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Respiratory Assessment Highlights Evolve
Adult Health II (NUR 2211)
Hillsborough Community College
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Chapter 25 Nursing Assessment: Respiratory System KEY POINTS STRUCTURE AND FUNCTION OF RESPIRATORY SYSTEM - The primary purpose of the respiratory system is gas exchange, which involves the transfer of oxygen and carbon dioxide between the atmosphere and the blood. - The upper respiratory tract includes the nose, mouth, pharynx, adenoids, tonsils, epiglottis, larynx, and trachea. - The nose warms, cleanses, and humidifies air before it enters lungs. - Vibrational sounds originating in the larynx lead to vocalization. - The trachea, bronchi, and bronchioles are passages that conduct air to the alveoli. These passages are called anatomic dead space because the air is not involved in gas exchange. - The lower respiratory tract consists of the bronchi, bronchioles, alveolar ducts, and alveoli. - Gas exchange takes place by diffusion across the alveolar-capillary membrane. - Surfactant is a lipoprotein that helps to keep the alveoli open, thus preventing alveolar collapse. - Contraction of the diaphragm, the major muscle of respiration, results in decreased intrathoracic pressure, allowing air to enter the lungs.
Physiology of Respiration
- Oxygenation involves the delivery of oxygen from the atmospheric air to alveolar capillaries and eventual diffusion into the alveoli.
- Ventilation involves inspiration (movement of air into the lungs) and expiration
(movement of air out of the lungs). Inspiration is an active process, involving muscle contraction.
- Expiration is a passive process. When elastic recoil is reduced, expiration becomes a more active, labored process.
- In adults, a normal tidal volume (VT), or volume of air exchanged with each breath, is about 500 mL.
- When compliance, or a measure of the ease of lung expansion, is decreased, the lungs are harder to inflate (“stiff lungs”).
- When resistance increases, this often indicates some type of impairment to air flow into the lungs, such as narrowed airways or presence of secretions.
- Arterial blood gases (ABGs) are measured to determine oxygenation status, ventilation status, and acid-base balance. ABG analysis includes measurement of the partial pressure of O 2 in arterial blood (PaO 2 ), arterial pressure of carbon dioxide (PaCO 2 ), acidity (pH), bicarbonate (HCO 3 – ), and arterial oxygen saturation (SaO 2 ) in arterial blood.
- Arterial oxygen saturation can be monitored continuously using a pulse oximetry probe, most often applied to a finger, toe, ear, or bridge of the nose.
- CO 2 monitoring can be done using transcutaneous carbon dioxide (PtCO 2 ) and end-tidal CO 2 (PetCO 2 ) capnography.
- Transcutaneous measurement of CO 2 capnography is a noninvasive method of estimating PaCO 2. It is presented as a graph of expiratory CO 2 plotted against time. Control of Respiration
- The respiratory center in the medulla in the brainstem responds to chemical and mechanical signals from the body.
medications, surgery or other treatments, family health history, psychosocial history, and a review of systems using functional health patterns. Explore and document common signs of respiratory problems (e., cough, dyspnea). Describe the course of the patient’s illness, including when it began, the type of symptoms, and factors that relieve or worsen symptoms.
- Evaluate a cough by the quality of the cough and presence or absence of sputum.
- Obtain vital signs prior to the physical examination. Assess the nose, mouth, pharynx, neck, thorax, and lungs and observe the respiratory rate, depth, and rhythm.
- When listening (auscultating) lung sounds:
- Determine air entry (adequate, slightly decreased, decreased or absent).
- Determine the presence or absence of 3 normal breath sounds: vesicular, bronchovesicular, and bronchial.
- Determine the presence of absence of abnormal (adventitious) sounds, including fine crackles, coarse crackles, wheezes, stridor, and pleural friction rub.
DIAGNOSTIC STUDIES OF RESPIRATORY SYSTEM
SpO 2 monitoring and ABG analysis are classic diagnostic tests used to evaluate the respiratory system.
A chest x-ray is the most common test for assessment of the respiratory system, as well as the progression of disease and response to treatment.
Sputum studies are examined to identify infecting organisms or help confirm a diagnosis.
Skin tests are done to test for allergic reactions or exposure to tuberculosis or fungi.
Bronchoscopy is a procedure in which the bronchi are visualized through a fiberoptic tube. It may be used for diagnostic purposes, to obtain biopsy specimens, and assess changes resulting from treatment. Thoracentesis is the insertion of a large bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space.
Pulmonary function tests (PFTs) measure lung volumes and airflow.
The results of PFTs can diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.
In the acute setting, more specific PFT parameters are used to determine the ability to wean and extubate from mechanical ventilation.
Exercise testing is used in diagnosis, measuring functional capacity and response to treatment, and determining level of activity tolerance.
Respiratory Assessment Highlights Evolve
Course: Adult Health II (NUR 2211)
University: Hillsborough Community College
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