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The Respiratory System. Thorax and Lungs Rachel S. Natividad, RN, MSN, NP. Lobes and Landmarks. Inspection… …Always first!!! The moment you see the patient. What position is most comfortable for him? Does he appear relaxed, anxious, uncomfortable? Is he having any trouble breathing?.

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the respiratory system

The Respiratory System

Thorax and Lungs

Rachel S. Natividad, RN, MSN, NP

assessment begins

…Always first!!!

The moment you see the patient.

What position is most comfortable for him?

Does he appear relaxed, anxious, uncomfortable?

Is he having any trouble breathing?

Assessment begins….

Tripod Position

focused assessment
Focused Assessment
  • Inspection-cont.
  • Color, Size and shape & symmetry of chest, any lesions or scars
    • Anterior Lateral Posterior
asymmetrical chest
Due to deformities of the spine: Scoliosis

Assymetrical chest expansion

Fractured ribs

flail chest



paralysis of the diaphragm

Asymmetrical chest


intercostal spaces and muscles
Intercostal Spaces and Muscles

Retractions – indicates respiratory distress

focused assessment cont
Focused Assessment Cont…
  • Resp. rate (per min.) and depth (shallow, even, deep)
  • Normal pattern of respiration – regular rhythm
  • Abnormal patterns
    • Hyperventilation
    • Tachypnea vs. bradypnea
    • Stertorous (Noisy)
    • Cheyne-Stokes
    • Kussmaul’s
  • Skin: cyanosis, pallor
  • Nails: Clubbing
    • Spongy nail matrix and nail angle of

greater than 160 degrees

focused assessment cont palpation
Check for tenderness

(normally nontender)

Crepitus – SQ air pockets

indicates air is leaking from the airways or lungs

Tactile fremitus – a palpable vibration that is caused by the trasmission of air through the bronchopulmunary system.

increased with fluid accumulation

Abnormal if tumor,

fractured ribs, chest

tubes, wound site, fluid

Focused Assessment Cont.:Palpation
adventitious abnormal breath sounds t 11 2 p 132
Continuous sounds



Sonorous (Rhonchi)


Discontinuous sounds

Crackles (Rales)



*Atelectic crackles

Pleural friction rub

Adventitious/AbnormalBreath Sounds (T 11-2) p.132
wheezes continuous
Wheezes (Continuous)

Sibililant wheeze

Heard 1st in expiration

  • high-pitched musical sounds
  • Due to partial blockage in airflow
    • Asthma, COPD, or foreign body obstruction.
wheezes continuous1
Wheezes (Continuous)

Sonorous wheeze (rhonchi)

Heard primarily in expiration

  • low pitched – snoring, rattling sound
  • Due to air passing through large airways filled with fluid/ secretions


Stridor- partial airway obtruction

viral croup, laryngeal or tracheal obstruction, epiglotottis

interpreting what you hear
Interpreting what you hear…
  • Is the sound is continuous or discontinuous?
  • Is the sound occur during inhalation or exhalation, or both?
crackles discontinuous
Crackles (Discontinuous)
  • FINE vs. COURSE Crackles
    • Caused by collapsed or fluid-filled alveoli popping open
    • usually heard in the lung bases during inhalation
  • Atelectic crackles
  • common in elderly, disappears after several deep breaths
  • ___________________________
  • Pleural friction rub – grating sound from fluid in the pericardial space due to inflamed pleura (Pericarditis)
abnormal breath sounds
Abnormal Breath Sounds
  • Diminished breathsounds
    • Obese, muscular chest wall
    • poor inspiratory effort (elderly)
    • pleural effusion
  • Absent breath sounds
    • Missing lung/lobe
    • airway obstruction, pneumothorax- collapsed lung
assessment guide gas exchange
Assessment Guide: Gas Exchange
  • Respiratory
    • Rate: 18 resp/min
    • Depth: deep, even, shallow
    • Effort: labored, unlabored
  • Breath Sounds
    • Describe: clear, rhonchi, inspiratory/expiratory wheezes, crackles
    • Location: all lobes, throughout lung fields, LLL, RUL/RML, lower lobes bilat.
    • Cough: present/not present
    • Describe: productive, moist, nonproductive
    • Sputum: large amount, thick yellow; moderate pink frothy sputum, sml. Amt. thin clear sputum.
Interventions in use:
  • Position, Turn, Cough, Deep breathe
  • O2 Method: nc, venti mask, rebreathing mask
    • Flow rate: 2L/min; 3l/min
    • Humidity: yes/no
  • Pulse Oximeter: continuous, spot monitoring
  • Incentive Spirometer: in use, n/a
    • Time used: 10 am, 11 am, 1 pm, 3 pm
    • Volume: 500 cc, 500 cc, 600 cc, 800 cc
  • Oropharyngeal Suctioning: Describe- moderate amount thick tan secretions
  • Med List: Albuterol inhaler, Prednisone, Theophylline