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Assessment of the respiratory system. Prepare by: Mrs. Mahdia Samaha Alkony. 1. Health History. The reason for seeking advice: dyspnea, hemoptysis, odema, cough, general fatigue, weakness. Chief complain , onset , duration, severity Assess risk factors

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assessment of the respiratory system

Assessment of the respiratory system

Prepare by: Mrs. Mahdia Samaha Alkony

1

health history
Health History
  • The reason for seeking advice: dyspnea, hemoptysis, odema, cough, general fatigue, weakness.
  • Chief complain , onset , duration, severity
  • Assess risk factors
  • Identify the impact of signs& symptoms on the patient ability to perform daily activities.

2

major signs and symptoms of the respiratory diseases
Major signs and symptoms of the respiratory diseases:
  • Dyspnea: difficulty in breathing, shortness of breath. Symptom common when there is decrease lung compliance or increase airway resistance.

Sudden dyspnea in healthy person indicates:

      • Pneumothorax.
      • Pulmonary embolism
      • RDS.
      • Acute respiratory obstruction.
major signs and symptoms of the respiratory diseases4
Major signs and symptoms of the respiratory diseases:

2.Orthopnea: inability to breath easily except in an upright position.

Found in pt. with COPD, heart disease.

  • Noisy breathing result from narrowing of the airway or localized obstruction of major bronchus by tumor or foreign body.

3.Cough: caused byirritation of the mucous membranes of the respiratory tract that may arise from an infectious process, irritant as smoke, dust…

It’s a protective mechanism against accumulation of secretion in the bronchi & bronchioles.

charachters of cough
Charachters of cough
  • A dry, irritant cough is an URTI of viral origin
  • High pitched cough laryngotracheitis caused by an irritation.
  • A cough in the morning with sputum production may indicate bronchitis.
  • A cough that worsen when the pt. is in supine position suggest postnasal drip (sinusitis).
  • Coughing after food intake may indicate aspiration of material into the tracheobronchial tree.
major signs and symptoms of the respiratory diseases6
Major signs and symptoms of the respiratory diseases:

4- Sputum production:

  • Thick, yellow, green; Indicate bacterial infection.
  • Thin, mucoid sputum; Indicate viral infection.
  • Pink tinged mucoid sputum; Indicate lung tumor.
  • Profuse, frothy, pink material ; Indicate pulmonary odema.
  • Foul-smelling sputum & bad breath ; Indicate lung abscess, infection from anaerobic organism.
major signs and symptoms of the respiratory diseases7
Major signs and symptoms of the respiratory diseases:
  • Cough management:
    • Adequate hydration (water).
    • Inhalation of nebulizer.
    • Stop smoking.
5 chest pain
5-Chest pain:

Chest pain may be sharp stabbing & intermittent or dull, aching & persistant:

Causes of chest pain:

    • It is a late symptom of bronchogenic carcinoma.
    • Pneumonia, pulmonary embolism, lung infarction & pleurisity.
    • Pleuritic pain from irritation of partial pleura is sharp (like the stabbing of knife). Pt. becomes comfortable when sleeps on the affected side.
  • Pain must assessed for quality, intensity, radiation of pain, relationship of pain to inspiratory & expiratory.
nursing interventions for chest pain
Nursing interventions for chest pain:
  • Analgesic medication but not to depress the respiratory center or productive cough.
  • NSAID for pleurituic pain.
  • Regional anesthetic block may be performed to decrease extreme pain.
major signs and symptoms of the respiratory diseases10
Major signs and symptoms of the respiratory diseases:

6- Wheezing: Is a major finding in pt. with bronchoconstriction or airway narrowing.

Wheezing is a high pitched, musical sound heard mainly on expiration.

Relived by: Oral or inhaled bronchodilator.

7- Clubbing of the fingers: is a sign of chronic hypoxic condition, chronic lung infections, CA of lung.

major signs and symptoms of the respiratory diseases11
Major signs and symptoms of the respiratory diseases:

7- Hemoptysis: Is symptom of both pulmonary & cardiac disorders.

  • Onset is sudden, may be intermittent or continuous.

Common cause:

  • Pulmonary infection.
  • CA of lung.
  • Abnormalities of heart & blood vessels.
  • Pulmonary artery or vein abnormalities.
  • Pulmonary emboli & infarction.
major signs and symptoms of the respiratory diseases12
Major signs and symptoms of the respiratory diseases:

9- Cyanosis: Is a bluish coloring of skin, very late indicator of hypoxia.

  • Cyanosis is not reliable singe of hypoxia. Because anemic pt. rarely manifest cyanosis.
  • In the presence of pulmonary disease cyanosis assessed by tongue & lips.
  • Peripheral cyanosis results from decrease blood flow to certain area & not indicate central problem.
diagnostic evaluation
Diagnostic evaluation
  • Pulmonary function test. Routinely used in pt. with chronic respiratory disorders, test should measurements of lung volume, ventilatory function & mechanism of breathing diffusion & gas exchange.
  • Arterial blood gas study. Aid in assessing the ability of the lungs to provide adequate O2 & remove CO2, the ability of kidney to reabsorb & excrete bicarbonate ions to maintain body normal PH.
diagnostic evaluation14
Diagnostic evaluation
  • Pulse oximetry; Monitor O2 sat. of hemoglin.

Normal O2 sat. is 95-100%, decrease 85 indicate that tissue are not receiving enough o2.

  • Culture; Specimen to lab must be within 2 hr.s (overgrowth of organisim). Specimen taken at morning.
  • Imagining studies;.

1-Chest x-ray: normal pulmonary tissue is radiolucent, there for densties produced by fluid, tumors, foreign bodies & pathogenic condition can be detected by x-ray.

2-CT : used to identify pulmonary nodules & small tumors that are not visible on routine chest x-ray.

diagnostic evaluation15
Diagnostic evaluation

3-MRI :are more diagnostic image than CT to characterized pulmonary nodules.

4-Fluoroscopic studies: used to detect diaphragm paralysis & lung masses.

5-Pulmonary angiography: used to investigate thromboembolic disease of the lung as congenital abnormalities of pulmonary vascular tree.

6-Radioisotope (lung scan).Ventilation- perfusion lung scan to measure the integrity of pulmonary vessels to evaluate blood flow abnormalities as seen in pulmonary emboli.

vi endoscopic procedure
VI. Endoscopic procedure;

Bronchoscopy is direct inspection & examination of the larynx, trachea, & bronchi through either a flexible fiberoptic scope or rigid bronchoscope.

Diagnostic Bronchoscopy.

  • To examine tissue or collect secreations.
  • To determine location & obtain tissue.
  • To determine if tumor can be resected surgically.
  • To DX. Bleeding site.

Therapeutic bronchoscopy :

  • Remove foreign bodies.
  • Remove Secreation from the tracheobronchial tree.
  • Treat post operative atelactasis.
  • Destroy & excise lesion.
nsg intervention
NSG intervention:
  • consent form
  • Keep NPO
  • Explain procedure
  • Preoperative medication ( atropine, sedation) that inhibit vagal stimulation, suppress cough.
  • Post op. pt. must be NPO until the cough reflex returns.
  • Ice-chips & fluid given.
  • Observe v/s, hypoxia, bleeding, hypotention, tachycardia, dysarythmia.
thoracentesis
Thoracentesis
  • Aspiration of fluid from the pleural cavity for DX. Or therapeutic purposes).
  • Study includes grams stain culture & sensitivity, acid- fast staining, PH.