4-RESPIRATORY ASSESSMENT presentation.pptx

4-RESPIRATORY ASSESSMENT presentation.pptx

1. UNIT-IV: ASSESSMENT OF RESPIRATORY SYSTEM By: Farzana Kausar Khattak Lecturer INS-KMU

2. OBJECTIVES By the end of the unit, learners will be able to : 1 . Describe the components of health history that should be elicited during assessment of respiratory system. 2. Describe the following: Chest contour and symmetry Respiratory rate and pattern Tactile fremitus Chest expansion Farzana Khattak 2 11/29/2023

3. CONT… Density of lung fields Diaphragmatic excursion Auscultated lung sounds 3. Assess the respiratory system including inspection, palpation, percussion and auscultation. 4. Document findings. 5. List the changes in respiratory system that are characteristics of aging process. Farzana Khattak 3 11/29/2023

4. INTRODUCTION The structures of the respiratory system (The airways, lungs, bony thorax, respiratory muscles, and central nervous system) work together to deliver oxygen to the bloodstream and remove excess carbon dioxide from the body. Pulmonology is the specialty that deals with anatomy, physiology and pathology of respiratory tract. Farzana Khattak 4 11/29/2023

5. FACTS AND FIGURES Asthma affecting more than 300 million people world wide. Accounts for at least one in every 250 deaths. About 12% of Pakistani adult population have Asthma. Prevalence is increasing by 5% annually. 6.9 Million people are suffering from chronic obstructive pulmonary disorder (COPD). ( Chiesi Pakistan, 2019) Pakistan is facing 5 th highest Tuberculosis burden in the world. (WHO, 2018) Farzana Khattak 5 11/29/2023

6. ANATOMY OF THE LUNGS The lungs are two in numbers, situated in the thoracic cavity and separated by mediastinum. Each lung has a base resting on the diaphragm and apex extended superiorly to the clavicle. The Right lung is larger than left lung. T he right lung has three lobes, upper lobe, middle lobe and lower lobe. The left lung has two lobes the upper lobe and lower lobe. Chest wall include ribs, pleura and muscle of respiration. Farzana Khattak 6 11/29/2023

7. ANTERIOR VIEW LATERAL VIEW POSTERIOR VIEW Farzana Khattak 7 11/29/2023

8. UPPER RESPIRATORY TRACT Upper respiratory tract includes: Nasal cavity Naso-pharynx Oropharynx Oral cavity Laryngo-phyrnx Larynx Farzana Khattak 8 11/29/2023

9. LOWER RESPIRATORY TRACT Lower respiratory tract includes: Trachea The bronchi Bronchiole Alveolar ducts Alveolar sac Alveoli Farzana Khattak 9 11/29/2023

10. PHYSIOLOGY Upper airways These structures warm , filter, and humidify inhaled air. Lower airways D irect air toward lungs Gas Exchange Farzana Khattak 10 11/29/2023

11. MECHANISM OF BREATHING Farzana Khattak 11 11/29/2023

12. NEEDED EQUIPMENT Gloves Mask Stethoscope Pulse Oximeter Gown or Drape sheet Ruler Marker Screen (Curtain ) Farzana Khattak 12 11/29/2023

13. GENERAL RULES FOR ASSESSMENT W Wash your hands I Introduce yourself to patient and attendant P Permission, Privacy, Position E Expose the area of examination R Right side approach S Setup, place, lighting, temperature Farzana Khattak 13 11/29/2023

14. HISTORY TAKING (SAMPLE TECHNIQUE) S Signs and symptoms (cough, Sputum, Pain, Temperature, Breathlessness), S moking history A Allergies (pets, drugs, seasonal) M M edication history P Past Medical, Surgical history L Last intake (when and what has been taken) E Events associated with condition Farzana Khattak 14 11/29/2023

15. SYMPTOMS Cough Headache Epistaxis Hoarseness Cyanosis Clubbing Sputum Hemoptysis Chest pain Dyspnea Wheezing Farzana Khattak 15 11/29/2023

16. COUGH TYPES: Dry, Productive, Persistent, Episodic. Note: Onset Duration Frequency Severity Activities Time of Day Weather Aggravating Factor Relieving Factor Farzana Khattak 16 11/29/2023

17. PHYSICAL EXAMINATION I nspection P alpation P ercussion A uscultation Farzana Khattak 17 11/29/2023

18. 1. INSPECTION C yanosis (Central , Peripheral) N ose (Nostrils, Nasal Flare) N ails (Color, Shape) C hest wall asymmetry R espiratory Rate and pattern A ccessory muscle use M asses, Scars P aradoxical movement Farzana Khattak 18 11/29/2023

19. RESPIRATORY RATES FOR DIFFERENT AGE GROUPS Age Respirations Per Minute Newborn 30–60 1 year old 18–30 16 year old 16–20 Adult 12–20 Farzana Khattak 19 11/29/2023

20. RESPIRATORY PATTERN Tachypnea Bradypnea Apnea Hyperapnea Kussmaul’s respirations Cheyne-Stokes respirations Farzana Khattak 20 11/29/2023

21. CONT… Tachypnea Rapid , shallow breathing more than 20 breaths/min Bradypnea Slower than normal rate (10 breaths/min), with normal depth and regular rhythm Apnea Period of cessation of breathing Hyperapnea Increased depth of breathing Kussmaul’s R espirations Rapid, deep breathing without pauses; in adults, more than 20 breaths/minute ; breathing usually sounds labored with deep breaths that resemble sighs Cheyne-Stokes Faster and deeper than normal, then slower, with periods of apnea Farzana Khattak 21 11/29/2023

22. CHEST SHAPES Barrel chest Funnel chest Pigeon chest Farzana Khattak 22 11/29/2023

23. BARREL CHEST Anterior-posterior diameter and transverse diameter are equal. It occurs in emphysema. Farzana Khattak 23 PIGEON CHEST Also called Pectus C arinatum . There is prominence of the sternum and costal cartilage. A complication of chronic respiratory disease in childhood. May also occur as result of rickets disease . 11/29/2023

24. FUNNEL CHEST Also called Pectus Excavatum. Depression of the lower portion of the sternum. Sever form interferes with cardio respiratory function. Complications: Heart Damage Decreased Cardiac Output 11/29/2023 Farzana Khattak 24

25. 2. PALPATION E Expansion (Chest Wall) C Crepitus (Consolidation) T Trachea Position, Tenderness, Tactile Fremitus Farzana Khattak 25 11/29/2023

26. EXPANSION (CHEST WALL) Place your hands on the front of the chest wall with your thumbs touching each other at the second intercostal space. As the patient inhales deeply, watch your thumbs. They should separate simultaneously and equally to a distance several centimeters away from the sternum. Repeat the measurement at the fifth intercostal space. The same measurement may be made on the back of the chest near the tenth rib . The patient’s chest may expand asymmetrically if he has pleural effusion , atelectasis, pneumonia, or pneumothorax Farzana Khattak 26 11/29/2023

27. EXPANSION (CHEST WALL) Farzana Khattak 27 11/29/2023

28. Chest wall symmetry and Expansion Symmetrical Expansion (2-5cm) Asymmetrical Pneumonia Pneumothorax Pleural effusion Atelectasis Farzana Khattak 28 11/29/2023

29. TACTILE OR VOCAL FREMITUS Ask the patient to fold his arms across his chest. This movement shifts the scapulae out of the way. Lightly place your open palms on both sides of the patient’s back, as shown, without touching his back with your fingers. Ask the patient to repeat the phrase “ninety-nine” loud enough to produce palpable vibrations. Then palpate the front of the chest using the same hand positions. Vibrations that feel more intense on one side than the other indicate tissue consolidation. Low or absent vibrations may indicate emphysema , pneumothorax , or pleural effusion. Farzana Khattak 29 11/29/2023

30. Tactile Fremitus Palpation Decreased fremitus Decreased fremitus Decreased fremitus Absent Increased fremitus Decrease fremitus Disorder Emphysema Asthma Pneumothorax Atelectasis Consolidation Pleural effusion Farzana Khattak 30 11/29/2023

31. 3. PERCUSSION Striking or tapping a part of the body & listening to the sound it makes. To determine if underlying tissue is hollow, filled with fluid, air or solid material. Thoracic percussion: Patient should be in sitting position for posterior chest percussion and lying supine for anterior chest percussion. Tap starting at shoulder. Compare right to left . Farzana Khattak 31 11/29/2023

32. SITES AND SEQUENCE Anterior Posterior Farzana Khattak 32 11/29/2023

33. METHODS: PLEXIMETER Distal inter phalangeal joint of left middle finger . PLEXOR Right middle finger tip ORDER Up to down Anterior to posterior Farzana Khattak 33 11/29/2023

34. PERCUSSION SOUNDS RESONANCE: Over Normal Lung HYPER-RESONANCE: Too much air (Emphysema/Pneumothorax) TYMPANIC: Hollow organ (Empty Stomach) FLATENESS: Over Bones & Muscles DULLNESS: Over Breast tissue, Heart, Liver, Pleural effusion, Tumor Farzana Khattak 34 11/29/2023

35. DIAPHRAGMATIC EXCURSION Ask the patient to exhale. Percuss the back on one side to locate the upper edge of the diaphragm, the point at which normal lung resonance changes to dullness. Use a pen to mark the spot indicating the position of the diaphragm at full expiration on that side of the back. Ask the patient to inhale as deeply as possible. Percuss the back when the patient has breathed in fully until you locate the diaphragm. Use the pen to mark this spot as well. Repeat on the opposite side of the back. Use a ruler or tape measure to determine the distance between the pen marks. The distance, normally 1¼ to 2 (3 to 5 cm), should be equal on both the right and left sides Farzana Khattak 35 11/29/2023

36. DIAPHRAGMATIC EXCURSION Farzana Khattak 36 11/29/2023

37. 4. AUSCULTATION Listening to the body sounds with or without stethoscope. A sk the patient to breath in and out slowly and deeply through the mouth to assess air flow in the bronchial tree. PROCEDURE Use diaphragm of stethoscope Superior to inferior Compare right to left Farzana Khattak 37 11/29/2023

38. CONT… AREAS OF ASCULTATION ANTERIOR From above the clavicle down to the 6 th ribs LATERAL From axilla to the 8 th rib POSTERIOR From scapula to downward to 11 th rib Farzana Khattak 38 11/29/2023

39. NORMAL BREATH SOUNDS Sound Quality Inspiration-expiration ratio(I:E) Location Tracheal Harsh, High-pitched I=E Above supraclavicular notch, over the trachea Bronchial Loud, High-pitched I<E Just above clavicles on each side of the sternum, over the manubrium Bronchovesicular Medium in Loudness and Pitch I=E Next to sternum, between scapulae Vesicular Soft, Low- Pitched I>E Remainder of lungs Farzana Khattak 39 11/29/2023

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42. ASSESSING VOCAL FREMITUS Bronchophony Egophony (also known as “E” to “A” change) Whispered Pectoriloquy Muffled---- Normal Loud----- Consolidated Muffled--- Normal A--- Consolidated Normal--- Indistinguishable Consolidate--- Loud and Clear Farzana Khattak 42 11/29/2023

43. ABNORMAL SOUNDS Stridor is a loud, high-pitched sound , usually hear without a stethoscope during auscultation. It's caused by upper airway obstruction. Can be heard in inspiration and expiration. Rhonchi are long continuous adventitious low pitch musical sounds , generated by obstruction to airway like Asthma or COPD. Wheeze is high pitched whistling (Musical) sound made while breathing specially during expiration. I t is caused by narrowed of air ways. Crackles are i ntermittent, non-musical , brief sounds. Heard more commonly with inspiration. Pleural Friction Rub is a low-pitched, grating, rubbing sound heard on inspiration and expiration. It’s caused by pleural inflammation. Farzana Khattak 43 11/29/2023

44. DISORDERS OF THE UPPER RESPIRATORY TRACT Tonsillitis Pharyngitis Laryngitis Influenza Whooping Cough Obstruction Tumor Farzana Khattak 44 11/29/2023

45. DISORDERS OF LOWER RESPIRATORY TRACT Asthma, bronchitis, COPD obstruction in air conductive system Restrictive Diseases Atelectasis Pneumonia Pleural effusion Pulmonary tuberculosis ARDS Pulmonary hypertension Pulmonary embolism Lung cancer Farzana Khattak 45 11/29/2023

46. DOCUMENTATION OF NORMAL SUBJECTIVE AND OBJECTIVE FINDINGS Patient denies cough, chest pain, or shortness of breath. Denies past or current respiratory illnesses or diseases. Symmetrical anterior and posterior thorax. Respiratory rate is 16 breaths/minute, unlabored, regular, and inaudible through the nose. No retractions, accessory muscle use, or nasal flaring. Chest rise and fall are equal bilaterally. Skin is pink, warm, and dry. No crepitus, masses, or tenderness upon palpation of anterior and posterior chest. Lung sounds clear bilaterally in all lobes anteriorly and posteriorly. No adventitious sounds. SpO2 saturation 99% on room air. 11/29/2023 Farzana Khattak 46

47. VIDIO LINKS https:// www.youtube.com/watch?v=9u13G9j81FY https:// www.youtube.com/watch?v=gRWSyqatWQQ 11/29/2023 Farzana Khattak 47

48. REFERENCES Brunner & Suddarth , ( 2010 )” Medical & Surgical Nursing” 12 th ed Guyton , A C & Hall, J. E. (2006) Medical Physiology 11 th ed Health Assessment Made incredibly visual 2 nd ed . Philadelphia: Lippincott Williams & Wilkins, 2011 Nasir , S.A & Inyatullah ,M.(2006)“Bed side Techniques: Methods of clinical Examination” 3 rd ed Ross and Wilson ,(2004)”Anatomy& Physiology in Health and Illness”9 th ed Farzana Khattak 48 11/29/2023

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