The Respiratory System Jean M. Wilson, BSN, RN, CCE.

The Respiratory System

Jean M. Wilson, BSN, RN, CCE

Assessment of the Chest and Lungs

• Equipment needed:

Tape measure

Stethoscope

Blanket or drape

Ruler

A & P

• Position of the Patient:

Sitting = best; Allows for inspection of both the back and the chest for: the 3 S’s

Size

Shape

Symmetry

Landmarks

• Landmarks:

Clavicle

Trachea

Intercostal spaces (ICS)

Midclavicular lines

Axillary lines

Landmarks Continued

Midsternal line

Sternum

Xiphoid process

Anterior Chest

• Lungs:

Right upper lobe Left upper lobe

Right middle lobe Left lower lobe

Right lower lobe

Posterior Chest

• Vertebral line

• Right and left lobes

• Scapula

• Scapula line

Assesessment

• Anteroposterior Diameter = half of the transverse diameter

• Unexpected findings:

Barrel chest

Pigeon chest

Funnel chest

Deviations

Assessment

• Assess the patient’s;

Lips: color, pursed lips

Nails: clubbing, cyanosis

Nares: flaring

Oxygen saturation

Breath: odor

Patients overall color

Respirations

• Expected:

Rhythm and pattern: even & easy with no distress

Repiration rate: 12-20 breaths per minute

Ratio of HR/RR: 1 to 4

Respirations

• Unexpected:

Shortness of Breath (SOB)

Tachypnea

Orthopnea

Use of accessory muscles

Retractions

Patterns of Respirations

• Normal: regular 12-20 per minute

• Bradypnea: slow, < 12

• Tachypena: fast, > 20

• Hyperpnea (hyperventilation) faster, >20 and deep

• Sighing: sigh/deep breath

Patterns of Respirations

• Air trapping: increase difference in the air getting out

• Cheyne Stokes: increase in depth with periods of apnea

• Kussmauls: rapid, deep, and labored

• Biots: apnea and disorganized breathing

Patterns of Respirations

• Ataxic: irregular, with varying depths

Listening

• Two types of breath sounds; normal and abnormal

• Normal are called; bronchial, bronchial vesicular, and vesicular

• Abnormal are also called; adventitious

Listening

• Review the proper use of the stethoscope

Normal Breath Sounds

• Bronchial: trachea, anterior only, and high pitch

• Bronchovesicular: main bronchus, anterior and posterior, medium pitch

• Vesicular: heard over most of the lung fields, bases, low pitch

Adventicious Breath Sounds

• Crackles: fine, medium, and coarse

Fine: not cleared by coughing, heard at the end of inspiration

Medium: lower, moist, heard during inspiration, not cleared by cough

Coarse: loud, bubbly, heard on inspiration, can be cleared by coughing

Adventicious Breath Sounds

• Wheezes: musical note, squeaky, heard on inspiration or expiration

• Rhonci: sunorous wheeze, loud, low, inspiration or expiration, coughing may clear, due to mucous accumulation

• Stridor: bark, no air exchange

• Pleural friction rub: rubbing, dry, grating sound, inspiration or expiration, anterior

Abnormalities

• Pulsations

• Tenderness

• Bulges

• Depressions

• Unusual movement

• Unusual positions

Thoracic Expansion

• Stand behind the patient

• Place palms lightly on patient’s back with thumbs at the 10th rib

• Have patient breathe & watch thumbs with each breath

• Symmetric expantions should be seen

• Repeat anteriorly under the xiphoid process

Trachea

• Midline

• Palpate gently with index finger about suprasternal notch

• A slight deviation to the right is normal

• Should be non-tender

• Pulsations = abnormal

Chest Percussion

• Direct:

• Indirect:

• Percuss all areas anteriorly and posteriorly

Percussion Tones

• Resonant: low pitch, hollow, loud, long

• Flat: soft, extremely dull, short, high pitch

• Dull: medium, medium-high pitch, thudlike

• Tympanic: loud, high pitch, drumlike

• Hyperresonant: very loud, very low pitch, long, booming sound

Vocal Resonance

• Have patient recite numbers or words as you listen to all lung fields (99)

• Muffled sound should be heard

Abnormalities

• Cancer

• Infections: upper respiratory, sputum production

• Asthma

• Chronic Obstructive Pulmonary Disease (COPD)

Abnormalities Continued

• Emphysema

• Pneumonai

• Barrel Chest

• Productive (sputum)/non-productive coughing

• Long expirations

Cough Descriptions

• Dry

• Moist

• Non-productive

• Productive: assess sputum color; yellow, green, rust, clear, purrulent, blood streaked, thick(viscous) or thin

Coughs

• Assess:

Onset

Frequency

Regularity; certain time of day or activities

Postural changes

Smoker/non-smoker

Environmental/work related issues

References

Schilling, J. A. et al (2007). Health

assessment made incredibly visual!

Philadelphia: Lippincott, Williams,

& Williams.