respiratory
Thoracic deformities and configurations
· Barrel chest
o Chest is 1 to 1
o Can happen to COPD
o Costal margins are greater than 90 degrees
· Pectus excavatum (funnel chest)
o Chest is funneled in
· Scoliosis
· Kyphosis
o Thoracic humpback
· Lordosis
o Sway in back
Inspection: accessory muscles
· Trapezius, or shoulder, muscles: Facilitate inspiration in acute and chronic airway obstruction or atelectasis.
· Tripod position seen in COPD
o Client leans forward
o Uses arms to support weight
o Lifts chest to increase breathing capacity
Application question
A nurse finds a patient in the tripod position
while assessing respiratory distress. Which
of the following actions should the nurse
prioritize?
▪ A) Ask the patient about their symptoms and medical history.
B) Administer prescribed bronchodilator medication.
C) Assess the patient’s vital signs and oxygen saturation.
D) Encourage the patient to relax and breathe slowly.
Inspection: pediatrics
· Flared nostrils
· Capillary refill greater than 2 seconds (super important in peds)
· Retracts in ribs (skin looks like it is caving into each rib as they breath)
· Pale skin
· Frightened look
Palpation: chest rise
· Thoracic expansion
· Have pt take deep breath in and out and your fingers should move 5-10 cm symmetrically
o Decrease in movement would mean:
§ Pneumonia
§ Collapsed lung
Palpate the anterior and posterior chest wall
· Tenderness
o Chest wall, musculoskeletal strain
· Crepitus
o When air is pushed through the soft tissue chest
o Popping under skin
o Looking for pneumothorax (collapsed lung)
o Airway or esophageal tear
· Masses or lesions
Tactile fremitus
· Vibration of chest wall
o Result of sound transmitting through lung tissue
· Have pt say 99 and the vibrations will decrease as you go down the back
· Decreased fremitus
o Excess air in lungs (COPD)
o Thickness of chest wall
· Excess fremitus
o Lung consolidation
§ Inflammatory exacerbate
o Pneumonia
o More vibrations and not symmetrical
o Mucus, puss
Percussion
· Tone—resonance
o Borders for cardiac dullness
· Hyperresonance: emphysema, pneumothorax
o Air trapping (excess air)
o Higher pitched
· Dullness: consolidation, pleural effusion, tumor
o Expected to hear:
§ Bone
§ Liver
o Either fluid mucus puss, or lump mass or tumor
Application question
A nurse is performing percussion of the lungs during a respiratory assessment. Which of
the following findings would indicate the presence of fluid in the pleural space?
A) Hyperresonance over the lung fields.
B) Dullness or flatness upon percussion.
C) Increased resonance in the lower lung fields.
D) Tympany in the upper lung fields.
Diaphragmatic excursion
· Place percussion hand at T7 (Scapular line)
· Have patient exhale forcefully and hold the breath
· Percuss downward until dullness is noted, mark the level
· Place percussion hand at the marked level
· Have patient inhale deeply and hold it
· Percuss downward until dullness is noted, mark the level
· Measure the distance between the two spots
· NORMAL - 3cm to 5cm (can be 7cm to 8cm in well-conditioned patients)
Application question
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
a) Shallow breathing
b) Normal lung tissue
c) Decreased adipose tissue
d) Increased density of lung tissue
Critical thinking question
The nurse hears tympany over the lung tissue posteriorly in the ER. What is the patient most likely suffering from?
a) Atelectasis
b) Pneumonia
c) Increased body habitus
d) Emphysema
Auscultation
· Auscultate for breath sounds
· Technique: Why in the following pattern?
· Do not attempt to listen through clothing or other materials.
· Listen for
o Normal lung sounds
o Bronchial (tracheal)
§ Over trchea
§ Very loud/high
§ Inspiration= exp
o Bronchovesicular (major bronchi)
§ 1st and 2nd intercostal spaces
§ inspiration and expiration are equal but not as loud
§ medium sound
o Vesicular (small bronchiole/alveoli)
§ Sound of alveoli
§ Inspiration is heard longer the expiration
§ softer
§ heard over the lungs
o Diminished or increased lung sounds
o Adventitious lung sounds
o Crackles (rales)
§ When there is fluid in the small airway
§ Short high pitched crackling sound
§ Fine or coarse
§ Pneumonia is coarse
§ Ask if you hear them late in inspiration or early
· Late
o Pneumonia or heart failure
· Early
o Asthma patients
o Wheeze (rhonchi)
§ High pitched musical sound
§ Bronchial tubes become inflamed and narrowed
· Haer in asthma exacerbation
· Pneumonia and bronchitis
o Atelectatic crackles
§ When there is a sudden opening of a closed airway
§ Sound like a fine crackle (popping)
§ Happens when alveoli become stuck or closed off and then opens up again
§ Need to get alveoli open and functioning again
· Incentive spirometers
· Coughing
· Moving around
o Stridor
§ Croupy cough
§ Normal lung sounds but hear this through the throat
§ Inflammation of vocal cords
§ Someone choking
Auscultation
· Vestibular all the way throughout
· Bronchovesicular from 2-3 ribs
· Bronchial in the trachea
Auscultation: voice sounds
· Bronchophony
o Ask the client to repeat the phrase “ninety-nine” while you auscultate the chest wall.
§ Want Symmetrical to both sides
· Egophony
o Ask the client to repeat the letter “E” while you listen over the chest wall.
§ If E turns to A there’s some type of fluid or consolation
· Pneumonia or tumor
· Whispered pectoriloquy
o Ask the client to whisper the phrase “one–two–three” while you auscultate the chest wall.
§ If heard more on one side than the other there’s either a tumor or pneumonia
KNOWLEDGE QUESTION:
Which of the following is an abnormal breath sound?
A. Bronchial
B. Bronchovesicular
C. Vesicular
D. Rhonchi another name for wheezing
Putting it all together
NORMAL lung findings include:
a) No chest distortions or deformities
b) No use of accessory muscles when breathing
c) AP to Lateral diameter 1:2 ratio
d) Costal angle of 90 degrees or less
e) Resonant percussion tones
f) Fremitus palpated symmetrically
g) Symmetric chest expansion
h) No tenderness or crepitus to skin over lung fields
i) Vesicular breath sounds over the peripheral lung fields
j) Clear lung sounds with no adventitious sounds
No wheezing, stridor, crackles
k) Muffled voice sounds
Bronchitis
· Inflammation of bronchial tree r/t excessive mucus secretions
· Symptoms: productive cough, fever?, fatigue, tachypnea
· What might we find on inspection? Percussion? Palpation? Auscultation?
o Make sure no acute distress
o May feel crepitus
o May have dullness
· Would hear:
o Fine crackles
o Wheezing
A nurse is developing a care plan for a patient diagnosed with acute bronchitis. Which of the following nursing interventions should be included?
A) Encourage the patient to engage in vigorous exercise to improve lung function.
B) Teach the patient about the importance of smoking cessation if applicable.
C) Instruct the patient to avoid all forms of hydration to reduce coughing.
D) Administer antibiotics routinely, regardless of the presence of a bacterial infection.
Pneumonia
· Causes infection to terminals of bronchioles, alveoli in one or both lungs
· Symptoms: fever, cough, tachypnea, sputum, chest pain
· What might we find on inspection? Percussion? Palpation? Auscultation?
o Percussion
§ Dullness
o Palpation
§ Crepitus
o Auscultation
§ Crackles
§ Late in inspiration
A nurse is caring for a patient diagnosed with pneumonia. Which of the following nursing
interventions should be prioritized in the care plan?
A) Encourage the patient to ambulate frequently to promote lung expansion.
B) Administer high-flow oxygen therapy immediately upon admission.
C) Restrict fluid intake to prevent fluid overload.
D) Instruct the patient to avoid deep breathing and coughing to reduce discomfort.
Tuberculosis
· Contagious (bacterial infection by Mycobacterium tuberculosis); Most prevalent infectious disease in the world; Sputum droplets containing the organism become airborne which can be then inhaled (cough, sneeze, talking)
· Risks: Immunocompromised, foreign countries, homeless, prison, nursing homes, illegal drug use
· Symptoms
o Asymptomatic in early stages of disease
o Initial clinical manifestations: Fatigue, anorexia, weight loss, fever.
§ Night sweats
§ Rust color sputum
o Later Findings: Cough with blood tinged sputum, apical crackles
Pulmonary embolism
· Obstruction of pulmonary arterial bed by dislodged undissolved material
· Symptoms: Dyspnea, chest pain, anxiety, tachycardia, diaphoresis
· What might we find on inspection? Percussion? Palpation? Auscultation?
o Impending doom
o Get really tachy and short of breath
o May not hear anything different or see anything different
A nurse is assessing a patient who is suspected of having a pulmonary embolism.
Which of the following findings would the nurse expect to observe during the assessment?
A) Bradycardia and hypotension
B) Sudden onset of shortness of breath and chest pain
C) Decreased respiratory rate andhypoventilation
D) Elevated blood pressure and bradypnea
Pleural effusion
· Clinical findings
o Dyspnea, intercostal bulging, or decreased chest wall movement, tachypnea, dry cough, cyanosis
o Decreased or absent tactile fremitus, decreased chest expansion, dull or flat percussion, decreased or absent breath sounds, tracheal shift away from affected side
o Caused by congestive heart failure
Asthma
· Chronic reactive airway (inflammatory) disorder resulting in reversible bronchoconstriction and air hunger in response to triggers
o Causes episodic airway obstruction r/t bronchospasms, increased mucus secretion, and mucosal edema
o Symptoms: wheezing, anxiety, dyspnea, tachycardia, chest tightness, dry cough, higher likelihood to occur at night
o Triggers: Allergens or pollutants, infection, cold air, vigorous exercise, or emotional stress
COPD
· 2 types
o Bronchitis
§ Inflammation of excess mucous, tight muscles
o Emphysema
§ Alveoli try and remodel themselves and they break down trapping air
§ Permanent destruction of alveolar walls and loss of connective tissue support of lower airways (Form of COPD)
§ Clinical findings:
· Classic appearance—Underweight with barrel chest, short of breath with minimal exertion
· “Pink puffer”
· Use of accessory muscles, pursed-lip breathing, cough, barrel chest
· SOB on exertion, excessive sputum, chronic cough, dypsnea
· Evidence of excess body fluids, cyanosis (late sign)
· Decreased breath sounds, decreased heart sounds, prolonged expiration, hyperresoonance, weight loss, possible wheezing or crackles, decreased diaphragmatic excursion
o Or both
APPLICATION QUESTION
▪ A nurse is educating a patient about the differences between chronic obstructive pulmonary disease (COPD) and asthma. Which of the following statements made by the patient indicates a correct understanding of these conditions?
▪A) "COPD is usually reversible, while asthma is a progressive disease."
B) "Asthma often has triggers that can be avoided, whereas COPD is primarily
caused by long-term exposure to irritants."
C) "Both COPD and asthma primarily affect children and young adults."
D) "COPD symptoms are more likely to improve with bronchodilator use than
asthma symptoms."
Pneumothorax
· Etiology/Pathogenesis
o Collapse of the lung (parital or complete)
o Causes/Types: Spontaneous; Traumatic (MVA, penetrating lung wound); Tension
· Symptoms: dyspnea, tachypnea, chest pain, dry cough, cyanosis, asymmetric lung expansion, tracheal shift to unaffected side (large tension pneumo), decreased or absent tactile fremitus, hyperresonance (rare), diminished or absent breath sounds, no adventitious sounds
Atelectasis
· Collapsed alveoli caused by external pressure
· Risk Factors
o Anesthesia, foreign object in airway (kids), lung diseases, mucus plug, pleural effusion, prolonged bedrest, shallow breathing (i.e. pain), tumors
· Symptoms: Cough, dyspnea/tachypnea, tachycardia, cyanosis, O2 sats may decrease <90%, possible tracheal shift to affected side, decreased chest expansion on affected side, decreased or absent tactile fremitus, dullness, Affected lobe has diminished or absent breath sounds
Pulmonary malignancies
· Lung cancer
o Uncontrolled growth of anaplastic cells in lung
· Risk Factors:
o Cigarette smoking is major cause (85%)
o Asbestos, ionizing radiation, and other noxious inhalants can be causative agents
· Clinical Manifestations:
· Most common initial symptom is a persistent cough
· Asymptomatic (10-25%)
· Weight loss, congestion, wheezing, labored breathing, or dyspnea, hemoptysis
· Percussion may be normal or may be dull over the tumor or with atelectasis
Older adult considerations
· Tenderness or pain at the costochondral junction of the ribs is seen with fractures, especially in older clients with osteoporosis.
· Older adults may experience dyspnea with certain activities related to aging changes of the lungs (loss of elasticity, fewer functional capillaries, and loss of lung resiliency).
· Chest pain related to pleuritis may be absent in older clients because of age-related alterations in pain perception.
· The ability to cough effectively may be decreased in the older client because of weaker muscles and increased rigidity of the thoracic wall.
· Deep breathing may be especially difficult for the older client, who may fatigue easily. Thus offer rest as needed.
· Kyphosis (an increased curve of the thoracic spine) is common in older adults.
· Because of calcification of the costal cartilages and loss of the accessory musculature, the older client’s thoracic expansion may be decreased, although it should still be symmetric.
· The sternum and ribs may be more prominent in the older client because of loss of subcutaneous fat.