Pulmonary assessment and disorders ch 33 34 35 36 osborn 2012

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Medical Surgical Nursing: Preparation for PracticeKathleen S. Osborn | Annita Watson | Cheryl E. Wraa

Complete Assessment

• History– Biographic and demographic data– Chief complaint– Past medical history– Family history– Risk factors– Social history




Complete Assessment

• Components of Physical Exam – Inspection– Auscultation– Percussion– Pain– Genetic and gerontological considerations




Social History

• Patients’ lifestyles and habits and • Risk for developing pulmonary disease• Current and previous work settings• Home environment• Social settings




Gerontological Considerations

• aging decreases respiratory function• lower arterial oxygen values, • increase risk of pneumonia• Risk of aspiration may increase with aging• Aging may affect patient comfort needs

during the examination




Genetic Considerations

• Cystic fibrosis (CF): genetic disorder, typically diagnosed in childhood

• CF has serious pulmonary complications – thick mucus builds up in lungs




Inspection

• Initial assessment activity• General appearance:

– Posture, facial expression and movements – Changes in mental status – Respiratory rates shallow breathing, irregular

patterns of breathing – Size and shape of the thorax, asymmetry– Diminished movement of rib cage, use of

accessory muscles




Inspection

• Color and appearance of skin– Pallor may indicate decreased oxygen-

carrying capacity of the blood due to anemia– Central cyanosis, where the mouth, lips, and

mucous membranes are blue-tinged, indicates hypoxia in adults




Inspection

• Inspection of the neck– Appearance of veins, trachea and

musculature may indicate chronic cardiac or pulmonary disease, pneumothorax

– Goiter or lesions may obstruct the upper airway




Inspection

• Palpation of skin and extremities– Edema of lower extremities– Skin temperature and moisture – Clinical reference points – Chest excursion – Tactile fremitus – Tenderness – Crepitus




Clinical Reference Points




Occupational Impact on Respiratory Disease

• Exposure to airborne particles, vapors, and irritants

• Can result in acute or chronic respiratory disease in susceptible individuals

• Early recognition, diagnosis, and treatment of occupational asthma can prevent pulmonary complications




Auscultating Breath Sounds

• Patient should be upright • Use the diaphragm of the stethoscope• Begin at C7 posteriorly and anteriorly from

above the clavicles• Move steadily from right to left upper and

lower• Compare breath sounds bilaterally• Do not auscultate over clothing




Diaphragm - best for higher pitched sounds, like breath sounds and normal heart sounds.

Bell - is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. It is used for the detection of bruits, and for heart sounds (for a cardiac exam, listen with the diaphragm, and repeat with the bell).




Figure 33.1 In a respiratory assessment, it is important to palpate and count ribs and interspaces to accurately record the location of lesions or adventitious breath sounds.





Figure 33.2 Lobes of the lung—anterior.





Figure 33.3 Lobes of the lung—posterior




Tracheal Breath Sounds

• Auscultated over the trachea• Loud and high pitched• Cause: airflow through tubular trachea• Best heard over the neck and trachea• Occurs during upper airway obstruction




Bronchial Breath Sounds

• Anterior: heard on either side of sternum, over main stems of the bronchus from 2nd to 4th intercostal spaces

• Posterior: best heard lateral to the spine between 3rd and 6th intercostal spaces

• Loud, harsh, less turbulent and lower than tracheal sounds




Bronchial Breath Sounds

• Pause between inspiration and expiration; expiration is heard for a longer time than inspiration

• Sounds over smaller airways are low pitched and softer




Bronchovesicular Breath Sounds

• Heard during inspiration and expiration• Midway in Pitch and loudness between

vesicular and bronchial breath sounds• Best heard in 1st and 2nd intercostal

spaces of anterior chest, between scapulae of the posterior chest

• Represent air movement in the moderate airways between the bronchi and the smaller airways




Vesicular Breath Sounds

• Heard over most of the thorax• Soft and low pitched, rustling, from air

moving through small airways• Heard longer during expiration, which

generally lasts twice as long as inspiration




Adventitious Breath Sounds

• Decreased or no sounds where normal sounds should occur

• Breath sounds occurring in abnormal locations

• Diminished breath sounds demonstrate decreased airflow and potentially decreased oxygen exchange




Adventitious Breath Sounds

• Adventitious/extra sounds: – Represent pathologic conditions of heart or

lungs– Indicate disrupted airflow due to airway

spasm, fluid, or secretions – Crackles (rales-term not used as much),

Wheezes, Stridor, Friction rubs




Crackles • Caused by fluid in the airways• Intermittent or discontinuous, nonmusical, or

popping sounds • Caused by fluid, inflammation, infection, or

secretions• Crackles are described as either fine or coarse• Occur when closed airways snap open during

inspiration• Softer, gentler sound may also be heard on

inspiration




Wheezes • Heard equally during inspiration and expiration• High-pitched musical sounds • Caused by air flowing across strands of mucus,

swollen pulmonary tissue that narrows the airway, bronchospasm

• Rhonchi (term for secretions in airways-not used as much)

• Inspiratory/expiratory, continuous/ discontinuous, mild/moderate/severe

• Asthma, allergies, reactive airway disease




Stridor

• Heard only during inspiration as air attempts to flow across an obstruction

• Heard without stethoscope as high-pitched, crowing sound

• With stethoscope, best heard over large airways, e.g., trachea or bronchus

• Report to the health care provider immediately • Indicates airway obstruction requiring

intervention




Pleural Friction Rubs

• Low-pitched, creaking or squeaking sounds • Occur when inflamed pleural surfaces rub

together • Heard on inspiration• Pitch usually increases with chest expansion• Have the patient hold breath to distinguish

between pleural and pericardial friction




Adventitious Lung Sounds




Travel and Area of Residence

• An important aspect of the history in diagnosing potential respiratory problems

• Exposure to region-specific infectious diseases

• Exposure to environmental conditions, e.g. high altitudes




High-Altitude Pulmonary Edema (HAPE)

• HAPE – can occur with travel to altitudes greater than 5,000 feet

• Increasing altitude → decreasing atmospheric pressure → decreasing available O2

• Rapid onset of hypoxemia may result• Compensatory increased respiratory rate

may contribute to fatigue




High-Altitude Pulmonary Edema (HAPE)

• This causes further respiratory insufficiency

• Initial compensatory mechanisms – pulmonary vascular vasoconstriction

• Later, inflammatory mediators cause vasodilation




Percussion • Assess presence of air, fluid, solid mass in

underlying tissues • Normal lungs produce a resonant, low-pitched clear

sound• Hyperresonance indicates airways are hyperinflated

or air is present outside of lung tissue• Dullness indicates that air is absent

– Pneumonia, pleural effusion, hemothorax, solid tumors




Pain

• Pain during respiration may decrease tidal volumes

• Pain management enables participation in rehabilitative activities

• Also promotes deep breathing to prevent pneumonia and atelectasis




Standard of Care

• For patients with cardiac and respiratory illness, standard is:– Continuous or intermittent observation of the

patient’s oxygen saturation – End-tidal carbon dioxide levels– Peak flow is utilized to trend treatment

effectiveness in patients with asthma




Assessment of Arterial Oxygen Levels

• ABG’s• Pulse oximetry• Physical assessment• FiO2 will increase the PaO2 four times

(normal patient)




Pulse Oximetry

• Measures O2 saturation of hemoglobin• Reflects light off the hemoglobin

molecules• Measures the absorption of light by

hemoglobin• Normal range is from 95% to 100%




Factors Interfering with Pulse Oximetry

• Nail polish • Automated BP cuffs, hemodialysis fistulas,

or arterial lines interfere with blood flow • Shock and hypovolemia • Patient movement, ambient light, and

venous pulsations may also cause inaccurate readings




Peak Flow Meters

• Track trends in a patient’s condition, evaluate air movement to determine severity of asthma exacerbation

• Measure the peak expiratory flow rate• Normal values based on age and body

size• Severity scale: Utilizes red, yellow, and

green zones to determine the severity of decrease in peak flow




Arterial Blood Gas Studies (ABG)

• Provide information on arterial oxygen and carbon dioxide levels

• Oxygen saturation, bicarbonate, and blood pH are also calculated

• CO2 is major determinant of respiratory alkalosis/acidosis

• Bicarbonate level is determinant of metabolic acidosis/alkalosis




Capnography

• Measurement of exhaled CO2

• Some utilize paper treated to detect the presence of acid such as CO2

• Others use spectrography, generate waveform readings




Capnography

• Useful in determining ventilatory status, readiness for extubation

• Also used to determine pulmonary vessel perfusion in patients with pulmonary embolus




Capnography Monitor




Medical Surgical NursingPreparation for Practice

CHAPTER

Caring for the Patient with Upper Airway Disorders

34




Facial Bones

• Mandible • Maxilla• Zygoma• Temporal bones • Frontal bone




Mandible

• U-shaped bone • Together with the maxilla, largest and

strongest bone of the face• Forms lower jaw, holds the lower teeth in

place• Articulates with temporal bones at the

temporomandibular joint• Only mobile bone of the facial skeleton;

motion is essential for mastication




Nursing Management for Mandibular Fractures

• Determine patient’s nutritional requirements and knowledge deficits

• Oral nutrition with high-protein liquid diet and calories is essential

• Avoid weight loss if possible to ensure nutritional adequacy for healing

• Nasogastric or oral gastric tube supports nutrition if patient has extensive facial swelling

• Observe for nausea and vomiting, intervene to prevent aspiration




Maxilla

• Largest component of the middle third of the facial skeleton

• Attaches laterally to the zygomatic bones • Key bone in the midface, provides

structural support • Fractures less frequently than mandible or

nose due to strong structural support




Classification System of Maxillary Fractures

• Le Fort I Fracture (horizontal)• Le Fort II Fracture (pyramidal)• Le Fort III Fracture (transverse)




Zygoma

• A paired bone, commonly called the cheekbone

• Articulates with maxilla, temporal, sphenoid, and frontal bones

• Forms prominence of the cheek• The masseter muscle is suspended from

the zygomatic arch




Temporal Bone

• Situated at the sides and base of the skull• Houses cochlear and vestibular end

organs, facial nerve, carotid artery, jugular vein




Nursing Management for Temporal Bone Fractures

• Care is conservative• Assess for nerve damage and hearing loss• Test for otorrhea; may indicate a CSF leak• Monitor lumbar drain if inserted • If facial nerve injury is present, provide eye

care • Institute CSF leak precautions – HOB 30o , no

straining, bending or lifting




Frontal Bone

• Makes up the forehead, upper edge and roof of the orbit

• Forms the anterior portion of the cranium• Frontal sinus – air-filled cavity between

lamina of the frontal bone• Serves as a mechanical barrier to protect

the brain

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Pulmonary assessment and disorders ch 33 34 35 36 osborn 2012

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