Respitatory

Respiratory Assessment in Hospital Setting

Frequency of Assessment

• Nurses complete respiratory assessments at least once every eight hours.

• Used as a baseline to monitor changes or improvements in client's condition.

Chronic Conditions

• Clients with chronic conditions may present different findings than healthy clients.

• Example: A client with COPD may develop a barrel-shaped chest, expected for them but not for healthy individuals.

Importance of Baseline

• Knowing individual baselines aids in recognizing significant changes indicating deterioration or improvement.

• Key observations include: chest pain, shortness of breath, cough, sputum color changes, and sleep disruptions.

Incentive Spirometry

• Used to build lung capacity and promote deep breathing.

• Follow proper usage procedure for maximum benefit: sitting upright, sealing the mouthpiece, inhaling slowly, and holding breath.

• Recommended for clients with lung diseases like COPD to prevent atelectasis.

Assessment Preparation

Essential Tools

• Watch: For counting respiratory rate.

• Stethoscope: For auscultation.

• Pulse Oximeter: Provides real-time oxygen saturation levels.

Visual Inspection

• Look for urgent indicators (e.g., uneven chest movement, respiratory distress).

• Familiarize yourself with normal sounds for better identification of abnormal findings.

Identifying Breath Sounds

Abnormal Sounds

• Distinguish between high-pitched musical sounds or low-pitched grating sounds.

• Use dual-checking with a colleague if uncertain about findings.

Pulse Oximetry

• Noninvasive measure of oxygen saturation; normal is 95% or above.

• Values <90% require immediate attention.

Incentive Spirometry Explained

• Flow-oriented vs. Volume-oriented: The first utilizes rising balls with inhalation, while the second uses a bellows mechanism.

• Instructions for patients include correct positioning and breath-holding techniques to maximize expansion of alveoli.

Anatomy and Landmarks

Key Landmarks for Assessment

• Angle of Louis: Identifies rib number and chest structures.

• Midsternal Line: Centerline of the sternum.

• Midclavicular Line: Vertical line from the clavicle.

• Other important lines: Anterior, midaxillary, and posterior axillary lines.

Lung Lobes

• Right Lobes:

  • Upper: Above the clavicle to the 4th rib.

  • Middle: 4th to the 6th rib.

  • Lower: Extends to the 8th rib.

• Left Lobes:

  • Upper: Extends from the clavicle to the 6th rib.

  • Lower: Wedge-shaped, ending at the 8th rib.

Respiratory Physiology

Gas Exchange Process

• Oxygen moves from high to low concentration areas, oxygenating body cells.

• CO2 is exchanged in the alveoli and expelled through exhalation.

• Alterations in gas exchange can lead to hypercarbia (elevated CO2 levels).

Visual and Auditory Inspection

Observations to Make

• Check respiratory rate, rhythm, and client's effort in breathing.

• Note signs like sweating, strained expressions, and audible noises.

• Position assessment: optimal positions may include upright or leaning forward for comfort.

Expected and Unexpected Findings

Expected Findings

• Relaxed posture indicates no respiratory distress.

• Thoracic breathing variations may occur based on gender.

Unexpected Findings

• Tripod position: Typically indicates respiratory distress.

• Intercostal Retractions: Suggest significant breathing difficulties.

Assessment of Consciousness and Skin

• Monitor for decreased consciousness and hypoxia symptoms (e.g., anxiety, confusion).

• Assess skin color (cyanosis) and extremity conditions (clubbing, pallor).

Check Respiratory Rate and Pulse Oximetry

Process

• Expected respiratory rate: 12-20 breaths per minute.

• Tachypnea (rapid breathing) may signal anxiety or illness.

• Document and monitor oxygen saturation readings appropriately.

Intervention for Hyperventilation

• Prioritize client's safety and comfort.

• Techniques to slow the breathing rate, including focused breathing exercises.

• Determine triggers and address them accordingly.

Comprehensive Assessment and Documentation

Steps to Follow

1. Inspect the client: posture, shape, breathing effort.

2. Palpate for symmetry and expansion.

3. Auscultate breath sounds systematically.

4. Document findings clearly and communicate any issues.

Notifying the Provider

• Alert the provider about new findings or changes in condition.

• Use communication tools like the SBAR to relay information effectively.

Summary of Documentation Requirements

• Accurately document subjective and objective findings, interventions, and observations.

• Important to be clear that interventions were performed as per the standard protocols.