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.