Medicine

17. Respiratory System Assesment

Respiratory System: Assessment

 

Objectives

1.     Identify the anatomy and physiology of the respiratory system.

2.     Distinguish landmarks that guide assessment of the respiratory system.

3.     Develop questions to be used when completing the focused interview.

4.     Explain client preparation for assessment of the respiratory system.

5.     Describe the techniques required for assessment of the respiratory system.

6.     Differentiate normal from abnormal findings in physical assessment.

7.     Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

8.     Discuss the focus areas related to the overall health of the respiratory system as presented in Healthy People 2010.

9.     Apply critical thinking in selected simulations related to physical assessment of the respiratory system.

Overview

  • The primary responsibility of the respiratory system is the exchange of gases in the body.

  • The intake of oxygen and release of carbon dioxide take place with each respiratory cycle.

  • The central nervous system regulates the rate and depth of each respiratory cycle.

  • The respiratory system helps maintain acid-base balance, helps maintain body fluids, and assists with speech.

Anatomy and physiology review

  • The thorax is a closed cavity containing the structures needed for respiration.

  • The thorax extends from the base of the neck to the diaphragm and is surrounded by muscles and ribs.

  • The thorax is divided into the mediastinum in which the heart, trachea, esophagus, and major blood vessels are located, and the right and left pleural cavities.

  • External respiration refers to the exchange of oxygen and carbon dioxide at the alveolar level of the lung.

  • Internal respiration refers to the exchange of oxygen and carbon dioxide at the cellular level.

  • The upper respiratory tract consists of the nose, mouth, sinuses, pharynx, larynx, and part of the trachea.

  • The lower respiratory tract includes the distal trachea, bronchi and lungs, the pleural membranes, muscles of respiration, and the mediastinum.

  • The lungs are elastic, spongy, cone-shaped, and air-filled structures on the left and right of the mediastinum.

  • The left lung has two lobes and the right lung has three lobes.

  • The intercostal muscles and diaphragm are muscles that assist the breathing process.

  • The respiratory cycle consists of the active process of inhalation and the passive process of exhalation.

Landmarks

  • Landmarks for assessment of the thorax include bony structures, horizontal and vertical lines, and the division of the thorax.

  • The thorax is divided into anterior and posterior sections or anterior, posterior, and lateral sections.

  • The sternum, the first bony landmark, is the flat line in the midline of the thoracic cavity.

  • The angle of Louis is a bony ridge of the location where the manubrium and the body of the sternum join.

  • The clavicles are long, slender bones that articulate with the manubrium medially and laterally form the acromion of the shoulder joint.

  • The 12 pairs of ribs form horizontal reference points.

  • The vertebral column is located at the midline of the posterior thoracic cage.

  • Five imaginary vertical lines are identified on the anterior thorax. These are the sternal, midclavicular, and anterior axillary lines.

  • The posterior aspect of the thorax contains the following imaginary vertical lines: the vertebral, scapular, and posterior axillary lines.

  • The landmarks serve as reference points for internal structures of the respiratory system.

Special considerations

  • During fetal development, breathing movements occur that strengthen muscles for respiration after birth, but gas exchange occurs at the placenta. At birth, gas exchange becomes an extrauterine function as fluid in the lungs is absorbed by the pulmonary capillary bed and lymphatic system, is expelled or suctioned from the trachea, and is replaced with air.

  • During infancy and early childhood, breathing involves the use of abdominal muscles.

  • Pregnancy produces changes in the respiratory system. The muscles and cartilage of the ribs relax, allowing an increase in tidal volume. Inspiratory capacity increases, but expiratory reserve volume is decreased. The total lung capacity remains the same. The mild respiratory alkalosis that occurs is necessary for placental gas exchange.

  • Stress, anxiety, fatigue, and pain may exacerbate respiratory problems.

  • Race, ethnicity, and socioeconomic status are significant factors in respiratory health. The incidence of respiratory diseases such as asthma, tuberculosis, chronic obstructive pulmonary disease, and obstructive sleep apnea is greater in non-Caucasians, in poor rural populations, and in recent immigrant groups.

  • Geography and environment influence respiratory health.

Gathering the data

  • Respiratory health assessment includes gathering subjective and objective data.

  • Subjective data is gathered during the client interview and includes data about illness, symptoms, family history, treatment, developmental considerations, behaviors, and the environment.

  • The focused interview guides physical assessment of the respiratory system.

Physical assessment

  • Age, gender, and culture must be considered when preparing for physical assessment of the respiratory system.

  • Equipment required for physical assessment of the respiratory system includes an examination gown and drape, examination gloves, an examination light, a stethoscope, a skin marker, a metric ruler, tissues, and a face mask.

  • Physical assessment of the respiratory system includes the techniques of inspection, palpation, percussion, and auscultation.

  • Physical assessment of the respiratory system proceeds in an organized fashion. It begins with a client survey, followed by inspection of the anterior thorax. The entire assessment of the posterior thorax follows. The assessment is completed with palpation, percussion, and auscultation of the anterior thorax.

  • Skin color is assessed to determine the client's oxygenation status.

  • The nurse visualizes landmarks prior to assessment of the thorax to form reference points for underlying structures.

  • Auscultation of lung sounds includes classification according to intensity, location, pitch, duration, and characteristics.

  • Four normal breath sounds are tracheal, bronchial, bronchovesicular, and vesicular.

Abnormal Findings

  • Eupnea is normal adult breathing characterized by a regular pattern of respirations of even depth.

  • Inspiration equals expiration, and sighs are occasionally interspersed.

  • Abnormal breathing patterns include tachypnea (rapid shallow breathing), bradypnea (slow regular respirations), hyperventilation, hypoventilation, Cheyne-Stokes, Biot’s, frequent sighs, and obstructive breathing.

  • The normal chest configuration for the adult is elliptical with a lateral diameter twice as large as the anteroposterior diameter.

  • Abnormalities in chest configuration include barrel chest, pectus excavatum, and pectus carinatum. Kyphosis and scoliosis are alterations in spinal alignment that impact chest configuration.

  • Respiratory disorders include asthma, atelectasis, bronchitis, emphysema, pneumonia, pleural effusion, pneumothorax, and congestive heart failure.

Glossary

adventitious sounds    Added sounds superimposed on normal breath sounds and often indicative of underlying airway problems or diseases of the cardiovascular or respiratory systems.

angle of Louis   (Sternal angle) A horizontal ridge formed at the point where the manubrium joins the body of the sternum.

bronchial sounds   Loud, high-pitched sounds heard next to the trachea and are longer on exhalation.

bronchophony   Auscultation of voice sounds, patient says "ninety-nine" and normal lung sound will be muffled.

bronchovesicular sounds   Sounds that are medium in loudness and pitch, heard between the scapula, posteriorly and next to the sternum, and anteriorly upon inhalation and exhalation.

dullness   The level of the diaphragm during quiet respiration.

dyspnea    A change in normal breathing pattern, producing shortness of breath or difficulty in breathing.

egophony   Ausculation of voice sounds, patient says "E", normal lungs sound like "eeeeee".

eupnea   The regular, even-depth, rhythmic pattern of inspiration and expiration; normal breathing.

fremitus   The palpable vibration on the chest wall when the client speaks.

landmarks   Thoracic reference points and specific anatomical structures used to help provide an exact location for the assessment findings and an accurate orientation for documentation of findings.

manubrium   The superior portion of the sternum.

mediastinum   Part of the thorax, or thoracic cavity, that contains the heart, trachea, esophagus, and major blood vessels of the body.

rales/crackles   Discontinuous sounds which are intermittent, nonmusical, and brief.

resonance   The usual sound in the thorax, a long, low-pitched hollow sound.

respiratory cycle   Consists of an inspiratory phase and an expiratory phase of breathing.

rhonchi   (Sonorous Wheezes) Sounds that are low-pitched with a snoring quality.

tracheal sounds   Harsh, high-pitched sounds heard over the trachea when the client inhales and exhales.

vesicular sounds   Sounds are soft and low-pitched and heard over the remainder of the lungs, longer on inhalation than exhalation.

wheezes    (Sibilant) Sounds that are high-pitched with a shrill quality.

whispered pectoriloquy   Auscultation of voice sounds, patient whispers "one, two, three", normal lung sounds will be faint, almost indistinquishable.

History

Obtaining accurate information from the client is important in determining the type and severity of pulmonary problems.

 

DEMOGRAPHIC DATA

Age, gender, and race can affect the physical and diagnostic findings related to respiratory function. Many of the diagnos­tic studies relevant to respiratory disorders (e.g., pulmonary function tests) use these demographic data for determining predicted normal values.

 

PERSONAL AND FAMILY HISTORY

Medical History

The nurse asks clients about their own respiratory history and that of their family members. The family history is obtained to consider respiratory disorders with a genetic component, such as cystic fibrosis, some lung cancers, and al­pha,-antitrypsin deficiency (one risk factor for emphysema). Clients with asthma often have a family history of allergic symptoms and reactive airways. The nurse assesses for a his­tory of infectious disease, such as tuberculosis, and considers that family members may have similar environmental or oc­cupational exposures.

Smoking History

The nurse questions the client about the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled sub­stances, and he or she notes whether the client has passive exposure to smoke in the home or workplace. If the client smokes, the nurse asks for how long, how many packs a day, and whether the client has quit smoking (and how long ago). The smoking history is documented in pack-years (number of packs smoked per day multiplied by number of years). Because the client may have guilt or denial about this habit, the nurse assumes a nonjudgmental attitude dur­ing the interview.

 

Smoking induces anatomic changes in the large and pe­ripheral airways, and these changes lead to varying degrees of airway obstruction. Men who continue to smoke experience a more rapid decline in their pulmonary function than do non-smokers. The pulmonary function of clients who have quit smoking for 2 or more years appears to decline less rapidly than in clients who continue to smoke.

 

Medication Use

The nurse asks about medications taken for breathing prob­lems and about drugs taken for other conditions. For example, a cough can be a side effect of the angiotensin-converting en­zyme (ACE) inhibitors. The nurse determines which over-the-counter medications (e.g., cough syrups, antihistamines, decongestants, inhalants, and nasal sprays) the client is using.

 

The use of home remedies also is assessed. The client is asked about past medication use and the reason for its discontinua­tion. For example, he or she may have used numerous bronchodilator metered dose inhalers but may prefer one particu­lar drug for relieving breathlessness. In addition, some medications for other conditions can cause permanent changes in pulmonary function. For example, clients may have residual pulmonary fibrosis if they received bleomycin (Blenoxane) as chemotherapy for cancer or amiodarone (Cordarone) for cardiac problems.

Allergies

Information about allergies is important to the respiratory his­tory. The nurse determines whether the client has any known allergies to environmental substances such as foods, dust, molds, pollen, bee stings, trees, grass, animal dander and saliva, or medications. The client is asked to explain a specific allergic response. For example, does he or she wheeze, have trouble breathing, cough, sneeze, or experience rhinitis after exposure to the allergen? Has he or she ever been treated for an allergic response? If the client has received treatment for allergies, the nurse asks about the circumstances leading up to the need for treatment, the type of treatment, and the response to treatment.

 

Travel and Area of Residence

Travel and area of residence may be relevant for a history of exposure to certain diseases. For example, histoplasmosis, a fungal disease caused by inhalation of contaminated dust, is found in the central United States, the Mississippi and Mis­souri river valleys, and Central America. Coccidioidomycosis, another fungal disease, is found predominantly in the western and southwestern United States, Mexico, and portions of Cen­tral America.

 

DIET HISTORY

An evaluation of the client's diet history may reveal allergic reactions to certain foods or preservatives. Signs and symptoms range from rhinitis, chest tightness, weakness, shortness of breath, urticaria, and severe wheezing to loss of conscious­ness. The nurse documents in a prominent location of the client's record any known allergies and the specific type of al­lergic response experienced. The client is asked about his or her usual food intake and whether any symptoms occur with eating. Malnutrition may occur if he or she has difficulty breathing during eating or the food preparation process.

 

OCCUPATIONAL HISTORY AND SOCIOECONOMIC STATUS

The nurse considers the home, community, and workplace for environmental factors that could cause or contribute to lung dis­ease. Occupational pulmonary diseases include pneumoconiosis, which results from the inhalation of dust (e.g., coal dust, stone dust, silicone dust); toxic lung injury; and hypersensitivity disease (e.g., hypersensitivity to latex). The occupational history includes the exact dates of employment and a brief job descrip­tion. Exposure to industrial dusts of any type or to the noxious chemicals found in smoke and fumes may cause respiratory dis­ease. Coal miners, stone masons, cotton handlers, welders, pot­ters, plastic and rubber manufacturers, printers, farm workers, and steel foundry workers are among the most susceptible.

The nurse obtains information about the home and living conditions, such as the type of heat used (e.g., gas heater, wood-burning stove, fireplace, and kerosene heater) and ex­posure to environmental irritants (e.g., noxious fumes, chem­icals, animals, birds, and air pollutants). The client is asked about hobbies and leisure activities. Pastimes such as paint­ing, working with ceramics, model airplane building, furni­ture refinishing, or woodworking may have exposed the client to harmful chemical irritants.

CURRENT HEALTH PROBLEMS

Whether the pulmonary problem is acute or chronic, the chief complaint is likely to include cough, sputum production, chest pain, and shortness of breath at rest or on exertion. Dur­ing the interview, the nurse explores the history of the present illness, preferably in chronologic order. This analysis of the problem(s) includes the following:

  Onset

  Duration

  Location

  Frequency

  Progressing and radiating patterns

  Quality and number of symptoms

  Aggravating and relieving factors

  Associated signs and symptoms

  Treatments

 

Cough

Cough is the cardinal sign of respiratory disease. The nurse asks the client how long the cough has persisted (e.g., 1 week, 3 months) and whether it occurs at a specific time of day (e.g., on awakening in the morning, which is common in smokers) or in relation to any physical activity. The nurse determines whether the cough is productive or nonproductive, congested, dry, tickling, or hacking.

 

Sputum Production

Sputum production is an important symptom associated with coughing. The nurse notes the duration, color, consistency, odor, and amount of sputum. Sputum may be clear, white, tan, gray or, if infection is present, yellow or green.

The nurse describes the consistency of sputum as thin, thick, watery, or frothy. Smokers with chronic bronchitis have mucoid sputum because of chronic stimulation and hypertro­phy of the bronchial glands. Voluminous, pink, frothy sputum is characteristic of pulmonary edema. Pneumococcal pneu­monia is often associated with rust-colored sputum, and foul-smelling sputum is often found in anaerobic infections such as a lung abscess. Blood in the sputum (hemoptysis) is most commonly noted in clients with chronic bronchitis or bronchogenic carcinoma. Clients with tuberculosis, pulmonary in­farction, bronchial adenoma, or lung abscess may expectorate grossly bloody sputum.

Sputum can be quantified by describing its production in terms of measurements such as teaspoon, tablespoon, and cups or fractions of cups. Normally, the tracheobronchial tree can produce up to 3 ounces (90 mL) of sputum per day. The nurse determines whether sputum production is increasing, possibly from external stimuli (e.g., an irritant in the work set­ting) or an internal cause (e.g., chronic bronchitis or a pul­monary abscess).

Chest Pain

A detailed description of chest pain helps the nurse differen­tiate pleural, musculoskeletal, cardiac, and gastrointestinal pain. Because the perception of pain is subjective, pain is an­alyzed in relation to the characteristics described in the his­tory of the present illness. Coughing, deep breathing, or swal­lowing usually worsens chest wall pain.

Dyspnea

The perception of dyspnea (difficulty in breathing or breathlessness) is subjective and varies among clients. A client's perception may not be consistent with the severity of the pre­senting problem. Therefore the nurse determines the type of onset (slow or abrupt), the duration (number of hours, time of day), relieving factors (changes of position, medication use, activity cessation), and evidence of audible sounds (wheez­ing, crackles, stridor).

The nurse tries to quantify dyspnea by asking whether this symptom interferes with activities of daily living (ADLs) and, if so, how severely. For example, is the client breathless while dressing, showering, shaving, or eating? Does dyspnea on exertion occur after walking one block or climbing one flight of stairs?

The nurse asks about paroxysmal nocturnal dyspnea (PND), which involves intermittent dyspnea during sleep, and about orthopnea, which is demonstrated by a shortness of breath that occurs when lying down but is relieved by sitting up. These two conditions are commonly associated with chronic pulmonary disease and left ventricular failure. In PND, the client has a sudden onset of breathing difficulty that is severe enough to awaken the client from sleep.

 

Physical Assessment

ASSESSMENT OF THE NOSE AND SINUSES

The nurse inspects the client's external nose for deformities or tumors and inspects the nostrils for symmetry of size and shape. Nasal flaring may indicate an increased respiratory ef­fort. To observe the interior nose, the nurse asks the client to tilt the head back for a penlight examination. The nurse may use a nasal speculum and nasopharyngeal mirror for a more thorough examination of the nasal cavity.

The nurse inspects for color, swelling, drainage, and bleed­ing. The mucous membrane of the nose normally appears redder than the oral mucosa, but it may appear pale, engorged, and bluish gray in clients with allergic rhinitis. The nasal sep­tum is checked for evidence of bleeding, perforation, or devi­ation. Some degree of septal deviation is common in most adults and appears as an S shape, inclining toward one side or the other. A perforated septum is noted if the light shines through the perforation into the opposite nostril; this condi­tion is often found in cocaine users. Nasal polyps, a common cause of obstruction, appear as pale, shiny, gelatinous struc­tures attached to the turbinates.

The nurse occludes one nare at a time to check whether air moves through the nonoccluded side easily. The nose and paranasal sinuses are palpated to detect tenderness or swelling. Only the frontal and maxillary sinuses are readily accessible to clinical examination because the ethmoid and sphenoid si­nuses lie deep within the skull. Using the thumbs, the nurse checks for sinus tenderness by pressing up­ward on the frontal and maxillary areas; both sides are as­sessed simultaneously. Tenderness in these areas suggests in­flammation or acute sinusitis. Tenderness in response to tapping a finger over these areas also indicates inflammation.

Transillumination of the sinuses may be used to detect si­nusitis. In a darkened room, the nurse places the bulb of a penlight on the client's cheek (just under the corner of the eye) and observes for light penetration through the roof of the mouth. Normally, a faint glow of light through the bone out­lines the sinus. Transillumination is absent or decreased in si­nusitis. However, this test is not conclusive for sinusitis.

ASSESSMENT OF THE PHARYNX, TRACHEA, AND LARYNX

Examination of the pharynx begins with inspection of the ex­ternal structures of the mouth. To examine the structures of the posterior pharynx, the nurse uses a tongue depressor to press down one side of the tongue at a time (to avoid stimu­lating the gag reflex). As the client says "ah," the nurse notes the rise and fall of the soft palate and uvula and observes for color and symmetry, evidence of discharge (postnasal drainage), edema or ulceration, and tonsillar enlargement or inflammation.

The neck is inspected for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. Lymph nodes are palpated for size, shape, mobil­ity, consistency, and tenderness. Tender nodes are usually movable and suggest inflammation. Malignant nodes are of­ten hard and are fixed to the surrounding tissue.

The nurse gently palpates the trachea for deviation, mobil­ity, tenderness, and masses. Firm palpation may elicit cough­ing or gagging. The space on either side of the trachea should be equal. Many pulmonary disorders cause the trachea to de­viate from the midline. Tension pneumothorax, large pleural effusion, mediastinal mass, and neck tumors push the trachea away from the affected area, whereas pneumonectomy, fibrosis, and atelectasis cause a pull toward the affected area. De­creased tracheal mobility may occur with carcinoma or fibro-sis of the mediastinum.

The larynx is usually examined by a specialist with a laryngoscope. The nurse may observe an abnormal voice, especially hoarseness, when there are abnormalities of the larynx.

 

ASSESSMENT OF THE LUNGS AND THORAX

 

 

Inspection

Inspection of the chest begins with an assessment of the ante­rior and posterior thorax. If possible, the client is in a sitting position during the assessment. He or she should be undressed to the waist and draped for privacy and warmth. The chest is observed by comparing one side with the other. The nurse works from the top (apex) and moves downward to­ward the base while inspecting for discoloration, scars, le­sions, masses, and spinal deformities such as kyphosis, scoliosis, and lordosis.

The nurse observes the rate, rhythm, and depth of inspira­tions as well as the symmetry of chest movement. An impaired movement or unequal expansion may indicate an underlying disease of the lung or the pleura. The nurse observes the type of breathing (e.g., pursed-lip or diaphragmatic breathing) and the use of accessory muscles. In observing respiration, the nurse documents the duration of the inspiratory (I) and expira­tory (E) phases. The ratio of these phases (the I/E ratio) is nor­mally 1:2. A prolonged expiratory phase indicates an obstruc­tion of air outflow and is often seen in clients with asthma or chronic obstructive pulmonary disease (COPD).

The nurse examines the shape of the client's chest and compares the anteroposterior (AP) diameter with the lateral diameter. This ratio normally ranges from 1:2 to approxi­mately 5:7, depending on body build. The ratio increases to 1:1 in clients with emphysema, which results in the typical barrel chest appearance.

Normally, the ribs slope downward. However, clients with air trapping in the lungs caused by chronic asthma or emphy­sema have little or no slope to the ribs (i.e., the ribs are more horizontal).

The nurse also checks for abnormal retractions of the in­tercostal spaces during inspiration, which indicate airflow ob­struction. These retractions may be due to fibrosis of the un­derlying lung, severe acute asthma, emphysema, or tracheal or laryngeal obstruction.

 

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Palpation

Palpation of the chest occurs after inspection. Palpation al­lows the nurse to assess respiratory movement symmetry and observable abnormalities, to identify areas of tenderness, and to elicit vocal or tactile fremitus (vibration).

The nurse assesses thoracic expansion by placing the thumbs posteriorly on the spine at the level of the ninth ribs and extending the fingers laterally around the rib cage. As the client inhales, both sides of the chest should move upward and outward together in one symmetric movement, and the nurse's thumbs move apart. On exhalation, the thumbs should come back together as they return to the midline. Decreased movement on one side (unilateral or unequal expansion) may be a result of pain, trauma, or pneumothorax (air in the pleural cavity). Respiratory lag or slowed movement on one side may indicate the presence of a pulmonary mass, pleural fi­brosis, atelectasis, pneumonia, or a lung abscess.

The nurse palpates any abnormalities found on inspection (e.g., masses, lesions, bruises, and swelling). The nurse also palpates for tenderness, particularly if the client has reported pain. Crepitus (subcutaneous emphysema) is felt as a crack­ling sensation beneath the fingertips and should be docu­mented, especially if it occurs around a wound site or if a pneumothorax is suspected. Crepitus indicates that air is trapped within the tissues.

Tactile (vocal) fremitus is a vibration of the chest wall produced when the client speaks. This vibration can be pal­pated on the chest wall. To elicit tactile fremitus, the nurse places the palm or the base of the fingers against the client's chest wall and instructs him or her to say the number 99. Us­ing the same hand and moving from the apices to the bases, the nurse compares vibrations from one side of the chest with those from the other side. Palpable vibrations are transmitted from the tracheobronchial tree, along the solid surface of chest wall, and to the nurse's hand.

The nurse notes the symmetry of the vibrations and areas of enhanced, diminished, or absent fremitus. Fremitus is de­creased if the transmission of sound waves from the larynx to the chest wall is slowed. This situation can occur when the pleural space is filled with air (pneumothorax) or fluid (pleural effusion) or when the bronchus is obstructed. Fremitus is increased over large bronchi because of their proximity to the chest wall. Disease processes such as pneumonia and abscesses increase the density of the thorax and enhance trans­mission of the vibrations.

 

Percussion

The nurse uses percussion to assess for pulmonary resonance, the boundaries of organs, and diaphragmatic excursion. Per­cussion involves tapping the chest wall, which sets the under­lying tissues into motion and produces audible sounds. The nurse places the distal joint of the middle finger of the less dominant hand firmly over the intercostal space to be per­cussed. No other part of the nurse's hand touches the client's chest wall because doing so absorbs the vibrations. The mid­dle finger of the dominant hand then delivers quick, sharp strikes to the distal joint of the positioned finger. The nurse maintains a loose, relaxed wrist while delivering the taps with the tip of the finger, not the finger pad. This tech­nique is repeated two or three times to determine the intensity, pitch, quality, and duration of the sound produced. Long fin­gernails limit the ability to percuss.

30FF8

Percussion produces five distinguishable notes. These sounds assist the nurse in determining the density of the underlying structures (i.e., whether the lung tissue contains air or fluid or is solid). Percussion of the thorax is performed over the intercostal spaces because percussing the sternum, ribs, or scapulae yields sound indicating solid bone. Percussion pene­trates only 2 to 3 inches (5 to 7 cm), and therefore deeper le­sions are not detected with this technique.

Percussion begins with the client sitting in an upright po­sition. The nurse assesses the posterior thorax first and pro­ceeds systematically, beginning at the apex and working to­ward the base. The apex of the lung extends anteriorly approximately ¾ to 1 ½  inches (2 to 4 cm) above the clavicle. Posteriorly, there is approximately a 2-inch (5-cm) width of lung tissue at the apex.

The nurse assesses diaphragmatic excursion by instructing the client to "take a deep breath and hold it" while percussing downward until dullness is noted at the lower border of the lung. Normal resonance of the lung stops at the diaphragm, where the sound becomes dull; this site is marked. The nurse repeats the process after instructing the client to "let out all your breath and hold." The difference between the two mark­ings or sounds is the diaphragmatic excursion, which may range from 1 to 2 inches (3 to 5 cm). The diaphragm is nor­mally higher on the right because of the location of the liver. Diaphragmatic excursion may be decreased or absent in clients with pleurisy, diaphragm paralysis, or emphysema.

The nurse continues to assess the thorax with percussion of the anterior and lateral chest. The percussion note changes from resonance of the normal lung to dullness at the borders of the heart and liver. The presence of fluid or solid material is indicated by a dull percussion note over lung tissue (as oc­curs with pneumonia, pleural effusion, fibrosis, atelectasis, and tumors).

charesteristic

Auscultation

Auscultation includes listening for normal breath sounds, ad­ventitious sounds, and voice sounds. Auscultation provides information about the flow of air through the tracheo-bronchial tree and helps the listener to identify fluid, mucus, or obstruction in the respiratory system. The diaphragm of the stethoscope is designed to detect high-pitched sounds.

Auscultation begins with the client sitting in an upright po­sition. With the stethoscope pressed firmly against the client's chest wall (clothing can distort or muffle sounds), the nurse instructs him or her to breathe slowly and deeply through an open mouth. (Breathing through the nose would set up turbu­lent sounds that are transmitted to the lungs.) A systematic ap­proach is used, beginning at the apices and moving down through the intercostal spaces to the bases. Lis­tening over bony structures is avoided while auscultating the thorax posteriorly, laterally, and anteriorly. The nurse listens to a full respiratory cycle, noting the quality and intensity of the breath sounds. The client is observed for signs of lightheadedness or dizziness caused by hyperventilation during auscultation. If these symptoms occur, the client is told to breathe normally for a few minutes.

NORMAL BREATH SOUNDS

Normal breath sounds are produced as air vibrates while passing through the respiratory passages from the larynx to the alveoli. Breath sounds are identified by their location, intensity, pitch, and duration within the respiratory cycle (e.g., early or late inspiration and expiration). Normal breath sounds are known as bronchial or tubular (harsh hollow sounds heard over the trachea and mainstem bronchi), bronchovesicular (heard over the branching bronchi), and vesicular (a soft rustling sound heard in the periphery over small bronchioles). The nurse describes these sounds as normal, increased, decreased (di­minished), or absent.

When bronchial breath sounds are heard peripherally, they are abnormal. This increased sound occurs when centrally generated bronchial sounds are transmitted to an area of in­creased density, such as in clients with atelectasis, tumor, or pneumonia. When audible in an abnormal location, bron­chovesicular breath sounds may indicate normal aging or an abnormality such as pulmonary consolidation and chronic air­way disease.

 

ADVENTITIOUS BREATH SOUNDS

Adventitious sounds are additional breath sounds superim­posed on normal sounds, and they indicate pathologic changes in the tracheobronchial tree. Table 27-6 classifies and describes adventitious sounds: crackle, wheeze, rhonchus, and pleural friction rub. Adventitious sounds vary in pitch, intensity, duration, and the phase of the respiratory cycle in which they occur. The nurse documents exactly what is heard on auscultation.

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VOICE SOUNDS

If the nurse discovers abnormalities during the physical as­sessment of the lungs and thorax, the client is assessed for vo­cal resonance. Auscultation of voice sounds through the nor­mally air-filled lung produces a muffled, unclear sound because sound vibrations travel poorly through air. Vocal res­onance is increased when the sound must travel through a solid or liquid medium, as it does in clients with a consoli­dated area of the lung, pneumonia, atelectasis, pleural effu­sion, tumor, or abscess.

BRONCHOPHONY. Bronchophony is the abnormally loud and clear transmission of voice sounds through an area of increased density. For assessment of bronchophony, the client repeats the number 99 while the nurse systematically auscultates the thorax.

WHISPERED PECTORILOQUY. Whispered pectoriloquy is the enhanced voice heard through the chest wall. It is much more sensitive than bronchophony and is perceived by having the client whisper the number sequence one, two, three. Whispered words normally sound faint and indistinct. If they are heard loudly and distinctly, the nurse suspects con­solidation of lung tissue.

EGOPHONY. Egophony is another form of abnormally enhanced vocal resonance and has a high-pitched, bleating, nasal quality. The nurse auscultates the thorax while the client repeats the letter E. Egophony exists when this letter is heard as a flat, nasal sound of A through the stethoscope. This ab­normal sound indicates an area of consolidation, pleural effu­sion, or abscess.

 

OTHER INDICATORS OF RESPIRATORY ADEQUACY

The nurse evaluates additional indicators of respiratory ade­quacy because gas exchange affects all body systems. Some indicators (e.g., cyanosis) indicate immediate oxygenation problems. Other changes (e.g., clubbing, weight loss, un­evenly developed muscles) reflect a more long-standing oxy­genation problem.

Skin and Mucous Membranes

The skin and mucous membranes are assessed for the pres­ence of pallor or cyanosis, which could indicate inadequate ventilation. Areas to assess include the nail beds and the mu­cous membranes of the oral cavity. The fingers are examined for clubbing, which would indicate hypoxia of long duration.

General Appearance

The nurse observes the client for muscle development and general body build. Long-term respiratory problems are often associated with an inability to maintain body weight and a loss of general muscle mass. Arms and legs may appear thin or poorly muscled. The muscles of the neck and chest may be hypertrophied, especially in the client with chronic obstruc­tive pulmonary disease (COPD).

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Endurance

The nurse observes how easily the client moves and whether he or she is short of breath while resting or becomes short of breath when walking 10 to 20 steps. As the client speaks, the nurse observes how often he or she pauses for breath between words.

Psychosocial Assessment

The nurse assesses aspects of the client's lifestyle that may significantly affect respiratory function. Some respiratory conditions may be worsened by stress. The nurse asks about present life stresses and usual coping mechanisms.

Chronic respiratory illnesses may cause changes in family roles and relationships, social isolation, financial problems, and unemployment or disability. By discussing coping mecha­nisms, the nurse assesses the client's reaction to these psy­chosocial stressors and discovers strengths and ineffective be­haviors. For example, the client may react to stress with dependence on family members, withdrawal, or noncompliance with interventions. After completing the psychosocial as­sessment, the nurse assists the client in determining the support systems available to help cope with respiratory impairment.

 

 

Diagnostic Assessment

I LABORATORY TESTS

Blood Tests

A red blood cell count provides data regarding the transport of oxygen from the lungs. A hemoglobin deficiency directly affects tissue oxy­genation because hemoglobin transports oxygen to the cells and could cause hypoxemia.

Arterial blood gas (ABG) analysis assesses oxygenation (partial pressure of arterial oxygen [Pao2]), alveolar ventila­tion (partial pressure of arterial carbon dioxide [Paco2]), and acid-base balance. Blood gas studies provide valuable infor­mation for monitoring treatment results, adjusting oxygen therapy, and evaluating the client's responses to treatment and therapy, such as during weaning from mechanical ventilation.

 

Sputum Tests

Sputum specimens obtained by expectoration or tracheal suctioning assist in the identification of pathogenic organisms or abnormal cells, such as in a malignancy or a hypersensitivity state. Sputum culture and sensitivity analyses identify bacter­ial infection with either gram-negative or gram-positive or­ganisms and determine the vulnerability to specific antibi­otics. Cytologic examination is performed on sputum to help diagnose malignant lesions by identifying cancer cells. Be­nign conditions, such as a hypersensitivity state, may also be identified by cytologic testing. Eosinophils and Curschmann's spirals (a mucous form) are often found by cytologic study in clients with allergic asthma.

 

RADIOGRAPHIC EXAMINATIONS

Standard Radiography

Chest x-ray examinations are performed for clients with respi­ratory tract disorders to evaluate the present status of the chest and to provide a baseline for comparison with future changes. Standard chest x-ray examinations are performed from posteroanterior (PA; back to front) and left lateral (LL) projec­tions. Portable chest x-ray studies (taken anteroposterior [AP], front to back) cost more, and the films produced are of lower quality and are more difficult for the radiologist to interpret. Consecutive, 10-mm cross-sectional views of the thorax and produces a three-dimensional assessment of the lungs and thorax.

Fat, cystic, and solid tissue can be distinguished with CT. By adding an intravenously injected contrast agent, vessels and other soft tissue structures can be identified. CT is espe­cially valuable in studying the mediastinum, hilar region, and pleural space. The newer high-resolution CT (HRCT) uses 1.5- to 2-mm "slices" to assist in assessing bronchial abnor­malities, interstitial disease, and emphysema. Nursing inter­ventions for the client undergoing CT include education about the procedure and determination of the client's sensi­tivity to the contrast medium (very important for anaphylaxis prevention).

Ventilation and Perfusion Scanning

A ventilation and perfusion scan (V/Q scan) identifies the ar­eas of the lung being ventilated and the distribution of pul­monary blood. It is used primarily to support or rule out a di­agnosis of pulmonary embolism.

To perform the study, the physician first injects a radionuclide with the client in a supine position and then takes six perfusion views: anterior, posterior, right and left lateral, and two obliques. If the perfusion scan is normal, there is no rea­son to continue with the ventilation scan. Otherwise, the client inhales a radioactive gas or radioaerosol, and the lung is scanned continuouslyas the gas makes its way into the lungs (the "wash-in" phase), once the gas has reached equi­librium within the lungs, and then while the gas is leaving the lungs (the "wash-out" phase).

The nurse teaches the client about the procedure and ex­plains that the radioactive substance clears from the body in approximately 8 hours.

 

OTHER NONINVASIVE DIAGNOSTIC TESTS

Pulse Oximetry

Pulse oximetry identifies hemoglobin saturation. Usually he­moglobin is almost 100% saturated with oxygen. The pulse oximeter uses a wave of infrared light and a sensor placed on the client's finger, toe, nose, earlobe, or forehead. Ideal nor­mal pulse oximetry values are 95% to 100%; values may be a little lower in older clients and in clients with dark skin. To avoid confusion with the Pao2 values from arterial blood gases, pulse oximetry readings are recorded as the Sao2 (arte­rial oxygen saturation), or Spo2.

A pulse oximetry reading can alert the nurse to desaturation before clinical signs occur (e.g., dusky skin, pale mucosa, and nail beds). The nurse considers client movement, hy­pothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and fingernail polish as possible causes for low readings. Cover­ing the sensor or changing its positioning could yield better accuracy if too much ambient light is present.

Results lower than 91% (and certainly below 86%) consti­tute an emergency and necessitate immediate treatment. When the Sao2 is below 85%, the tissues of the body have a difficult time becoming oxygenated. An Sao2 of less than 70% is usually life threatening, but in some cases values below 80% may be life threatening. Pulse oximetry is less accurate at lower values.

 

Pulmonary Function Tests

Pulmonary function tests (PFTs) evaluate lung function and dysfunction and include studies such as lung volumes and ca­pacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation. The physician in­terprets the results by comparing the client's data with normal findings predicted according to age, gender, race, height, weight, and smoking status.

PFTs are useful in screening clients for pulmonary dis­ease even before the onset of signs or symptoms. Serial test­ing provides objective data that may be used as a guide to treatment (e.g., changes in pulmonary function can support a decision to continue, change, or discontinue a specific therapy). Preoperative evaluation with PFTs may identify the client at risk for postoperative pulmonary complications. One of the most common reasons for performing such tests is to determine the cause of dyspnea. When performed while the client exercises, PFTs help to determine whether dys­pnea is caused by pulmonary or cardiac dysfunction or by muscle deconditioning. These tests are also useful for deter­mining the effect of the client's occupation on pulmonary function and for evaluating any related disability for legal purposes.

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CLIENT PREPARATION. The nurse prepares the client for PFTs by explaining the purpose of the tests for plan­ning care. He or she is advised not to smoke for 6 to 8 hours before testing. According to institutional policy and proce­dure, bronchodilator medication is withheld for 4 to 6 hours before the test. The client with respiratory impairment often fears further breathlessness and is usually anxious before these "breathing" tests. The nurse helps to reduce apprehen­sion by describing what will be experienced during and after the testing.

PROCEDURE. PFTs can be performed at the bedside or in the respiratory laboratory. The client is asked to breathe through the mouth only. A nose clip may be used to prevent air from escaping. The client performs different breathing ma­neuvers while measurements are obtained.

FOLLOW-UP CARE. Because numerous breathing ma­neuvers are performed during PFTs, the nurse observes for in­creased dyspnea or bronchospasm after such studies. The nurse documents whether bronchodilator medication was ad­ministered during testing and alters the client's medication schedule as indicated.

 

Exercise Testing

Exercise, or activity in general, increases metabolism and gas transport as energy is generated. These tests are per­formed on a treadmill or bicycle or by a self-paced 12-minute walking test. The normal client's exercise is limited by hemodynamic factors, whereas the pulmonary client is limited by ventilatory capacity, pulmonary gas exchange compromise, or both. The nurse explains exercise testing and assures the client of close monitoring by trained profes­sionals throughout the test.

 

Skin Tests

Skin tests are used in combination with other diagnostic data to identify various infectious diseases (e.g., tuberculosis), vi­ral diseases (e.g., mononucleosis and mumps), and fungal dis­eases (e.g., coccidioidomycosis and histoplasmosis). The presence of allergic hypersensitivity and the status of the im­mune system can be demonstrated through skin testing. Ex­posure to the allergen or organism used in testing produces a specific reaction (delayed hypersensitivity reaction) of the client's immune system.

 

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is used in the diagnosis of respiratory system disorders to provide information about the type and condition of the tissues being imaged along any plane inside the body: vertically, horizontally, and diagonally. This costly procedure requires little client preparation other than the removal of all metal objects. Because of the power­ful magnets used in MRI, clients with pacemakers, aneurysm clips, inner-ear implants, cardiac valves, or any other metallic foreign objects in the body are not candidates for MRI.

The nurse informs the client of possible claustrophobia and discomfort from lying on a hard, cool table inside the magnet's small cylinder. The nurse instructs the client in the use of re­laxation techniques and imagery to help decrease these sensa­tions. Sedation may be necessary in some cases. The nurse explains that the noises heard during the examination are the natural, rhythmic sounds of radiofrequency pulses. These noises may range from barely audible to noticeable.

 

OTHER INVASIVE DIAGNOSTIC TESTS

Endoscopic Examinations

Endoscopic diagnostic studies to assess respiratory disorders include bronchoscopy, laryngoscopy, and mediastinoscopy. The most common complications are those related to the medications and bleeding.

Thoracentesis

Thoracentesis is used for diagnosis or treatment and involves the aspiration of pleural fluid or air from the pleural space. Microscopic examination of the pleural fluid helps in making a diagnosis. Pleural fluid may be drained to relieve pulmonary compression and the resultant respiratory distress caused by cancer, empyema, pleurisy, or tuberculosis. Thoracentesis is often followed by pleural biopsy to assist in further assess­ment of the parietal pleura. Thoracentesis also allows the in­stillation of medications into the pleural space.

CLIENT PREPARATION. Adequate client prepara­tion is essential before thoracentesis to ensure cooperation during the procedure and to prevent complications. The nurse tells the client to expect a stinging sensation from the local anesthetic agent and a feeling of pressure when the needle is inserted. The nurse reinforces the importance of not moving during the procedure (avoiding coughing, deep breathing, or sudden movement) to avoid puncture of the visceral pleura or lung.

These positions widen the intercostal spaces and permit easy access to the pleural fluid. The nurse properly positions and physically supports the client. Pillows are used to make the client comfortable and to provide physical support.

Before the procedure, the nurse checks the client's history for hypersensitivity to local anesthetic agents and checks to make sure the client has signed an informed consent. The en­tire chest or back is exposed, and the aspiration site is shaved if necessary. The actual site depends on the volume and loca­tion of the effusion, which are determined by radiography and physical examination procedures such as percussion.

 

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PROCEDURE. Thoracentesis is usually performed at the bedside, although ultrasonography or computed tomogra­phy may be used to guide it. After draping the client and cleaning the skin with a germicidal solution, the physician uses aseptic technique and injects a local anesthetic agent into the selected intercostal space. The nurse keeps the client in­formed of the procedure while observing for shock, pain, nau­sea, pallor, diaphoresis, cyanosis, tachypnea, and dyspnea.

The physician advances the short 18- to 25-gauge thora­centesis needle (with an attached syringe) into the pleural space. Gentle suction is applied as the fluid in the pleural space is slowly aspirated. A vacuum collection bottle is some­times necessary to remove larger volumes of fluid. To prevent re-expansion pulmonary edema, usually no more than 1000 mL of fluid is removed at one time. If a pleural biopsy is to be performed, a second, larger needle with a cutting edge and collection chamber is used. After the physician withdraws the needle, pressure is applied to the puncture site, and a small sterile dressing is applied.

FOLLOW-UP CARE. After thoracentesis, the physi­cian orders a chest x-ray study to rule out possible pneumothorax and subsequent mediastinal shift (shift of center thoracic structure toward one side). The nurse monitors the client's vital signs and auscultates breath sounds while not­ing absent or diminished sounds on the affected side. The puncture site and dressing are observed for leakage or bleed­ing. The nurse also assesses for other complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, pyrogenic infection, and tension pneumothorax. The client is encouraged to breathe deeply to promote reexpansion of the lung. The nurse documents the proce­dure, including the client's tolerance, the volume and character of the fluid removed, any specimens sent to the labo­ratory, the location of the puncture site, and respiratory as­sessment findings before, during, and after the procedure.

 

Lung Biopsy

A lung biopsy is performed to obtain tissue for histologic analysis, culture, or cytologic examination. The physician uses tissue samples to make a definite diagnosis regarding the type of malignancy, infection, inflammation, or lung dis­ease. Biopsy procedures include transbronchial biopsy (TBB) and transbronchial needle aspiration (TBNA), both of which are performed during bronchoscopy; transthoracic needle aspiration (percutaneous approach for areas not ac­cessible by bronchoscopy); and open lung biopsy (in the op­erating room).

 

CLIENT PREPARATION. The client may have prede­termined ideas about the outcome of the biopsy and may closely associate the terms biopsy and cancer. Therefore the nurse explains what to expect before and after the procedure and explores the client's feelings and fears. To reduce dis­comfort and anxiety, the physician may prescribe an anal­gesic or sedative before the procedure. The nurse informs the client undergoing percutaneous biopsy that discomfort is minimized with a local anesthetic agent but that a sensation of pressure may be experienced during needle insertion and tissue aspiration. Open lung biopsy is usually performed in the operating room with the client under general anesthesia, and the usual preoperative preparations apply.

PROCEDURE. Percutaneous lung biopsy may be per­formed in the client's room or in the radiology department af­ter an informed consent has been obtained. Fluoroscopy, CT, or ultrasonography is often used to better visualize the area undergoing biopsy and to guide the procedure. Positioning of the client is similar to that for thoracentesis. The physician cleans the skin with an antibacterial agent and administers a local anesthetic agent. Under sterile conditions, the physician inserts a spinal-type 18- to 22-gauge needle through the skin into the desired area (e.g., tissue, nodule, or lymph node) and obtains the tissue needed for microscopic examination. The nurse applies a dressing after the procedure.

An open lung biopsy is performed in the operating room. The client undergoes a thoracotomy where lung tissue is ex­posed. At least two tissue specimens are taken (usually from an upper lobe and a lower lobe site). The surgeon places a chest tube to remove air and fluid so the lung can reinflate and then closes the chest.

FOLLOW-UP CARE. The nurse monitors the client's vi­tal signs and breath sounds every 4 hours for 24 hours and assesses for signs of respiratory distress (e.g., dyspnea, pallor, di­aphoresis, and tachypnea). Pneumothorax is a serious complica­tion of needle biopsy and open lung biopsy, and therefore it is important for the nurse to report untoward signs and symptoms promptly. The nurse also monitors for hemoptysis (which may be scant and transient) or, in rare cases, for frank bleeding from vascular or lung trauma.