Respiratory Assessment
Terms
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- Purposes of the Respiratory System
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Gas exchange- transfer of oxygen and CO2 between the atmosphere and blood.
Maintain acid-base balance
Speech
Sense of smell
Fluid balance
Thermoregulation - Upper Respiratory Tract
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Nose and sinuses- warm, moisten and filter air; promote vocal resonance
Pharynx and Tonsil- filter bacteria or foreign matter
Larynx- major function is vocalization
Trachea- -or windpipe serves as the passage between the larynx and the bronchi - Lower Respiratory Tract
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Bronchi
Bronchioles
Lungs
Alveolar ducts and alveoli
Functions:
Filter dust and bacteria
Warm air to body temperature
Humidify air
Surfactant production by alveoli - Physiology of Respiration
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Pulmonary circulation or perfusion (blood flow through the pulmonary circulation)
RV---PA ( R and L)—Alveolar-capillary membrane (gas exchange or diffusion)– PV- LA- LV - Neurochemical Control of Ventilation
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Respiratory center— transmits impulses to the respiratory muscles causing them to contract and relax.
Chemoreceptors– central and peripheral
Central – monitor arterial blood indirectly by sensing changes in the ph.
Peripheral- primarily sensitive to O2 levels in arterial blood. - Factors the Affect the Mechanics of Breathing
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Major and accessory muscles—diaphragm and external intercostal muscles.
Elastic properties of the lung and chest wall.
Elastic recoil- tendency of the lungs to return to the resting state after being stretched or distended.
Compliance– measure of lung and chest wall distensibility. It represents the relative ease with which these structures can be stretched.
Airway Resistance- edema, obstruction, bronchospasm. - Ventilation-Perfusion (V/Q)
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Ventilation is the movement of gas in and out of the lungs (V).
Perfusion is the filling of the pulmonary capillaries with blood (Q).
Normal V/Q ratio is 1:1. - Conditions that Result In V/Q Mismatch
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Increased secretions in the airways (COPD); alveoli (pneumonia), and when bronchospasm is present (asthma).
Alveolar collapse (atelectasis)
Pain
Pulmonary embolus—affects perfusion—limits blood flow but has no effect on airflow to the alveoli - Terminology for Ventilatory Insufficency
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Hypoxia- deficiency of O2.
Anoxia- without O2.
Hypercapnia- increased amount of CO2 in blood.
Cheyne-Stokes- period of apnea followed by increasing depth and frequency or resp.
Kussmaul breathing- abnormally deep, very rapid sighing respirations.
Orthopnea
Dyspnea - Physical Assessment
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Patient history
Inspection
Palpation
Percussion
Auscultation - Patient History (Upper Respiratory)
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Upper Airway
hx of mouth breathing
hx of sinus surgery and/or sinusitis
pain on swallowing
presence of nasal discharge, allergy
change in voice: hoarseness
hx of smoking/alcohol use - Patient History (Lower Respiratory)
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Lower Airway
dyspnea
chest pain
cough/sputum production
wheezing
current medications - Patient History (Use of Oxygen)
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Use of Oxygen
Nasal cannula- 1-6 l/min (24%-44%)
Simple mask- 40%-60%. Minimum flow rate 5l/min to prevent rebreathing of exhaled air.
Partial rebreather mask- 60-75% with flow rate of 6-11 l/min.
Nonrebreather mask- >90%
Venturi mask- high flow system; delivers the most accurate O2 concentration-24%-100% - Inspection
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Chest shape and size
Spinal deformities
Skin color, scars, lesions
Type of breathing
Use of accessory muscle
Respiratory rate, depth and rhythm
Clubbing - Palpation
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Symmetry of chest expansion
Fremitus
Tenderness
Crepitus
Tracheal position - Patient Assessment
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Percussion- assesses density or aeration of the lungs.
Dull/Resonance
Diaphragm position and movement
Auscultation
Crackles
Wheezes
Rhonchi
Pleural friction rub- creaking or grating sound from roughened, inflamed pleural surface - Diagnostic Studies of the Respiratory System
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Blood studies- CBC, ABGs
Oximetry
Sputum studies--Gram stain, C and S, AFB, cytology
Skin tests
Radiologic studies
Chest X-ray V/Q Scan
CT scan/MRI Pulmonary Angiography
PET (Positron Emission Tomography) - Diagnostic studies
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Bronchoscopy
Mediastinoscopy
Lung Biopsy
Thoracentesis
Pulmonary Function tests - Arterial Blood Gases
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Assess adequacy of oxygenation.
Assess alveolar ventilation
Assess acid-base balance
Monitor patients on ventilators
Establish pre-op baseline parameters
Enlighten electrolyte therapy - Acid-Base Balance
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pH: 7.35-7.45
Regulated by chemical, respiratory and renal mechanisms
Change in ph will cause:
Hormone and electrolyte changes, alterations in membrane response and drug uptake.
Acidosis- pH <7.35
Alkalosis- pH >7.45 - Components of ABGs
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pH 7.35-7.45
PaCO2 35-45 mm Hg
HCO3 22-26 mEq/L
PaO2 80-100 mm Hg
SaO2 93-100% - Arterial Oxygenation
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PaO2- amount of O2 dissolved in plasma; Partial pressure exerted by O2 as it diffuses across the alveolocapillary membrane.
SaO2- Percentage of O2 bound to Hg. Changes in Hg concentration affect oxygenation. - ABG Analysis
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Determine the extent of compensation.
-Complete= pH is normal
-Partial= pH is abnormal, the value that does not match the PH is not normal.
-Absent= pH is abnormal and the component that does not match the pH is normal (i.e. no compensation occurring yet.) - Interpreting ABGs
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J. B, 68, with Acute Pneumonia. He has productive cough, circumoral cyanosis, labored breathing at 28/min and he is using accessory muscle to breath.
PaO2 56 mmHg
SaO2 88%
pH 7.32
PaCo2 50 mmHg
HCO3 24 mEq/L - Interpreting ABGs (answer)
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PaO2= 56: SaO2=88%
PaO2 < 80 and SaO2 <93% indicate hypoxemia
2. pH=7.32= (Acid) Acidosis
PCO2=50= (Acid) Acidosis
HCO3=24=Normal
3. pH and PCO2 match= respiratory acidosis
4. pH is abnormal and HCO3 is normal= no compensation. - Uncompensated respiratory acidosis (Nursing Dx)
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Conclusion: Uncompensated respiratory acidosis.
Nursing Dx: Ineffective airway clearance; Impaired Gas Exchange
Interventions: O2; remove secretions to maintain airway patency; HOB elevated for maximum lung expansion.