Assessment

of the
Respiratory
System

Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

 Objectives
 Review A&P of respiratory system
 Review history taking and assessment of
resp. system

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 Anatomy & Physiology Review
Anatomy
 Upper respiratory tract
 Lower respiratory tract
 Lungs
 Accessory muscles of respiration

Physiology
 Oxygen delivery
 CO2 removal
 Respiratory changes associated with aging
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 Patient History
 Family and personal data
 Smoking (pack-years)ppd x yrs smoking
 Drug/Medication use
 Allergies
 Travel, geographic area of residence
 Occupational exposure
 Nutritional status
 Cough, sputum production, chest pain,
dyspnea, orthopnea

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 Assessment of the
Nose & Sinuses
 External nose—deformities or tumors
 Nares—symmetry of size and shape
 Nasal cavity—color, swelling, drainage,
bleeding, polyps, septal defects
 Mucous membranes—abnormalities
 Turbinates

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 Assessment of the
Pharynx, Trachea, & Larynx
 Mouth
 Posterior pharynx
 Neck—symmetry, alignment, masses,
swelling, bruises, use of accessory neck
muscles for breathing
 Trachea—palpate for position, mobility,
tenderness, masses

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 Assessment of the
Lungs & Thorax
 Inspect: thorax with patient sitting up

 Auscultate: apices to base (from side to

side)

 Note: rate, rhythm, depth of inspiration,

symmetry of chest movement & AP/Lateral

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 Assessment of the
Lungs & Thorax (cont’d)
 Lung sounds(very important!!) covered in lab
 Bronchial
 Broncho-vesicular
 Vesicular

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 Assessment of the
Lungs & Thorax (cont’d)
 Adventitious sounds (covered in lab)
 Crackles
 Wheezes
 Rhonchi
 Pleural friction rub

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 Assessment of the
Lungs & Thorax (cont’d)

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 Other Indicators of
Respiratory Adequacy
 Clubbing
 Weight loss
 Skin and mucous membrane changes-
cyanosis
 General appearance
 Endurance

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 Psychosocial Assessment
 Stress may worsen some respiratory
problems
 Chronic respiratory disease may cause
changes in family roles, social isolation,
financial problems due to unemployment or
disability
 Discuss coping mechanisms, offer access to
support systems

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 Laboratory Tests
 Blood
 Sputum
 Standard chest x-rays, digital chest
radiography, CT
 Ventilation and perfusion scan
 Pulse oximetry (noninvasive)
 ABG (RT only) scope of practice

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 Hazards & Complications of
Oxygen Therapy
 Increased Combustion
 Oxygen-induced hypoventilation
 Drying of mucous membranes

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 Bronchial and Oral Hygiene
 Turn/reposition every 1 to 2 hours, support
out-of-bed activities, encourage early
ambulation
 Coughing and deep breathing, chest
percussion, vibration, and postural drainage
promote pulmonary cure
 Avoid glycerin swabs or mouthwash
containing alcohol for oral care; assess for
ulcers, bacterial/fungal growth, infection

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Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
 Care of Patients with
Noninfectious Lower
Respiratory Problems
Objectives
 Discuss the assessment findings of
asthma
 Prioritize nursing care for an asthmatic
patient
 Discuss treatment options and teaching for
an asthmatic patient

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 Prevalence of Asthma
 Estimated 20 million (8.4%) Americans
affected and growing
 More common in adult women than men
 Slightly more prevalent among African-
Americans than Caucasians

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 Asthma
 Condition that occurs intermittently
 Occurs in two ways:
 Inflammation
 Airway hyperresponsiveness leading to
bronchoconstriction

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Pathophysiology of Asthma
(cont’d)

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 Status Asthmaticus
 Severe, life-threatening, acute episode of
airway obstruction
 Intensifies once it begins, often does not
respond to common therapy
 Patient can develop pneumothorax and
cardiac/respiratory arrest
 Treatment—IV fluids, potent systemic
bronchodilator, steroids, epinephrine, oxygen

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 Objectives
 Compare and contrast pathology of
emphysema and chronic bronchitis
 Compare and contrast assessment
findings of two forms of COPD
 Discuss nursing interventions and
treatments for emphysema and chronic
bronchitis

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 Chronic Obstructive Pulmonary
Disease (COPD)
 Includes:
 Emphysema
 Chronic bronchitis
 Characterized by bronchospasm and
dyspnea
 Tissue damage not reversible; increases in
severity, eventually leads to respiratory failure

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 Emphysema
 Loss of lung elasticity and hyperinflation of
lung
 Dyspnea; need for increased respiratory rate
 Air trapping caused by loss of elastic recoil in
alveolar walls, overstretching and
enlargement of alveoli into bullae, collapse of
small airways (bronchioles)

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 Chronic Bronchitis
 Inflammation of bronchi and bronchioles caused by
chronic exposure to irritants, especially cigarette
smoke
 Inflammation, vasodilation, congestion, mucosal
edema, bronchospasm
 Affects only airways, not alveoli
 Production of large amounts of thick mucus

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 Complications
 Hypoxemia/tissue anoxia
 Acidosis
 Respiratory infections
 Cardiac failure, especially cor pulmonale
 Cardiac dysrhythmias

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 Physical Assessment & Clinical
Manifestations
 History
 General appearance
 Respiratory changes
 Cardiac changes

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 Laboratory Assessment
 ABG values for abnormal oxygenation,
ventilation, acid-base status
 Sputum samples
 CBC
 Hemoglobin and hematocrit
 Serum electrolytes
 Serum AAT
 Chest x-ray
 Pulmonary function test

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 Interventions
 Improve oxygenation and reduce carbon
dioxide retention
 Prevent weight loss
 Minimize anxiety
 Improve activity tolerance
 Prevent respiratory infection

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 Drug Therapy
 Beta-adrenergic agents
 Cholinergic antagonists
 Methylxanthines
 Corticosteroids
 NSAIDs
 Mucolytics

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 Community-Based Care
 Home care management
 Long-term use of oxygen
 Pulmonary rehabilitation program
 Teaching for self-management
 Drug therapy
 Manifestations of infection
 Breathing techniques
 Relaxation therapy
Dyspnea Management
 Needed during mealtime; can be reduced by
resting before meals & 4 to 6 small meals a
day
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Occupational Pulmonary Disease
 Caused by occupational or environmental
exposure—fumes, dust, vapors, gases,
bacterial/fungal antigens, allergens

 Worsened by cigarette smoke

 Prevention through special respirators and

adequate ventilation

Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 32

 Question 1
To prevent aspiration in a patient admitted for treatment
of neck and throat cancer, the nurse’s first step should
be to:

A. Encourage hydration with water and juices.

B. Encourage the patient to eat juicy fruits to address
the sensation of thirst.
C. Stop feeding the patient if coughing occurs.
D. Encourage the patient to sit in a chair for meals.

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 Question 3
An important nursing intervention to prevent airway
obstruction in an older patient with dementia is:

A. Ensuring the patient is out of bed twice a day

B. Maintaining the head of bed greater than 45 degrees
C. Performing daily oral hygiene and removing
secretion buildup
D. Teaching the family to use oral suction for excessive
secretions

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Care of Critically Ill Patients with
Respiratory Problems

Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

 Pulmonary Embolism
 Collection of particulate matter
 solids, liquids, air
 that enters venous circulation and lodges in
pulmonary vessels

 Usually occurs when blood clot from a VTE in

leg or pelvic vein breaks off; travels through
vena cava into right side of heart

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 Risk Factors
 Prolonged immobilization
 Central venous catheters
 Surgery
 Obesity
 Advancing age
 Conditions that increase blood clotting
 History of thromboembolism

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 Health Promotion & Illness
Prevention
 Smoking cessation
 Weight reduction
 Increased physical activity
 If traveling or sitting for long periods
 get up frequently and drink plenty of fluids

 If suspected, Do Not:
 Massage
 Compress leg muscles

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 Clinical Manifestations
 Respiratory
 Dyspnea, tachypnea, tachycardia, pleuritic chest
pain, dry cough, hemoptysis
 Cardiac
 Distended neck veins, syncope, cyanosis,
systemic hypotension, abnormal heart sounds,
abnormal ECG
 Low grade fever, petechiae, flu-like
symptoms

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 Nonsurgical Management
 Oxygen therapy (nasal cannula, mask)
 Continuous patient monitoring
 Obtain adequate venous access
 Continuous monitoring of pulse oximetry
 Drug therapy
 Anticoagulants
 Fibrinolytics

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 Interventions
 Ensure appropriate antidotes are present on
the nursing unit!
 Assess for bleeding every 2 hr
 Examine all stool, urine, drainage, vomitus for
gross blood; test for occult blood
 Measure abdominal girth every 8 hr
 Monitor laboratory values

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 Dyspnea Interventions
 Oxygen therapy
 Position of comfort
 Relaxation, diversion, guided imagery
 Energy-conserving measures
 Drugs

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