Assessing Thorax & Lungs; Oxygen Therapy - Health Assessment Exam 2

Structure of the thorax

Base of neck to diaphragm. Contains lungs, bronchi, and parts of trachea.

Identify the green, blue, and purple

Green = manubrium of sternum

Blue = body of sternum

Purple = Xiphoid process of sternum

What is the green structure?

Suprasternal notch

What is the green structure?

Sternal angle

What is normal costal angle?

Normal is less than 90 degrees. Greater than 90 degrees indicates hyperinflated lungs.

Identify the anterior vertical reference lines

Yellow = left clavicular line

Pink = Midclavicular line

Blue = right clavicular line

Identify the posterior vertical reference lines

Yellow = left scapular line

Pink = midspinal line

Blue = right scapular line

What is the difference between the right and left bronci and why is this important?

Right is shorter and more vertical than the left. This means that the right is more prone to aspiration.

Pulmonary edema

Fluid in lungs/alveoli. Prevents proper gas exchange.

Pneumonia

Infection causes inflammation and mucus in alveoli, preventing gas exchange.

Emphysema

Damaged alveoli trap air and accumulate CO₂

How many lobes does the right vs left lung have?

Right lung has 3 lobes, left has 2 lobes

What are the 4 main functions of the lungs?

1. Supply oxygen to the body

2. Removes CO₂

3. Maintains acid-base balance

4. Maintains heat exchenge

What happens during inspiration?

Inflow of air into lungs. Diaphragm contracts + moves down

What happens during expiration?

Intercostal muscles relax, diaphragm relaxes and moves up. Air pushed out of lungs.

History of present health concern in respiratory exam

Difficulty breathing, chest pain, cough, sputum when coughing, GI symptoms?

What does white/clear sputum indicate?

Viral infection

What does yellow/green sputum indicate?

Bacterial infection

What does red sputum indicate?

Bleeding

What does brown sputum indicate?

An old bleed

What does black sputum indicate?

Smoke inhalation

What does pink frothy sputum indicate?

Pulmonary edema

Personal health history in respiratory exam

Prior respiratory problems, allergies, medication, respiratory treatments, chest x-ray, TB test, other pulmonary studies, recent travel outside U.S.?

Family history in respiratory exam

Lung disease, second hand smoke?

Lifestyle and health practices in respiratory exam

Smoking, smoking cessation, vaping/e-cig, environmental exposure, difficulties with ADLs, herbal/alternative therapy?

Inspection in respiratory exam

Assess position, inspect for nasal flaring/purse lip breathing, color of face and chest, color and shape of nails, look for clubbing, use of accessory muscles, and LOC.

What is clubbing?

Clubbing is when the nail beds are wider and rounder. This happens d/t vasodilation as the body complicates for obstructive respiratory disease.

What changes in LOC does hypoxemia create?

Pt becomes more confused, restless, and agitated

Somnolent LOC

Pt becomes sleepy and tired d/t increased CO₂ or sleep apnea.

Palpation in respiratory exam

Palpate for tenderness and sensation, for crepitus, for lesions, for masses.

Palpating for fremitus

Palpate client with both palms as they repeat “99”. You should feel symmetric vibrations.

Assessing for chest expansion

Thumbs should be placed at T9-T10 posterior. Your thumbs should move outward 5-10 cm as pt breaths deeply.

Percussing for tone in respiratory assessment

Use same locations as when auscultating lung sounds. Resonance heard over normal lungs.

Percussing for diaphragmatic excursion

Have pt exhale and hold. Percuss down until tone changes to dullness. Have pt inhale and hold. Percuss down until tone is dull. Compare differences. Should be equal bilaterally and measure 3-5cm.

Bronchovesicular breath sounds

Moderate pitch, moderate amplitude. Heard over major airways.

Vesicular breath sounds

Low pitch, soft amplitude. Heard over lungs.

Bronchial breath sounds

High pitch loud sounds. Heard directly over trachea.

Bronchophony voice sounds

Have pt repeat “99” as you move though lung fields. Voice should be soft, muffled, and indistinct. Having the pt clearly is abnormal.

Egophony voice sounds

Have pt repeat the letter “E” as you move though lung fields. Voice should be soft and muffled but the “E” should be distinguishable. Sounding like “A” is abnormal (indicates mucous).

Whispered pectoriloquy voice sounds

Have pt whisper “1-2-3” as you move though lung fields. Sound should be faint and muffled. Clear sound is abnormal.

On how many locations do we auscultate lung sounds?

8 on the front (anterior)

10 on the back (posterior)

4 on each of the sides

Fine crackles

High-pitched, short, popping sounds. From air breathed in colliding with a deflated airway.

Pleural friction rub

Low-pitched, dry, grating sound. Occurs d/t inflamed pleural surfaces rubbing together.

Wheezing

High-pitched “musical” sounds. From constricted airway.

Sonorous (rhonchi)

Low-pitched snoring/moaning sounds during expiration. Common in sleep apnea.

Stridor

High-pitched sound from blocked airflow in larynx or trachea. Auscultate for over trachea.

Diminished breath sounds

Soft, decreased, or distant sound.

Tachypnea

More than 24 breaths per min / regular. Can be d/t anxiety, exercise, fever, pain, etc.

Bradypnea

Less than 10 breaths per min / regular. Can be d/t medications.

Hyperventilation

Increased rate/depth of breathing. Can be d/t severe anxiety/fear.

Kussmaul respirations

Rapid, deep, and labored breathing. Seen in diabetic keto acidosis.

Hypoventilation

Decreased rate, depth, and irregular pattered. Can be d/t overdose or end-of-life condition.

Cheyne-Stokes

Alternating periods of rapid, dep breathing followed by apnea. Seen in heart failure, renal failure, or end-of-life care.

Newborn respiratory assessment considerations

Begin to aerate immediately after birth. Alveoli continue to develop and form until 8y/o. Lung tissue can regenerate itself at this time. RR 30-60.

Child and adolescents respiratory assessment considerations

New alveoli form until 8y/o. Airways smaller and narrower. RR 20-28 until ~10 then normalizes to 12-20.

Childbearing respiratory assessment considerations

Shortness of breath common in last trimester. Increased oxygen requirements.

Older adults respiratory assessment considerations

May experience dyspnea with activity. Decreased cough. Decreased thoracic expansion. Decreased lung elasticity. Deep breathing my be difficult and pts may need rest during resp exam.

COPD

Chronic inflammatory lung disease that causes obstructed airflow from lungs. Very common.

COPD risk factors

Smoking + secondhand smoke, asthma, occupational exposure, genetics.

Smoking cessation education.

The 5 A’s: ask, advise, assess, assist, arrange.

COPD breathing techniques education.

Pursed lip breathing to better expel CO₂. Tripod positioning. Energy conservation via pacing activities, resting frequently, and always resting until dyspnea goes away.

Normal ABG pH

7.35-7.45

Normal ABG pCO₂

80 - 100 mmHg

Normal ABG pCO₂

35-45 mmHg

Normal ABG HCO₃^-

22-26

Factors essential to normal respiratory function

Integrity of airway system to and from lungs. Properly functioning alveolar system. Properly functioning cardiovascular and hematologic systems.

Hypoxia definition

Inadequate amount of oxygen available to cells

Dyspnea definition

Difficulty breathing

Hypoventilation definition

Decreased rete or depth of air movement into lungs

Newborn/infant RR

30-60 breaths per min

Early childhood (1-5 yrs) RR

20-40 breaths per min

Late childhood (6-12 yrs) RR

15-25 breaths per min

How do medications impact respiratory?

Meds like opioids can decrease the respiratory rate. It is important to monitor rate and depth of these pts breathing.

What environmental factors impact respiratory?

Air pollution or occupation exposures.

What lifestyle factors impact respiratory?

Smoking and physical activity.

How does stress/anxiety impact respiratory?

Hyperventilation can lead to hypoxia.

What is room air?

Room air is when the pt is receiving no oxygen therapy. Room air is 21% oxygen.

What is oxygen therapy?

Increases the amount of oxygen transported in the blood and can be delivered different ways. Oxygen must be ordered by a provider unless it is an emergency.

Low-flow oxygen/low-fraction of inspired oxygen (FiO2)

Provide supplemental oxygen often less than the pt’s total minute ventilation. Room air blended with the oxygen, diluting the concentration.

Low-flow oxygen delivery systems

Nasal cannula, non-rebreather mask

High-flow oxygen

Delivers precise amounts of FiO2. Meets or exceeds pt’s full inspiratory flow demand (pt will not be breathing in any room air, all O2 is from mask).

High-flow oxygen delivery systems

Venturi-mask

Nasal cannula

Delivers low-flow O2 through plastic cannulas in the pt’s nares with tubing wrapping around the ears and under the chin.

What is the max oxygen that a nasal cannula can deliver?

6 L/min = 44%

What % O2 is 1L/min

24%

What % O2 is 2L/min

28%

What % O2 is 3L/min

32%

What % O2 is 4L/min

36%

What % O2 is 5L/min

40%

What % O2 is 6L/min

44%

Disadvantages of nasal cannula

Easily dislodged, nasal dryness, skin irritation

Signs of hypoxia

Early: Restlessness, Anxiety, Tachycardia/Tachypnea. Late: Bradycardia, Extreme restlessness, Dyspnea (severe). (Remember early RAT is late to BED)

Humidification w/O2 delivery

Used with extreme dryness or delivery > 4L/min. Small container of water is attached to flowmeter and oxygen connection to humidify before delivery.

Non-rebreather mask

Has reservoir bag and one way valves that make sure the pt is breathing in only oxygen and no CO2.

How much O2 does a non-rebreather mask deliver.

Up to 80-90% or a minimum of 10L/min. Make sure bag is inflated before delivering to pt.

Venturi mask

Uses different adaptors to provide different flows of oxygen to pt.

What is the max O2 a venturi mask can deliver

12-15L/min = 60%

What % O2 is 2-4L/min w/ venturi adaptor

24%

What % O2 is 4-6L/min w/ venturi adaptor

28%

What % O2 is 8-10L/min w/ venturi adaptor

35%