Assessment of Respiratory system: Assessment of Respiratory system Conducted by: Ms.Monika Clinical instructor Army college of nursing Define nursing assessment: Define nursing assessment Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status. The way in which a nurse gathers and evaluates data about a client (individual, family, or community). The assessment includes a physical examination, interviewing, and observations. Assessment is also the first step in the nursing process. Nursing assessment of respiratory disorder: Nursing assessment of respiratory disorder A nurse who care for client experiencing respiratory disorder performs & interpret variety of assessment. The assessment data are used to plan the client care . It include the following aspects: a) History taking: a) History taking A respiratory disorder contains information about a client present condition & previous respiratory problems. History should be found on a clinical manifestations of the CHIEF COMPLAINTS ,events leading up to the current condition , past health history , family history & psychosocial history . History should be focused on the clinical manifestation of the chief complaints , events leading up to the current conditions , past health history ,family history & psychosocial history . The history taking consist of following aspects: a) Biographical & demographic data: a) Biographical & demographic data History should be begin by obtaining the biographical data. It include the client’s name ,age ,gender & living situation. It should be noted in planning in the client care. b) Chief complaints: b) Chief complaints The chief compliant helps to establish priorities for interventions & to assess the level of understanding of the current conditions. Common respiratory complaints include dyspnea ,cough ,sputum production ,hemoptysis ,wheezing & chest pain. In emergency or acute situation simple questions are often asked until the client is stable & comfortable. c) Symptoms analysis: c) Symptoms analysis To obtain a complete history of the respiratory system & assess the characteristic of all the clinical manifestations. When a client describes a specific respiratory manifestations ,assess the following factors. Onset Location Duration Characteristics Relieving factors severity d) Past health history: d) Past health history The client also must be interviewed for the past health history to collect the data & to find out the causative factor of the disease condition. the past health history consist of the following aspects: 1)Childhood & infectious disease : in addition to obtaining data regarding common childhood diseases ?& vaccination. e.g.: ask the client about the occurrence of bronchitis ,asthma & pneumonia. Cont………..d: Cont………..d Determine the existence of congenital problems such as premature birth history. These problems are associated with respiratory complications. 2) Immunization 3) Major illness & hospitalization : ask the client about previous hospitalization or treatment for respiratory problem. - Determine the previous time of illness or hospitalization ,the specific respiratory problem ,medical treatment ,o2 therapy inhalation treatment. Cont………….d: Cont………….d 4) Medication : obtain detailed information regarding both prescribed and over the counter medications including herbal remedies. 5) Allergies : Question the client about a history of allergies & timings of manifestations to help identify the possible allergic treatment for the condition. - Ask about precipitating factor such as foods ,medication ,pollens ,smoke ,fumes & dust etc. Cont…………….d: Cont…………….d 6) Family health history :- obtain the family history about the respiratory diseases. -Identify the history about the family members who have had asthma ,emphysema ,copd ,lung cancer ,tb or allergies. - History of cigarette smoking ,secondary inhalation of smoke often precipitating or worsens respiratory manifestations. f) Psychosocial history: f) Psychosocial history It include: 1) occupation : identify the environmental agents that might be contributing the client condition. Focus on exposure to dust ,beryllium ,silica and other toxins or pollutants. It also involve chemicals ,heat ,dust and airborne particles. 2) Geographical location : ask the pt about the geographical location of his livings. - Polluted city has also been r/t increasing incidence & severity of asthma. Cont…………..d: Cont…………..d 3 ) environment : ask about the client’s living condition. Crowded living condition increase the risk of exposure to infectious respiratory disease such as tb and cold viruses. 4) habits : Inquire about any history of smoking tobacco products & alcoholism. 5) exercise : ask the client the onset of cough and wheezing sounds during exercise. - Ask the client to describe typical activities such asking ,light housekeeping work ,shopping that results in shortness of breathe. Cont…………..d: Cont…………..d 6) Nutrition : maintaining a nutrition diet is important for client with chronic respiratory disorder. - It is needed for increased lung capacity & greater workload. Physical examination: Physical examination Introduction to physical examination: Introduction to physical examination A physical examination is an evaluation of the body and its functions using inspection, palpation (feeling with the hands), percussion (tapping with the fingers), and auscultation (listening). Physical examination must be done following the health history. In physical examination INSPECTION ,PALPATION ,PERCUSSION & PERCUSSION TECHNIQUE are used. Through out the examination note the condition & color of the client skin & record the abnormalities. Assess the client level of consciousness & orientation throughout the examination. a) inspection: a) inspection visual observation of the body in the course of a medical examination is called inspection. The physical examination begins during the history taking stage as you observe the client and client’s response to questions. During inspection note any manifestations of respiratory distress at this time position of comfort ,tachypnea,cyanosis ,flared nostril ,dyspnea. During the physical examination ,the client should be bare to waist. So privacy and warmth should be maintained. Cont………….d: Cont………….d Specific areas should be inspected of client with respiratory disorder: Head & neck Chest Finger & toes 1) Head & neck: 1) Head & neck The nurse must begin inspections with observation of the head & neck for any gross abnormalities that can interfere with respiration. Note the rate & depth of breathe ,cyanosis of mucous membrane & use of accessory muscle ( such as sternocleido mastoid muscle) 2) chest: 2) chest The chest should be inspected for: Chest wall configuration : continue inspection by observing the chest wall configuration. Observe chest size & contour ,& note the anteroposterior ( AP ) diameter. b) Barrel chest :A large chest with increased anteroposterior diameter and usually some degree of kyphosis. Cont……………d: Cont……………d Barrel chest is present when AP diameter is increased. It is characteristic findings in client with chronic disorder that interfere with ventilation. c) Pigeon chest: c) Pigeon chest Pectus carinatum: also called pigeon chest , is a deformity of the chest characterized by a protrusion of the sternum and ribs In pigeon chest ,the sternum just forward & increased the AP diameter. Congenital atrial or ventricular septal defects are the most common cause of pigeon chest. d) Funnel chest: d) Funnel chest Pectus excavatum: is the most common congenital deformity of the anterior wall of the chest .This produces a caved-in or sunken appearance of the chest & sternum is depressed. The organs that lies below the sternum are compressed. In severe cases ,the sternum may touch the spinal column. e) Thoracic kyphoscoliosis: e) Thoracic kyphoscoliosis A condition in which the spinal disorders of kyphosis and scoliosis occur together. Thoracic kyphoscoliosis is an accentuation of the normal thoracic curve. The client takes on an hunched over or hunched back appearance. Scoliosis kyphosis: Scoliosis kyphosis An abnormal lateral curve to vertebral column An abnormal back ward curve to vertebral column. Cont………..d: Cont………..d The cause include congenital defect ,osteoporosis secondary to aging ,spinal tuberculosis ,rheumatoid arthritis and poor posture over a long period. f) Chest movement: f) Chest movement Observe chest movement during inspiration. Normal respiration rate is 12 to 22 breathe /mins. Note the use of accessory muscles ,retraction . 3) Fingers & toes: 3) Fingers & toes Examination of the fingers & toes may reveal clubbing which may be present in client with pulmonary fibrosis ,lung cancer or bronchietasis. Note the color of the nail beds to assess the status of peripheral tissue oxygenation Nail beds should be pink & without cyanosis b) Palpation : b) Palpation Palpation is used as part of a physical examination in which an object is felt (usually with the hands of a healthcare practitioner) to determine its size, shape, firmness, or location. It is used to feel various structure on & below the surface of the body. Some body parts should be palpated: Cont…………….d: Cont…………….d Trachea Chest wall Thoracic excursion Tactile fremitus a) Trachea : a) Trachea Gently place the thumb of the palpating hand on one side of the trachea & the remaining fingers on the other side. Move the trachea gently from side to side along its length and palpate for masses or duration from the midline. A chest mass ,goiter or an acute chest injury may displace the trachea. b) Chest wall: b) Chest wall Assessment of the chest wall is done with combination of palpation & inspection. Assess the chest wall for defects ,tenderness of the chest wall ,muscle tone ,edema. c) Thoracic excursion: c) Thoracic excursion Thoracic Excursion - thoracic (chest) movement, indicating respiratory effort. Usually measured by the placement of a sensor band, The sensor band records chest wall movement associated with respirations During evaluation of the thoracic excursion ,the client sits upright. Place your hands on the client’s posterior chest wall The thumb oppose each other on either side of the spine and fingers face upward and out like butterfly As the client inhales your hands should move up and out symmetrically. Any asymmetry suggests a disease process in that region. d) Tactile fremitus: d) Tactile fremitus A tremulous vibration of the chest wall during speaking that is palpable on physical examination. Tactile fremitus may be decreased or absent when vibrations from the larynx to the chest surface are impeded by chronic obstructive pulmonary disease, obstruction, pleural effusion, or pneumothorax. Palpate the posterior chest wall while the client says word that produces relatively intense vibrations ( ninety nine ,blue balloon) Decreased tactile fremitus is usually associated with abnormalities that move the lung farther from the chest wall such as pleural effusion & pneumothorax . 3) Percussion : 3) Percussion Percussion is an assessment technique of producing sounds by tapping on the chest with the hands. Percussion is used to assess the lung & the position & movement of the diaphragm. Cont………………d: Cont………………d percussion notes are produced from vibrations created by tapping the chest wall. Percussion Normal Abnormal Lung field Resonant : (strong & deep in tone) low pitched ,hollow ,heard over normal lungs Hyper resonant: sounds indicate an increased amount of air in the lungs. These sounds are louder. It can due to pneumothorax. Diaphragm movement & position Resting diaphragm at 10 th thoracic vertebrae. It moves 3-6 cm downward. High position: stomach distention Decreased position: no movement. 4) Auscultation : 4) Auscultation The act of listening for sounds made by internal organs, as the heart and lungs, to aid in the diagnosis of certain disorders. It involves listening to chest sounds with a stethoscope. In auscultation the client is assessed for: The character of the breathe sounds The presence of adventitious sounds a) Normal breathe sounds: a) Normal breathe sounds Breathe sounds are the noises resulting from the transmission of vibrations produced by the movements of air in the respiratory passage: vesicular breathe : sounds are heard throughout the chest and heard best in the bases of the lungs. - They are low pitched & soft. And best hear during inspiration. Cont……………..d: Cont……………..d b) Bronchial breathe : sounds are heard over the manubrium. It heard only anteriorly and heard best during expiration. Theses sounds are loud and high pitched. c) Bronchovesicular sounds: these sounds heard anteriorly & posteriorly over the central. - They are heard equally during inspiration & expiration d) Absent or diminished breathe sounds: d) Absent or diminished breathe sounds It is the breathe sounds are confirmed during deep respiration after the client has been instructed to take deep breathe and sounds cannot be heard. If the breathe sounds are diminished or absent ,immediate medical attention is required. It can indicates respiratory emergency. b) Adventitious breathe sounds: b) Adventitious breathe sounds Adventitious sounds are the abnormal sounds. It include: a) Crackles : a small, sharp sound heard on auscultation. It is usually heard during inspiration and donot clear with cough. Crackles can be found with client with pulmonary edema ,pulmonary fibrosis or pneumonia. b) Rhonchi : b) Rhonchi Rhonchi is the sound somewhat like snoring, usually caused by secretion in bronchial airways. It occurs as the result of air passing through fluid filled ,narrow passage. It is usually heard on expiration and may clear with the cough. It can caused due to pneumonia ,bronchitis. c) wheezes: c) wheezes A wheeze is a continuous, whistling sound produced in the respiratory airways during breathing results from the passage of air through the narrowed airway. Wheezes are heard during inspiration or expiration both. Severe wheezes are audible without a stethoscope. It is commonly associated with asthma ,edema.