Nurs 232 - Respiratory System Lecture

Respiratory Cycle

the physical movement of air from the atmosphere into the lungs/alveoli is breathing or ventilation

Inspiration

breathing in air from the outside and air going into the lungs

• air is mostly full of oxygen

Expiration

air moving out of the lungs and into the atmosphere

• mostly full of CO2

Perfusion

the exchange of gases across membranes

• usually takes place in the alveoli

Right lung

has 3 lobes (UL, ML, LL)

• is larger, shorter, and wider

Left lung

has 2 lobes (UL, LL)

• is thinner, allows for room for the heart

Horizontal fissure on the right lung

connects the RUL and the RML

Oblique fissure on the right lung

connects the RML and RLL

Left oblique fissure

connects the LUL and LLL

Apex of the lungs

top of the lungs

• located at one inch above the clavicle

Base of lungs

bottom of the lungs

• located around 6-8th rib

Posterior lung fields

are almost all lower lobes

• right and left lungs have two lobes posteriorly (upper and lower lobes)

the upper lobes start at apicles (T1) and extend to T3 or T4

the lower lobes start at T3-T4

• when expiration occurs, they go to T10 (lungs are going back to normal size)

• when inspiration occurs, they go to T12 (lungs are expanding)

Lateral Lung Field - Left

LUL extends from the apex to the sixth midclavicular line (MCL)

LLL extends from the 8th rib across the midaxillary line (MAL)

Lateral lung field - right

UL extends from apex to the axilla to the 5th rib

ML extends from the horizontal fissure to the 6th rib

LL extends from the 5th rib to the 8th rib

Anterior assessment landmarks

• mid sternal line

• mid clavicular line

• anterior axillary line

posterior assessment landmarks

• scapular

• vertebral

lateral assessment landmarks

• anterior axillary line

• mid axillary line

• posterior axillary line

Respiratory WDL

• regular depth and pattern; unlabored; expansion symmetrical

• breath sounds are clear and equal bilaterally

• mucous membranes and nailbeds are pink

• no cough

• no retractions

History Taking/ROS

SOB

• onset, frequency

• duration

• aggravating factors

• alleviating factors

• activity/position of comfort

History of respiratory disease

cigarette smoking (# of packs a day x # of years smoking)

risk factors

• job, school, home environment

home treatments

immunizations/vaccines

cough

• onset, frequency, aggravating factors, alleviating factors, type (productive, non-productive)

sputum produciton

• onset, frequency

• color

• amount

• consistency

• odor

Order of Assessment

1. Focused Interview

2. Inspection

3. Palpation

4. Percussion

5. Auscultation

Inspection

inspect for overall breathing (rate, depth and work of breathing (effort)), general appearance/overall skin color

• skin color pink/normal for race

• looking both generally and specifically at thorax/chest

• count RR and observe depth or respirations

• relaxed facial expressions

• relaxed limb movements

• quiet, easy breathing

Normal breathing pattern

regular with occasional signs, also called eupnea

• rate is 12-20 breaths per minute for adults

• ratio of pulse to respiration is generally 4:1

• inspiration = expiration

Abnormal findings

tachypnea = >20 breaths/min

bradypnea = <12 breaths/min

hyperventilation = rapid, deep respirations > 20 breaths/min

apneustic = stopped for a period of time; neurological, sustained respiratory effort

cheyenne-strokes = neurological - altering patterns of depth separated by brief periods of apnea

• head injury or old age can cause this

Kussmaul’s = rapid, deep, and labored — common in DKA (diabetic ketoacidosis)

air trapping = difficulty during expiration - emphysema

Tachypnea

rapid rate with generally regular rhythm

• depth may be shallow

• R/T increased activity, maybe stress, or pain, as with pleurisy (inflammation of the lining of the lungs)

Hyperpnea/hyperventlation

rapid with deep inspiration

• R/T anxiety/stress, metabolic acidosis, hypoglycemia

Bradypnea

very slow, regular rythym

• rate <10 breaths/min

• R/T drug overdose, diabetic coma, head injury with increased intracranial pressure

Cheyne-Strokes

pattern of increasing/decreasing rate

• includes periods of deep breathing alternating with apnea

• R/T heart failure, chronic renal failure/uremia, drug-induced respiratory depression, brain-damage

• can be normal finding in infants and elderly during sleep

kind of like the brain grasping at straws, common at end of life

Biot’s Respirations

similar to cheyne-strokes but has 3-4 normal respirations followed by apnea

• causes: trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis

Hypoventilation

irregular shallow resp.

• causes: overdoes or anesthetic, bed rest, chest splinting from pain, such as following a rib fracture

Integumentary inspections

color:

• cyanosis → blue

• pallor → pale

• clubbing → nails

in infants:

• flared nostrils indicate serious distress

  • infants are obligate (they cannot breathe through their mouth), if the nose is not moving this indicates that they are not breathing

Inspection of the AP-Transverse Diameter

normal configuration:

• symmetrical

• anterioposterior (AP) diameter is less than transverse diameter (1:2 ratio)

  • side is 1, back is 2

Barrel Chest

anterioposterior diameter is equal to the tranverse diamater

• AP: 1=1

• ribs are horizontal

• chest looks like it is constantly in inspiration

• commonly due to COPD/emphysema (chronic conditions trapping air inside the lungs)

anterioposterior considerations for infants

infants have a 1:1 ratio until about age 6 when it becomes 1:2

Pectus Carinatum/pigeon chest

the ribs and sternum are pushed outward due to an overgrowth of cartilage

Pectus Excavatum/Funnel Chest

the sternum is pushed back

• looks like a divot in the chest

Chest wall palpation

done on anterior and posterior side

• when palpated, the chest wall should be stable (ribs should not move out of place), no crepitus, no buldging, and have no tenderness/pain

Trachea positioning

normal position should be midline with no deviation

• when a trachea is deviated, it is usually deviated to the side of which lung is giving better air

• a deviated trachea is always a bad sign

Thoracic Respiratory Expansion Test

place hands on the patients posteriolateral chest wall at T9 and T10 with the thumbs close to the vertebrae

• hands pinch up a small fold or skin

• breathe deep and hands should move apart symmetrically

• if it is asymmetric: trauma, pneumonia, fracture, atelectasis, or pneumothorax (chest the trachea for shifting)

Tactile Fremitus

vibrations felt/palpated through the chest wall that are produced when the patient speaks

• increased with consolidation, decreased with air trapping

• have patient say 99 as you move your hands side-to-side over palpated areas

Auscultation

diaphragm of stethoscope is used to hear high-pitched sounds

breathe deeply in and out mouth; be cautious and make sure the patient doesn’t become light headed (if needed, ask the patient to breathe in through their nose and breath out their mouth)

compare the right and left

proceed from apex to the base (top to bottom) in a SNAKE pattern (side-to-side)

• DO NOT auscultate over the bones

Bronchial sounds

loud and harsh

• heard over the trachea

• quiet sounds in this area is a concern

• will be louder during expiration

Bronchovesicular sounds

not as loud, medium sound

• heard the same during expiration and inspiration

Vesicular sounds

soft and breezy

• will be louder during inspiration than expiration

• comprises most of lung fields

Rales/crackles

small clicking, bubbling, or rattling sounds in the lungs; heard most on INHALATION

• heard in the lower lungs

can be caused by cardiac problems when fluid is pushed into the alveoli, causing pulmonary edema

Rhonchi

sounds that resemble snoring

• “musical”

• usually in UPPER AIRWAYS d/t obstruction

wheezing

high-pitched sounds produced when airways are narrowed or obstructed

• can be in upper or lower airways

• can be in inspiration and expiration

can be with asthma, expect reduced breath sounds

Stridor

harsher wheeze-like sound heard in upper airway

• can be heard without a stethoscope

Bronchophony

ask patient to say “99” each time you place the stethoscope on their chest

• normal = soft, muffled

• abnormal is the 99 will be extremely loud, caused by lung consolidation and fluid buildup inside the alveoli

egophony

ask the patient to say “E” each time you place the stethoscope on their chest

• E is normal

• Aaayyyy is abnormal

Whispered Pectriloquy

patient whispers “1, 2, 3” each time you place the stethoscope on their chest

• normal = faint or unheard

• abnormal = heard very loudly

Infants and Children

normal respiratory rate for children is 30-40 but can spike from 60 breaths per minute

• AP diameter is 1:1

• infant is obligatory nose breather until 3 months

• count RR for a full minute up until the age of 2 years

Expected findings for older adults

lungs lose elasticity, skeletal muscles began to weaken, bones lose density, drier mucous membranes and decreased cilia function, weakened ability to cough due to weakened muscles

• there is a decreased # of capillaries in pulmonary tissue so less blood flow for gas exchange; normal alveoli enlarge and their walls become thinner and become elastic and therefore more difficult to keep open

• AP diameter may appear to be 1:1

• kyphosis

• fatigue during physical exam auscultation

NANDAs

impaired gas exchange

ineffective breathing pattern

ineffective airway clearance

activity intolerance

fatigue for ineffective peripheral tissue perfusion

dysfunctional ventilatory weaning response

Normal values

pH - 7.35-7.45 pH units

PO2 - 80-100 mmHg

PCO2 - 35-45 mmHg

HCO3 - 22-26 mEq/L

O2 saturation

ideally above 95% (happy above 90%)

• patients with COPD will normally have a O2 stat. > 88%

Respiratory Testing

includes:

• O2 saturation

• Chest X-ray, CT, or MRI

• CT PE → do quickly and urgently (testing to see if there are clots (pulmonary emboli) in the lungs)

• Bronchoscopy (“broncho”) → visual exam of the airways to see inside or get samples of mucus or tissue

• pulmonary function testing → tests to find out how well you move air in and out of your lungs and how well oxygen enters your blood stream

• sputum evaluation (COVID, bacteria, viruses)

• nasal swabbing (COVID, bacteria, viruses e.g., influenza)

• tuberculin skin testing

PFTs

spirometry → how large of a breathe you can take

diffusion studies → how well do you pass O2 into the blood from the air sacs of the lungs, and pass CO2 back into the lungs from the blood

body plethysmography → how much air is in your lungs after you take a deep breath