Respiratory Health Assessment

8/7/2019 Respiratory Health Assessment

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VentilationVentilation

The movement of air in and out of the airways.

The thoracic cavity is an air tight chamber. thefloor of this chamber is the diaphragm.


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VentilationVentilation

Inspiration: contraction of the diaphragm (movementof this chamber floor downward) and contraction ofthe external intercostal muscles increases the space inthis chamber. lowered intrathoracic pressure causesair to enter through the airways and inflate the lungs.

Expiration: with relaxation, the diaphragm movesup and intrathoracic pressure increases. this increased

pressure pushes air out of the lungs. expirationrequires the elastic recoil of the lungs.

Inspiration normally is 1/3 of the respiratory cycleand expiration is 2/3.


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Physiology of Respiratory SystemPhysiology of Respiratory System

DRIVING FORCE FOR AIR FLOW

Airflow driven by the pressure difference

between atmosphere (barometric pressure) andinside the lungs (intrapulmonary pressure).

AIRWAY RESISTANCE

Resistance is determined chiefly by the radius

size of the airway.


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Causes ofIncreased Airway Resistance

1. Contraction of bronchial mucosa 2. Thickening of bronchial mucosa

3. Obstruction of the airway

4. Loss of lung elasticity


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RESPIRATION

The process of gas exchange between atmosphericair and the blood at the alveoli, and between the blood

cells and the cells of the body. Exchange of gases occurs because of differences in

partial pressures.

Oxygen diffuses from the air into the blood at the

alveoli to be transported to the cells of the body. Carbon dioxide diffuses from the blood into the air

at the alveoli to be removed from the body.


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NEUROCHEMICAL CONTROL

MEDULLA OBLONGATA respiratory center initiateseach breath by sending messages to primary respiratorymuscles over the phrenic nerve

- has inspiration and expiration centers

PONS has 2 respiration centers that work with theinspiration center to produce normal rate of breathing 1.PNEUMOTAXICCENTERaffects the inspiratory effort

by limiting the volume of air inspired 2. APNEUSTICCENTERprolongs inhalation


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Respiratory HealthRespiratory Health

AssessmentAssessment


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Health HistoryHealth History

ChiefComplaintChiefComplaint

When did you first notice you werent feeling well?When did you first notice you werent feeling well?

What has happened since then that brings you hereWhat has happened since then that brings you here

today?today?

Current Health HistoryCurrent Health History

Patients biographic dataPatients biographic dataAge, sex, marital status, occupation, education, religion,Age, sex, marital status, occupation, education, religion,

and ethnic backgroundand ethnic background


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Current Health HistoryCurrent Health History

Analysis of his/her symptomsAnalysis of his/her symptoms

OnsetOnset

IncidenceIncidence

DurationDuration

MannerManner

Aggravating factorsAggravating factors

Alleviating factorsAlleviating factors

Associated factorsAssociated factors

LocationLocation

QualityQuality

DurationDuration

SettingSetting


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Six important respiratory symptomsSix important respiratory symptoms

CoughCough

Sputum productionSputum production DyspneaDyspnea

HemoptysisHemoptysis

Chest painChest pain

WheezingWheezing


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CoughCough

Ask these questions:Ask these questions:

Is the cough productive?Is the cough productive?

If the cough is a chronic problem, has it changedIf the cough is a chronic problem, has it changed

recently?recently?

If so, how?If so, how?

What makes the cough better?What makes the cough better?

What makes it worse?What makes it worse?


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CoughCough

Also investigate the characteristics of the cough:Also investigate the characteristics of the cough:

Severe, disrupting daily activities and causing chest pain or acuteSevere, disrupting daily activities and causing chest pain or acuterespiratory distressrespiratory distress

Dry, signaling a cardiac conditionDry, signaling a cardiac condition

Hacking, signaling pneumoniaHacking, signaling pneumonia

Congested, suggesting cold, pneumonia, or bronchitisCongested, suggesting cold, pneumonia, or bronchitis

Increased amounts of mucoid sputum, suggesting acuteIncreased amounts of mucoid sputum, suggesting acutetracheobronchitis or cute asthmatracheobronchitis or cute asthma

Chronic productive with mucoid sputum, signaling asthma orChronic productive with mucoid sputum, signaling asthma orchronic bronchitischronic bronchitis

Changing sputum, fro white to yellow or green, suggesting aChanging sputum, fro white to yellow or green, suggesting abacterial infectionbacterial infection


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Cough (cont.)Cough (cont.)

Occurring in the early morning, indicating chronicOccurring in the early morning, indicating chronic

airway inflammation, possibly from cigaretteairway inflammation, possibly from cigarette

smokingsmoking

Occurring in late afternoon, indicating exposure toOccurring in late afternoon, indicating exposure to

irritantsirritants

Occurring in the evening, suggesting chronicOccurring in the evening, suggesting chronicpostnasal drip or sinusitispostnasal drip or sinusitis


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Sputum productionSputum production

Ask to estimate the amount produced in teaspoonsAsk to estimate the amount produced in teaspoons

or some other common measurement.or some other common measurement.

Find out what time of day he usually coughs andFind out what time of day he usually coughs and

the color and consistency of his sputum.the color and consistency of his sputum.

Ask if his sputum is a chronic problem and if it isAsk if his sputum is a chronic problem and if it is

recently changed. If he has, ask him how.recently changed. If he has, ask him how. Ask if he coughs up blood; if so, find out howAsk if he coughs up blood; if so, find out how

much and how often.much and how often.


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DyspneaDyspnea

Ask the patient to rate his usual level of dyspneaAsk the patient to rate his usual level of dyspnea

on a scale of 1 to 10, in which 1 means no dyspneaon a scale of 1 to 10, in which 1 means no dyspnea

and 10 means the worst dyspnea he hasand 10 means the worst dyspnea he has

experienced. Then ask hi to rate the level that day.experienced. Then ask hi to rate the level that day.

Count the number of words the patient speaksCount the number of words the patient speaks

between breaths.A

normal individual can speak 10between breaths.A

normal individual can speak 10to 12 words. A severely dyspneic patient mayto 12 words. A severely dyspneic patient may

speak only 1 to 2 words per breath.speak only 1 to 2 words per breath.


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DyspneaDyspnea

Grade dyspnea as it realtes to activity. Ask theGrade dyspnea as it realtes to activity. Ask thepatient what hedoes to relieve the dyspnea andpatient what hedoes to relieve the dyspnea and

how ell those measures work.how ell those measures work. Ask the patient about its onset and severity.Ask the patient about its onset and severity.

A sudden onsetA sudden onset-- indicate acute problem, such asindicate acute problem, such aspneumothorax or pulmonary embolus, or may alsopneumothorax or pulmonary embolus, or may also

result from anxiety caused by hyperventilationresult from anxiety caused by hyperventilation A gradual onsetA gradual onset-- suggest a slow, progressive disorder,suggest a slow, progressive disorder,

such a emphysema, whereas acute intermittent attackssuch a emphysema, whereas acute intermittent attacksmay indicate asthma.may indicate asthma.


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HemoptysisHemoptysis

May result from violent coughing or from seriousMay result from violent coughing or from serious

disorders, such as pneumonia, lung cancer, lingdisorders, such as pneumonia, lung cancer, ling

abscess, tuberculosis, pulmonary embolism,abscess, tuberculosis, pulmonary embolism,

bronchiectasis, and leftbronchiectasis, and left--sided heart failure.sided heart failure.

If the hemoptysis is mild (sputum streaked withIf the hemoptysis is mild (sputum streaked with

blood), reassure the patient, make sure to ask himblood), reassure the patient, make sure to ask himwhen he first noticed it and how often it occurs.when he first noticed it and how often it occurs.



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Chest painChest pain

Ask these questions:Ask these questions:

Where is the pain?Where is the pain?

What does it feel like?What does it feel like?

Is it sharp, stabbing, burning, or aching?Is it sharp, stabbing, burning, or aching?

Does it move to another area?Does it move to another area?

How long doest it last?How long doest it last? What causes it to occur?What causes it to occur?

What makes it better?What makes it better?


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WheezingWheezing

Initially determine the severity of the condition.Initially determine the severity of the condition.

If the patient isnt in acute distress, then ask theseIf the patient isnt in acute distress, then ask thesequestions;questions;

When does wheezing occurs?When does wheezing occurs?

What makes you wheeze?What makes you wheeze?

Do you wheeze loudly enough for others to hear it?Do you wheeze loudly enough for others to hear it? What helps stop your wheezing?What helps stop your wheezing?


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Past health historyPast health history

Identify previous respiratory problems, such as asthma andIdentify previous respiratory problems, such as asthma andCOPDCOPD

Ask about childhood illness

Ask about childhood illness

Obtain an immunization history, especially of influenza andObtain an immunization history, especially of influenza andpneumococcal vaccinationpneumococcal vaccination

Travel historyTravel history include dates, destinations, and length ofinclude dates, destinations, and length ofstaystay

Ask what problems in the past caused the patient to see aAsk what problems in the past caused the patient to see ahealthcare provider or required hospitalization. Ask tohealthcare provider or required hospitalization. Ask todescribe the prescribed treatment, whether he followed thedescribe the prescribed treatment, whether he followed thetreatment plan and whether the treatment helped.treatment plan and whether the treatment helped.


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Past health history (cont.)Past health history (cont.)

History should also include brief personal details;History should also include brief personal details;

Ask the patient if he smokes; if he does, ask when heAsk the patient if he smokes; if he does, ask when he

started and how many packs of cigarettes he smokes perstarted and how many packs of cigarettes he smokes per

day.day.

Ask about patients alcohol use and about his dietAsk about patients alcohol use and about his diet

Allergy historyAllergy history

MedicationsMedications


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Health HistoryHealth History Family historyFamily history

Do any members if the family suffer from a respiratoryDo any members if the family suffer from a respiratorydisorder?disorder?

Determine whether the patient lives with anyone who hasDetermine whether the patient lives with anyone who has

an infectious disease, such as influenza or TB.an infectious disease, such as influenza or TB. Psychosocial historyPsychosocial history

Tobacco, alcohol, and caffeine consumption (type, amount,Tobacco, alcohol, and caffeine consumption (type, amount,frequency)frequency)

Anxiety and adaptation associated with acute illness orAnxiety and adaptation associated with acute illness orchronic pulmonary diseasechronic pulmonary disease

Home environment and exposure to irritants (odors, smoke,Home environment and exposure to irritants (odors, smoke,sprays, allergens, air conditioning and heating system,sprays, allergens, air conditioning and heating system,humidity, ventilation)humidity, ventilation)


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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Positioning the patientPositioning the patient

Undressed to the waistUndressed to the waist

Sitting at the side of the bedSitting at the side of the bed

GENERALGENERAL

yy Watch the pt for signs of dyspnea at rest. Is the ptWatch the pt for signs of dyspnea at rest. Is the pt

in respiratory distress ? Use of accessory musclesin respiratory distress ? Use of accessory muscles

of respiration.of respiration.


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GENERAL (cont.)GENERAL (cont.)

yy Is there any specific pattern of respiration?Is there any specific pattern of respiration?

NORMAL RESPIRATORY PATTERNNORMAL RESPIRATORY PATTERN


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ABNORMAL RESPIRATORY PATTERNABNORMAL RESPIRATORY PATTERN

BradypneaBradypnea

Decreased rate but regular breathingDecreased rate but regular breathing


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TachypneaTachypnea

Shallow breathing with increased respiratory rateShallow breathing with increased respiratory rate


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Kussmauls RespirationsKussmauls Respirations

Rapid, deep breathing without pauses; in adults, moreRapid, deep breathing without pauses; in adults, more

than 20 breaths/minute; breathig usually sounds laboredthan 20 breaths/minute; breathig usually sounds labored

with deep breaths that resemble sighs.with deep breaths that resemble sighs.


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Biots RespirationBiots Respiration

Rapid, deep breathing with abrupt pauses between eachRapid, deep breathing with abrupt pauses between each

breath; equal depth to each breath.breath; equal depth to each breath.


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Cheyne Stokes RespirationCheyne Stokes Respiration

Breaths that gradually become faster and deeper thanBreaths that gradually become faster and deeper than

normal, then slower, during a 30normal, then slower, during a 30--to 170to 170--second period;second period;

alternates with 20 to 60 seconds periods of apnea.alternates with 20 to 60 seconds periods of apnea.


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ApneaApnea

Absence of breathing; may be periodicAbsence of breathing; may be periodic


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GENERAL (cont.)GENERAL (cont.)

Count the respiratory rate (should be aroundCount the respiratory rate (should be around

14 / min)14 / min) Is the patient cyanosed?Is the patient cyanosed?

Examine the hands for clubbing.Examine the hands for clubbing.


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Examine theExamine the

chestchest

InspectionInspection

Shape andShape and

symmetry of thesymmetry of the

chestchest


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Inspect for lesions in the chest wallInspect for lesions in the chest wall

InspectInspect movement of the chest wall: look ormovement of the chest wall: look or

amount of expansion and asymmetry ofamount of expansion and asymmetry ofexpansionexpansion


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PalpationPalpation

Four Uses for Palpation of the Chest.Four Uses for Palpation of the Chest.

Identify areas of tendernessIdentify areas of tenderness. Any area where the patient has reported pain or. Any area where the patient has reported pain orwhere there are lesions (a hurt, injury, wound) should be palpated.where there are lesions (a hurt, injury, wound) should be palpated.

Assess observed abnormalities.Assess observed abnormalities.If you have seen masses or sinus tracts (blind,If you have seen masses or sinus tracts (blind,inflammatory, tubeinflammatory, tube--like structures opening into the skin), palpate the area tolike structures opening into the skin), palpate the area to

evaluate the problem further.evaluate the problem further.

Further assess the respiratory excursionFurther assess the respiratory excursion. Determine the range of respiratory. Determine the range of respiratorymovement (how far the chest expands when he inhales and how far the chestmovement (how far the chest expands when he inhales and how far the chestcontracts when he exhales). You can also feel symmetry of respiratory movementcontracts when he exhales). You can also feel symmetry of respiratory movement(whether or not the body parts feel the same on both sides during a respiration).(whether or not the body parts feel the same on both sides during a respiration).

Elicit tactile fremitusElicit tactile fremitus. When a person speaks, vibrations that can be felt are. When a person speaks, vibrations that can be felt aretransmitted through the bronchopulmonary system to the chest wall. Thesetransmitted through the bronchopulmonary system to the chest wall. Thesevibrations can best be felt when a person says the words "ninetyvibrations can best be felt when a person says the words "ninety--nine" or "onenine" or "one--oneone." Ask the person to speak louder or lower his head if you cannot feel theoneone." Ask the person to speak louder or lower his head if you cannot feel thevibrations.vibrations.


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PalpationPalpation

Trachea for midline alignmentTrachea for midline alignment

Tactile and vocal fremitus and location ofTactile and vocal fremitus and location of

increases or decreasesincreases or decreases

yy Use one hand to compare localized areas in bothUse one hand to compare localized areas in both

lungs . Do it in front and the back .Causes arelungs . Do it in front and the back .Causes are

similar to vocal resonancesimilar to vocal resonance


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Posterior palpation Anterior palpation


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Figure 2-4. Sequence of tactile fremitus examination.


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PERCUSSION OF CHESTPERCUSSION OF CHEST

Table of percussion notes.


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Areas of Percussion.Areas of Percussion.

Posterior percussion.Anterior percussion


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AUSCULTATION OF CHESTAUSCULTATION OF CHEST

Listen to the breath sounds with the diaphragmListen to the breath sounds with the diaphragm

of a stethoscope after instructing the patient toof a stethoscope after instructing the patient tobreath deeply through an open mouth.breath deeply through an open mouth.

Use the pattern below, moving from one sideUse the pattern below, moving from one side

to the other and comparing symmetrical areasto the other and comparing symmetrical areas

of the lungsof the lungs


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Auscultated normal breath sounds.


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Check for abnormal soundsCheck for abnormal sounds. Check for sounds in the lungs that are not. Check for sounds in the lungs that are notmodifications of breath or voice.modifications of breath or voice.

Rhonchi.Rhonchi. These are coarse, rattling sounds produced when the patientThese are coarse, rattling sounds produced when the patientexhales. The sounds are usually very clear but might change with coughing.exhales. The sounds are usually very clear but might change with coughing.LowLow--pitched, these sounds occur when there is mucus in the bronchi.pitched, these sounds occur when there is mucus in the bronchi.

Rales (Crackles).Rales (Crackles).R

ales, also called crackles, are fine, rattling sounds.R

ales, also called crackles, are fine, rattling sounds.These are noncontinuous, highThese are noncontinuous, high--pitched, fine crackles, like the sound ofpitched, fine crackles, like the sound ofcarbonated beverages. The sounds are usually heard when the patientcarbonated beverages. The sounds are usually heard when the patientbreathes in and sometimes when the patient begins to exhale. These soundsbreathes in and sometimes when the patient begins to exhale. These soundsare usually caused by the presence of fluid in the alveoli and theare usually caused by the presence of fluid in the alveoli and thebronchioles. Sometimes the fluid is in these parts of the respiratory system,bronchioles. Sometimes the fluid is in these parts of the respiratory system,and sometimes the fluid is not there. This is the reason that sometimes theand sometimes the fluid is not there. This is the reason that sometimes the

fine rattling can be heard, and sometimes it is not heard. Coughing usuallyfine rattling can be heard, and sometimes it is not heard. Coughing usuallymakes the sounds louder.makes the sounds louder.

Wheezes.Wheezes. Wheezes are musical sounds like the highWheezes are musical sounds like the high--pitched notes on apitched notes on aclarinet. Wheezes are produced by constricted or partially obstructedclarinet. Wheezes are produced by constricted or partially obstructedairways. The sounds can be heard when the patient breathes in.airways. The sounds can be heard when the patient breathes in.

Pleural friction rubPleural friction rub. These are scratchy sounds like crinkling Saran. These are scratchy sounds like crinkling Saranwrap. The sounds are produced by the movement of inflamed pleuralwrap. The sounds are produced by the movement of inflamed pleuralsurfaces rubbing together.surfaces rubbing together.


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Incentive SpirometerIncentive Spirometer


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Incentive SpirometerIncentive Spirometer

A method of deep breathing that providesA method of deep breathing that provides

visual feedback to encourage patient to inhalevisual feedback to encourage patient to inhale

slowly and deeply to maximize lung inflationslowly and deeply to maximize lung inflation

and prevent or reduce atelectasis.and prevent or reduce atelectasis.


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TypesTypes

Volume typeVolume type


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TypesTypes

Flow typeFlow type


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ProcedureProcedure

Introduce oneself to the patient and assess the

appropriateness of the therapy for the patient

A

ssume a semi- Fowlers position or anupright position before initiating therapy.

Hold the incentive spirometer in an upright

position.

Place the mouthpiece in your mouth and seal

your lips tightly around it.


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ProcedureProcedure

Breathe in slowlyBreathe in slowly and as deeply as possible, raisingand as deeply as possible, raisingthe yellow piston toward the top of the column. Thethe yellow piston toward the top of the column. Theyellow coach indicator should be in the blue outlinedyellow coach indicator should be in the blue outlinedarea.area.

Hold your breath as long as possible (for at least fiveHold your breath as long as possible (for at least fiveseconds).Allow the piston to fall to the bottom of theseconds).Allow the piston to fall to the bottom of thecolumn.column.

A

ssist the patient while he/she performs 10maneuvers. Encourage the patient to perform thetechnique independently with five to ten breaths persession every hour while awake.


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ProcedureProcedure

Position the yellow indicator on the left side ofPosition the yellow indicator on the left side of

the spirometer to show your best effort. Usethe spirometer to show your best effort. Use

the indicator as a goal to work toward duringthe indicator as a goal to work toward during

each repetition.each repetition.

Encourage the patient to cough during and

after the session using optimal technique and

effort.


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ProcedureProcedure

Supervision and monitoring should be performed

intermittently (at least once daily) to include:

4.1.1 Number of attempts per session

4.1.2Inspiratory volume achieved

4.1.3 Effort/motivation and compliance

Chart these data


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Respiratory Health Assessment

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