Assessment of the Respiratory System

Irene Owens MSN, FNP-BC

Anatomy and Physiology Review

Upper respiratory tractLower respiratory tractLungs Accessory muscles of respirationRespiratory changes associated

with aging

Assessment TechniquesCollect history of client data on

family, personal, smoking, drug use, allergies, travel, place of residence, dietary history, occupational history, and socioeconomic level.

Assess current health problems such as cough, sputum production, chest pain, and dyspnea.

Physical AssessmentAssessment of the nose and

sinusesAssessment of the pharynx,

trachea, and larynxAssessment of the lungs and

thorax–Inspection–Palpation, check fremitus–Percussion–Auscultation

Breath SoundsNormal breath sounds include

bronchial, bronchovesicular, and vesicular.

Adventitious breath sounds include:–Crackle–Wheeze–Rhonchus–Pleural friction rub

Other AssessmentsVoice soundsBronchophonyWhispered pectoriloquyEgophonySkin and mucous membranesGeneral appearanceEndurance

Psychosocial AssessmentSome respiratory problems may be

worsened by stress.Chronic respiratory disease may

cause changes in family roles, social isolation, and financial problems due to unemployment or disability.

Discuss coping mechanisms and offer access to support systems.

Laboratory Tests

Blood testsSputum testsRadiographic examinations

including standard chest x-rays, digital chest radiography, CT

Ventilation and perfusion scanningPulse oximetry

Pulmonary Function Testing

These tests evaluate lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation.

Client preparationProcedure for performing tests at

the bedside

Other Testing and Follow-Up Care

Exercise testingSkin testing

Other Invasive Diagnostic TestsEndoscopic examinationsThoracentesis: aspiration of pleural

fluid or air from the pleural space–Client preparation for stinging sensation and feeling of pressure

–Correct position–Motionless client–Follow-up assessment for complications

Lung Biopsy

Performed to obtain tissue for histologic analysis, culture, or cytologic examination

Client preparationMay be performed in client’s room

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Lung Biopsy (Continued)

Follow-up care:–Assess vital signs and breath sounds at least every 4 hours for 24 hours.

–Assess for respiratory distress.–Report reduced or absent breath sounds immediately.

–Monitor for hemoptysis.

Interventions for Clients Requiring Oxygen Therapy

Oxygen Therapy

Hypoxemia: low levels of oxygen in the blood

Hypoxia: decreased tissue oxygenation

Goal of oxygen therapy: to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects

Hazards and Complications of Oxygen Therapy

CombustionOxygen-induced hypoventilationOxygen toxicityAbsorption atelectasisDrying of mucous membranesInfection

Low-Flow Oxygen Delivery Systems

Nasal cannulaSimple face maskPartial rebreather maskNon-rebreather mask

High-Flow Oxygen Delivery Systems

Venturi maskFace tentAerosol maskTracheostomy collarT-piece

Noninvasive Positive-Pressure Ventilation

BiPAP cycling machine delivers a set inspiratory positive airway pressure each time the client begins to inspire. At exhalation, it delivers a lower set end-expiratory pressure. Together the two pressures improve tidal volume.

Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation.

Continuous Nasal Positive Airway Pressure

Technique delivers a set positive airway pressure throughout each cycle of inhalation and exhalation.

Effect is to open collapsed alveoli.Clients who may benefit include

those with atelectasis after surgery or cardiac-induced pulmonary edema; it may be used for sleep apnea.

Transtracheal Oxygen Delivery

Used for long-term delivery of oxygen directly into the lungs

Avoids the irritation that nasal prongs cause and is more comfortable

Flow rate prescribed for rest and for activity

Home Oxygen Therapy

Criteria for home oxygen therapy equipment

Client education for use–Compressed gas in a tank or cylinder

–Liquid oxygen in a reservoir–Oxygen concentrator

Interventions for Clients with

Noninfectious Problems of the

Upper Respiratory Tract

Fracture of the NoseDisplacement of either the bone or

cartilage of the nose can cause airway obstruction or cosmetic deformity and is a potential source of infection.

Cerebrospinal fluid could indicate skull fracture.

Interventions:–Rhinoplasty–Nasoseptoplasty

Epistaxis Nosebleed is a common problem.Interventions if nosebleed does not

respond to emergency care:–Affected capillaries are cauterized with silver nitrate or electrocautery and the nose is packed.

–Posterior nasal bleeding is an emergency.

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Epistaxis (Continued)

–Assess for respiratory distress and for tolerance of packing or tubes.

–Administer humidification, oxygen, bedrest, antibiotics, pain medications.

Nasal Polyps

Benign, grapelike clusters of mucous membranes and connective tissue

May obstruct nasal breathing, change character of nasal discharge, and change speech quality

Surgery: treatment of choice

Cancer of the Nose and SinusesCancer of the nose and sinuses is

rare and can be benign or malignant.

Onset is slow and manifestations resemble sinusitis.

Local lymph enlargement often occurs on the side with tumor mass.

Radiation therapy is the main treatment; surgery is also used.

Facial Trauma

Le Fort I nasoethmoid complex fracture

Le Fort II maxillary and nasoethmoid complex fracture

Le Fort III combination of I and II plus an orbital-zygoma fracture, often called craniofacial disjunction

First assessment: airway

http://en.wikipedia.org/wiki/Le_Fort_fracture_of_skull

Facial Trauma Interventions

Anticipate the need for emergency intubation, tracheotomy, and cricothyroidotomy.

Control hemorrhage.Assess for extent of injury.Treat shock.Stabilize the fracture segment.

Obstructive Sleep ApneaBreathing disruption during sleep

that lasts at least 10 seconds and occurs a minimum of five times in an hour

Excessive daytime sleepiness, inability to concentrate, and irritability

Nonsurgical management and change of sleep position

Surgical management: uvulopalatopharyngoplasty

Disorders of the Larynx

Vocal cord paralysisVocal cord nodules and polypsLaryngeal trauma

Interventions for Clients with

Noninfectious Problems of the

Lower Respiratory Tract

Chronic Airflow Limitation

Chronic lung diseases of chronic airflow limitation include:–Asthma–Chronic bronchitis–Pulmonary emphysema

Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis characterized by bronchospasm and dyspnea.

Asthma

Intermittent and reversible airflow obstruction affects only the airways, not the alveoli.

Airway obstruction occurs due to inflammation and airway hyperresponsiveness.

Aspirin and Other NonsteroidalAnti-Inflammatory Drugs

Incidence of asthma symptoms after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)

However, response not a true allergy

Results from increased production of leukotriene when other inflammatory pathways are suppressed

Collaborative ManagementAssessmentHistoryPhysical assessment and clinical

manifestations:–No manifestations between attacks

–Audible wheeze and increased respiratory rate

–Use of accessory muscles–“Barrel chest” from air trapping

Laboratory Assessment

Assess arterial blood gas level.Arterial oxygen level may decrease

in acute asthma attack.Arterial carbon dioxide level may

decrease early in the attack and increase later indicating poor gas exchange.

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Laboratory Assessment (Continued)

Atopic asthma with elevated serum eosinophil count and immunoglobulin E levels

Sputum with eosinophils and mucous plugs with shed epithelial cells

Pulmonary Function Tests

The most accurate measures for asthma are pulmonary function tests using spirometry including:–Forced vital capacity (FVC)–Forced expiratory volume in the first second (FEV1)

–Peak expiratory rate flow (PERF)–Chest x-rays to rule out other causes

Interventions

Client education: asthma is often an intermittent disease; with guided self-care, clients can co-manage this disease, increasing symptom-free periods and decreasing the number and severity of attacks.

Peak flow meter can be used twice daily by client.

Drug therapy plan is specific.

Drug Therapy

Pharmacologic management of asthma can involve the use of:

BronchodilatorsBeta2 agonistsShort-acting beta2 agonistsLong-acting beta2 agonistsCholinergic antagonists

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Drug Therapy (Continued)

MethylxanthinesAnti-inflammatory agentsCorticosteroidsInhaled anti-inflammatory agentsMast cell stabilizersMonoclonal antibodiesLeukotriene agonists

Other Treatments for Asthma

Exercise and activity is a recommended therapy that promotes ventilation and perfusion.

Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack.

Emphysema In pulmonary emphysema, loss of

lung elasticity and hyperinflation of the lung

Dyspnea and the need for an increased respiratory rate

Air trapping, loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles)

Classification of Emphysema

Panlobular: destruction of the entire alveolus

Centrilobular: openings occurring in the bronchioles that allow spaces to develop as tissue walls break down

Paraseptal: confined to the alveolar ducts and alveolar sacs

Chronic Bronchitis

Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke

Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm

Affects only the airways, not the alveoli

Production of large amounts of thick mucus

Complications

Chronic bronchitisHypoxemia and acidosis Respiratory infectionsCardiac failure, especially cor

pulmonaleCardiac dysrhythmias

Physical Assessment and Clinical Manifestations

Unplanned weight loss; loss of muscle mass in the extremities; enlarged neck muscles; slow moving, slightly stooped posture; sits with forward-bend

Respiratory changesCardiac changes

Laboratory Assessment

Status of arterial blood gas values for abnormal oxygenation, ventilation, and acid-base status

Sputum samplesHemoglobin and hematocrit blood

testsSerum alpha1-antitrypsin levels

drawnChest x-rayPulmonary function test

Impaired Gas Exchange

Interventions for chronic obstructive pulmonary disease:–Airway management–Monitoring client at least every 2 hours

–Oxygen therapy–Energy management

Drug Therapy

Beta-adrenergic agentsCholinergic antagonistsMethylxanthinesCorticosteroidsCromolyn sodium/nedocromilLeukotriene modifiersMucolytics

Surgical Management

Lung transplantation for end-stage clients

Preoperative care and testingOperative procedure through a

large midline incision or a transverse anterior thoracotomy

Postoperative care and close monitoring for complications

Ineffective Breathing PatternInterventions for the chronic

obstructive pulmonary disease client:–Assessment of client–Assessment of respiratory infection

–Pulmonary rehabilitation therapy–Specific breathing techniques–Positioning to help alleviate dyspnea

–Exercise conditioning–Energy conservation

Ineffective Airway ClearanceAssessment of breath sounds

before and after interventions Interventions for compromised

breathing:–Careful use of drugs–Controlled coughing–Suctioning –Hydration via beverage and humidifier

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Ineffective Airway Clearance (Continued)

–Postural drainage in sitting position when possible

–Tracheostomy

Imbalanced NutritionInterventions to achieve and

maintain body weight:–Prevent protein-calorie malnutrition through dietary consultation.

–Monitor weight, skin condition, and serum prealbumin levels.

–Address food intolerance, nausea, early satiety, loss of appetite, and meal-related dyspnea

Anxiety

Interventions for increased anxiety:–Important to have client understand that anxiety will worsen symptoms

–Plan ways to deal with anxiety

Health Teaching

Instruct the client:–Pursed-lip and diaphragmatic breathing

–Support of family and friends–Relaxation therapy–Professional counseling access–Complementary and alternative therapy

Activity Intolerance

Interventions to increase activity level:–Encourage client to pace activities and promote self-care.

–Do not rush through morning activities.

–Gradually increase activity.–Use supplemental oxygen therapy.

Potential for Pneumonia or Other Respiratory Infections

Risk is greater for older clients Interventions include:

–Avoidance of large crowds–Pneumonia vaccination–Yearly influenza vaccine

Sarcoidosis

Granulomatous disorder of unknown cause that can affect any organ, but the lung is involved most often

Autoimmune responses in which the normally protective T-lymphocytes increase and damage lung tissue

Interventions (corticosteroids): lessen symptoms and prevent fibrosis

Occupational Pulmonary Disease

Can be caused by exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens

Worsened by cigarette smokeInterventions: special respirators

that ensure adequate ventilation See page 640 Iggy

BOOP

Patho: inflammatory process that allows connective tissue plugs to form in the lower airways and in the tissue between the alveoli. Inflammation triggers WBC’s with connective cell growth that occludes and obliterates these airways and leads to restricted lung volume with decreased VC. Not a true pneumonia. No known cause

BOOP cont Triggers Infectious organisims, drugs

antiseizure medications cocaine, RA, SLE, also related to chest radiation therapy for cancer. Solid organ transplant patients

Usually S?S present for months and do not improve with standard ABX.

CT will suggest BOOP not confirm it Biopsy needed to confirm BOOP Treatment Corticosteroids

Interventions for Clients with Infectious

Problems of the Respiratory Tract

RhinitisInflammation of the nasal mucosaOften called “hay fever” or

“allergies”Interventions include:

–Drug therapy: antihistamines and decongestants, antipyretics, antibiotics

–Complementary and alternative therapy

–Supportive therapy

Sinusitis

Inflammation of the mucous membranes of the sinuses

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Sinusitis (Continued)

Nonsurgical management–Broad-spectrum antibiotics–Analgesics–Decongestants–Steam humidification–Hot and wet packs over the sinus area

–Nasal saline irrigations

Surgical Management

Antral irrigationCaldwell-Luc procedureNasal antral window procedureEndoscopic sinus surgery

Pharyngitis

Sore throat is common inflammation of the mucous membranes of the pharynx.

Assess for odynophagia, dysphagia, fever, and hyperemia.

Strep throat can lead to serious medical complications.

Epiglottitis is a rare complication of pharyngitis.

Tonsillitis

Inflammation and infection of the tonsils and lymphatic tissues located on each side of the throat

Contagious airborne infection, usually bacterial

AntibioticsSurgical intervention

Peritonsillar Abscess

Complication of acute tonsillitisPus behind the tonsil, causing one-

sided swelling with deviation of the uvula

Trismus and difficulty breathingPercutaneous needle aspiration of

the abscessCompletion of antibiotic regimen

Laryngitis

Inflammation of the mucous membranes lining the larynx, possibly including edema of the vocal cords

Acute hoarseness, dry cough, difficulty swallowing, temporary voice loss (aphonia)

Voice rest, steam inhalation, increased fluid intake, throat lozenges

Therapy: relief and prevention

Influenza

“Flu” is a highly contagious acute viral respiratory infection.

Manifestations include severe headache, muscle ache, fever, chills, fatigue, weakness, and anorexia.

Vaccination is advisable.Antiviral agents may be effective.

Pneumonia Excess of fluid in the lungs

resulting from an inflammatory process

Inflammation triggered by infectious organisms and inhalation of irritants

Community-acquired infectious pneumonia

Nosocomial or hospital-acquiredAtelectasisHypoxemia

Laboratory Assessment

Gram stain, culture, and sensitivity testing of sputum

Complete blood countArterial blood gas levelSerum blood, urea nitrogen levelElectrolytesCreatinine

Impaired Gas Exchange

Interventions include:–Cough enhancement–Oxygen therapy–Respiratory monitoring

Ineffective Airway Clearance

Interventions include:–Help client to cough and deep breathe at least every 2 hours.

–Administer incentive spirometer—chest physiotherapy if complicated.

–Prevent dehydration.

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Ineffective Airway Clearance (Continued)

–Monitor intake and output of fluids.

–Use bronchodilators, especially beta2 agonists.

–Inhaled steroids are rarely used.

Potential for SepsisPrimary intervention is

prescription of anti-infectives for eradication of organism causing the infection.

Drug resistance is a problem, especially among older people.

Interventions for aspiration pneumonia aimed at preventing lung damage and treating infection.