill

Radial pulse

Shape of nails

Leg and foot inspection

Hair distribution

Lesions

• varicosities

• Thrombophlebitis

Edema

Color

Measure circumference

Leg and foot palpation

edema

Temperature

Superficial

Inguinal lymph

Nodules

Pulses

• Femoral

• Popliteal

• Dorsalis pedis

• Posterior tibal

Leg and foot auscultation

Pulses

• Posterior tibal

• Dorsalis pedis

• Popliteal

• Femoral

Validation and documentation

Discrepancies of data

• Subjective

• Objective

Validate

• Verifies reliability, and accuracy

Document

• AACC Nursing program policy

• Healthcare facility policy

Heart sound landmarks, aortic

2nd ICS, R sternal border, S2

Heart sound landmarks, pulmonic

2nd ICS, L sternal border, S2

Heart sound landmarks, tricuspid

4th ICS, L sternal border, S1

Heart sounds landmark, mitral

5th ICS, midclavicular line, S1