Respiratory Assessment Research Paper
Using the guidelines in Wilson & A ; Giddens’ Ch. 11 and pictures. execute a respiratory appraisal procedure on a patient or a important other. Write up your findings following the guidelines and post them here. It is of import for nurses in all pattern scenes to be able to execute a basic respiratory appraisal. This includes taking a pertinent patient history and utilizing the techniques of review. tactual exploration. percussion. and auscultation. Immediately upon run intoing a patient I am looking to see if they are able to ambulate without marks or symptoms of respiratory hurt and I find out if they have had a recent external respiration intervention that is working to temporarily alleviate their status – it is of import to maintain in head that they may deteriorate faster than originally anticipated.Respiratory Assessment Research Paper
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Important inquiries for respiratory assessment include: past and current medical problems- do they hold a diagnosing of asthma. emphysema. chronic clogging pneumonia upset. or lung malignant neoplastic disease? Were they late diagnosed with an upper respiratory infection. bronchitis. or pneumonia? Do they presently have a cough- strong or weak. for how long. and is it productive or non- productive? If there is sputum production- what is the color and consistence? Has at that place been any hemophiliacs? Is at that place any wheezing or increased shortness of breath with exertion- from speaking and/ or walking? Have they experienced any chest hurting? If yes I ask about strength. location. continuance. is it consistent?Respiratory Assessment Research Paper
Is it relieved by anything or made worse by anything? I ask if they have experienced any dark workout suits or if they have noted any swelling in their upper or lower appendages. I find out about their smoke habits- do they smoke presently? If they say they have quit so I ask when and how many battalions per a twenty-four hours for how many old ages did they smoke prior to discontinuing? Besides. I like to happen out if they are around 2nd manus fume. Do they utilize drugs- particularly 1s that are inhaled. What do they hold for allergic reactions? If none to drugs I ask about environmental. animate being. and work related thorns. Is at that place any household history of lung disease. malignant neoplastic disease. TB. cystic fibrosis. emphysema. or asthma?
I besides ask the patient whether or non they have had an one-year grippe and/ or pneumonia vaccine. After the interview is completed. I proceed through the stairss of a respiratory physical appraisal: review. tactual exploration. percussion. and auscultation. Ideally. I would place the patient vertical and have them breathe through their oral cavity to better detect respiratory rate. form. attempt. and chest enlargement. I am looking for clubbing. weight loss. unevenly developed musculuss. tegument & A ; mucous membrane alterations. and the general visual aspect of the patient.Respiratory Assessment Research Paper
I use my stethoscope to listen to breath sounds- I’m comparing the front tooth. buttocks. and sidelong thorax. I am listening for quality. strength. and the possible presence of adventitious sounds. I palpate the windpipe. thoracic musculuss. and thoracic wall looking for proper place. symmetricalness and tactile fremitus. every bit good as. any marks of tenderness or bumps. ( Wilson & A ; Giddens. 2013. pp. 191- 216 ) My pattern patient is a 28 twelvemonth old healthy looking male who is able to ambulate with a steady & A ; independent pace free of any acute respiratory hurt. He denies any past or current medical jobs. He besides denies any household history of lung jobs but subsequently admits that he was adopted so he “doesn’t really know” . He has no known drug allergic reactions but provinces that he normally suffers from seasonal allergic reactions in the spring clip
. This patient denies smoke and drug usage but adds “I do bask smoking narghile now and so. ” As antecedently mentioned this is a healthy looking male patient who is good developed and whose tegument. lips. and nails are appropriate colour. His external respiration is quiet and effortless with a regular rate. Thoracic enlargement is symmetric bilaterally. His thorax is symmetric with ribs inclining downward at 45 grades comparative to the spinal column. His windpipe is midline.Respiratory Assessment Research Paper
He denies any tenderness and no bumps are noted with tactual exploration. Breath sounds are clear bilaterally- vesicular sounds heard over most lung Fieldss. bronchovesicular sounds heard in the posterior thorax over the upper centre country of the dorsum and around the sternal boundary line. and bronchial breath sounds heard over the windpipe. ( 2013. pp. 217 ) 2. What are the “patient’s” respiratory hazard factors? What lifestyle alterations could take down these hazards? What would it take to do even some minor alterations in their life style to profit their wellness position? The patient above was healthy but still has hazard factors.Respiratory Assessment Research Paper
He is adopted and does non cognize his birth parents medical history and although he ab initio responded no to smoking he did finally acknowledge that he “enjoys smoking narghile. ” Hookah is a centuries-old tradition that involves smoking flavored baccy through a H2O pipe “an unsloped device with a little platform where baccy is burned. a metal organic structure. a basal half-filled with H2O. and a hosiery with a mouthpiece for inhaling” ( Dugas. Tremblay. Low. Cournoyer. O’Loughlin. 2010 ) .Respiratory Assessment Research Paper
Research workers have found that narghile is more popular among people who are under 30. male. speak English. make non populate with their parents. and have a higher household income. ( 2010 ) Harmonizing to Doctor Lowell Dale from the Mayo Clinic ( 2013 ) “Hookah smoke is non safer than coffin nail smoke. Hookah smoke contains high degrees of toxic compounds. including pitch. C monoxide. heavy metals and cancer-causing chemicals ( carcinogens ) . In fact. narghile tobacco users are exposed to more C monoxide and fume than coffin nail tobacco users. “Respiratory Assessment Research Paper
As with coffin nail smoke. narghile smoke is linked to lung and unwritten malignant neoplastic diseases. bosom disease. and other serious unwellnesss. Hookah smoke can perchance take to tobacco dependance because the participant is having every bit much nicotine as person who smokes coffin nails. And hookah pipes used in narghile bars and coffeehouse may non be cleaned decently which increases the hazard of undertaking an infective disease. ( 2013 ) My patient merely has to halt smoke narghile to significantly diminish his hazards and profit his health- that’s my prejudice. When asked about the frequence of his narghile usage my patient responds “I don’t fume that often- likely one time every twosome months when out with friends. ” 3. With the cognition you have gained therefore far in holistic nursing and self-care patterns how could you train the client to better upon their ain self-care?
Use Dossey and Keegan Chapters 9-10 to assist ease their lifestyle hazard factor alteration procedure? I would utilize motivational interviewing because the cardinal premiss is that a patient’s ambivalency affects their motive and preparedness to change behaviour. ( Dossey & A ; Keegan. 2013. pp. 207 ) When utilizing motivational questioning the nurse must defy the impulse to leap in with a solution to the job because it is the patient who should be acknowledging the demand and puting ends toward alteration.Respiratory Assessment Research Paper
The nurse must research the patient’s concerns. perceptual experiences. and motivation- leting them to see themselves doing the alterations is the key of the partnership. The nurse must concentrate on being a good hearer and demoing empathy. “The nurse helps the patient detect how alteration can happen… Supplying ongoing encouragement to further the belief that ends are accomplishable can assist the patient carry out a program to alter behaviour. ” ( 2013. pp 207 ) 4. Using Dossey and Keegan Ch. 23. p. 535. consider all of the countries for “nurse therapist reflections” and back uping clients through smoke surcease.Respiratory Assessment Research Paper
What holistic stairss could be used to back up an person with the desire to halt smoke? In fixing to utilize smoking surcease intercessions the nurse must first buttocks non merely the patient’s degree of dependence to coffin nails. but besides the existent emotional significance of smoking to the patient. their attitudes and beliefs about successful smoke surcease. their motive to larn. their current phase of alteration. their exercising and eating wonts. bing stress direction forms. and support web. ( Dossey & A ; Keegan. 2013. pp. 530 )
It is of import to taking clip to use “pre-quitting” schemes such as a diary- this helps supply penetration into feelings environing the existent act of smoke. encephalon storm with the patient sing schemes that they think would assist them discontinue. hold the patient wage particular attending to diet and exercise- cleanse the organic structure and auto and house off all things nicotine – wage attending to smell- promote them to pattern little Acts of the Apostless of detaining satisfaction to construct up their feelings of self-denial and remind them to utilize household and friends as support. Have the patient choose the quit day of the month and subscribe a contract.Respiratory Assessment Research Paper
Practice relaxation and ocular imagination accomplishments. Discuss high hazard state of affairss and come up with ways to forestall a backsliding. Work together to set up ends of behavior alterations and new wont creative activities. Make a agenda of wagess for run intoing their personal ends. Evaluate. encourage. support. and reinforce. Helping the patient turn to their implicit in emotional issues and temper perturbations is most of import to assisting the patient accomplish a new degree of self-awareness. enhance healing. and prevent backsliding.
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In our survey, we have tried to measure the frequency of incidence of respiratory piece of land infections in grownups and other correlative factors intensifying the happening of such diseases in our metropolis, Kolkata. We have explored the most common Respiratory Tract Infections suffered from, the cor relativity between Upper and Lower Respiratory Tract Infections, the seasonal fluctuation and frequency of the disease, the relationships between age and the type of disease, age and frequency of the disease ; the relationship between smoke and the disease enduring from, smoking and frequency of the disease and smoke and the seasonal fluctuation of the disease. The Pearson Chi-Square trial for in dependency has been principally applied as a tool for set upping the above relationships on the footing of a sample size of 68. The information’s were procured by go a rounding a questionnaire among patients of different age groups with standard inquiries on the information we required. The probe has revealed that the most common respiratory piece of land diseases suffered from are Chronic Obstructive Pulmonary disease ( COPD ) and Bronchitis. Patients enduring from Upper Respiratory tract infections show greater susceptible to Lower Respiratory tract infections as good. Seasonal fluctuation of respiratory piece of land infections is infrequent although there is an increased incidence during the winter. The frequency of the diseases increases with age and the patients in the age group 60 – 70 and 70-80 suffer chiefly from COPD while those have age less than 20, suffer chiefly from Asthma. The frequency of these infections is more for tobacco users than for non-smokers. Non-smokers chiefly suffer from Bronchitis and Asthma while the regular tobacco users suffer chiefly from COPD.Respiratory Assessment Research Paper
In our survey, we have tried to measure the frequence of incidence of respiratory piece of land infections in grownups and other correlative factors intensifying the happening of such diseases in our metropolis, Kolkata. We have explored the most common Respiratory Tract Infections suffered from, the correlativity between Upper and Lower Respiratory Tract Infections, the seasonal fluctuation and frequence of the disease, the relationships between age and the type of disease, age and frequence of the disease ; the relationship between smoke and the disease enduring from, smoking and frequence of the disease and smoke and the seasonal fluctuation of the disease. The Pearsonian Chi-Square trial for independency has been principally applied as a tool for set uping the above relationships on the footing of a sample size of 68. The informations were procured by go arounding a questionnaire among patients of different age groups with standard inquiries on the information we required. The probe has revealed that the most common respiratory piece of land diseases suffered from are Chronic Obstructive Pulmonary disease ( COPD ) and Bronchitis. Patients enduring from Upper Respiratory tract infections show greater susceptibleness to Lower Respiratory tract infections as good. Seasonal fluctuation of respiratory piece of land infections is infrequent although there is an increased incidence during the winter. The frequence of the diseases increases with age and the patients in the age group 60 – 70 and 70-80 suffer chiefly from COPD while those have age less than 20, suffer chiefly from Asthma. The frequence of these infections is more for tobacco users than for non-smokers. Non-smokers chiefly suffer from Bronchitis and Asthma while the regular tobacco users suffer chiefly from COPD.Respiratory Assessment Research Paper
Given the current addition in incidences of respiratory piece of land upsets every bit good as increasing mortality caused by them worldwide we have undertaken this little survey to measure the state of affairs in our metropolis, Kolkata.Respiratory Assessment Research Paper
Respiratory piece of land upsets can be classified as either Upper respiratory piece of land upsets or lower respiratory tract 1s. Upper respiratory piece of land upsets are by far the most common ailments worldwide. They are for the most portion self-limiting, but however topographic point a considerable load of work on general practioners and have an of import economic impact on the community. Such unwellness may besides be complicated by lower respiratory tract infections in both kids and grownups likewise, particularly in the development states where deficiency of proper anti-microbial therapy leads to considerable mortality. Coryzal symptoms of viral beginning often precede the oncoming of pneumococcal pneumonia which like common cold shows an increased incidence in the winter months. The season of viral respiratory piece of land infections is besides associated with an increased frequence of asthma and other lower respiratory piece of land diseases like chronic bronchitis and Chronic Obstructive Pulmonary Disease ( COPD ) . Upper respiratory piece of land infections may besides be debatable in immunocompromised patients as a consequence of assorted conditions, including immunosuppression following organ transplant and AIDS.Respiratory Assessment Research Paper
While frequently used as a equivalent word for pneumonia, the rubric of lower respiratory tract infections can besides be applied to other types of infections including acute bronchitis, TB, lung abscess and even emphysema. Lower respiratory tract infections are by and large more serious than Upper respiratory piece of land infections. Since 1993, there has been a little decrease in the entire figure of deceases from Lower respiratory tract infections. However, in 2002, they were still the taking cause of deceases among all infective diseases, accounting for 3.9 million deceases worldwide.Respiratory Assessment Research Paper
Etiology: Respiratory tract infections can be throughout the respiratory piece of land with redness of the mucosal surfaces of the person ‘s nose, fistulas, pharynx, ears and thorax. The inflammatory response to the pathogen and/or the air pollutants produces swelling, discharge and even local hurting. Most of the common upper respiratory tract infections such as bronchitis are caused by viruses belonging to the Rhinovirus and Corona virus households. Bronchitis occurs when the windpipe and the big and little bronchial tube within the lungs become inflamed. Apart from colonisation by bugs, inspiration of annoying exhausts and dust, chemical dissolvers and fume have besides been found to be related to acute bronchitis. Asthma is caused by chronic redness of the air transitions of lungs which swell and fill with mucous secretion, doing narrowing of the transitions and troubles in halitus of air.Respiratory Assessment Research Paper
Serious lower respiratory tract infections include pneumonia, Chronic Obstructive Pulmonary Diseases ( COPD ) and pneumobronchitis, among many others. Pneumonia is an infection of the little bronchioles and air sacs that can affect the pleura. Pathogens doing this include Streptococcus pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila. In COPD, there is a cardinal infective function which progresses to obstruction by doing deformation and fibrosis of terminal air passages, loss of alveolar fond regards, mucous secretion hypersecretion and smooth musculus contraction. Here, exposure to allergens, pollutants, inhaled thorns and particularly coffin nail smoking drama of import functions. Bacterial infection is present in 70 to 75 % of aggravations including Sptreptococcus pneumoniae, Haemophilus pneumoniae and Moraxella catarrhalis. Harmonizing to the latest WHO estimates ( 2007 ) , presently 210 million people have COPD and 3 million people died of COPD in 2005. WHO predicts that COPD will go the 3rd prima cause of decease worldwide by 2030.Respiratory Assessment Research Paper
Smoke and Respiratory Tract Infection: Surveies reveal that coffin nail smoke alters the respiratory piece of land ‘s ability to support itself from infection. Smokers appear to hold a higher frequence of respiratory piece of land infections than non-smokers, and an increased badness of symptoms when infected. Exposure to passive smoke additions opportunities of respiratory unwellnesss in non tobacco users and kids. Cigarette smoke is associated with changes in mechanisms of the host defence system: ciliary map of the piece of land is impaired, mucose volume is increased, humoral response to antigens altered, and quantitative and qualitative alterations in cellular constituents occur. Some of these changes in host defence mechanisms revert to normal after smoking surcease.Respiratory Assessment Research Paper
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Treatment: Despite the viral causes of Upper Respiratory Tract Infections, several surveies have shown that the bulk of instances of Upper Respiratory Infections are treated with antibiotics. Randomized controlled tests of antibiotic intervention of Upper Respiratory Infections have systematically demonstrated no benefit from taking antibiotics. Alternatively, an addition in side-effects and even antibiotic opposition was found with their usage. Hence diagnostic attention and some antiviral drugs like Amantidine and Rimantidine remain the intervention of pick. However, the usage of antibiotics is justified in certain higher hazard patients with underline lung diseases like COPD. Antibiotic therapy for lower respiratory infections as COPD and pneumonia includes augmented penicillin, Amoxycillin and fluoroquinolones. ( Grossman R et Al, 2005 ) Systemic alleviation is brought about by bronchodilators. A short class of systemic steroids may besides supply of import benefits in patients with COPD aggravations.Respiratory Assessment Research Paper
Respiratory failure is one of the most common reasons for admission to the intensive care unit (ICU) and a common comorbidity in patients admitted for acute care. What’s more, it’s the leading cause of death from pneumonia and chronic obstructive pulmonary disease (COPD) in the United States. This article briefly reviews the physiologic components of respiration, differentiates the main types of respiratory failure, and discusses medical treatment and nursing care for patients with respiratory failure.Respiratory Assessment Research Paper
Physiologic components of ventilation and respiration
The lung is highly elastic. Lung inflation results from the partial pressure of inhaled gases and the diffusion-pressure gradient of these gases across the alveolar-capillary membrane. The lungs play a passive role in breathing, but ventilation requires muscular effort. When the diaphragm contracts, the thoracic cavity enlarges, causing the lungs to inflate. During forced inspiration when a large volume of air is inspired, external intercostal muscles act as a second set of inspiratory muscles.
Accessory muscles in the neck and chest are the last group of inspiratory muscles, used only for deep and heavy breathing, such as during intense exercise or respiratory failure. During expiration, the diaphragm relaxes, decreasing thoracic cavity size and causing the lungs to deflate. With normal breathing, expiration is purely passive. But with exercise or forced expiration, expiratory muscles (including the abdominal wall and internal intercostal muscles) become active. These important muscles are necessary for coughing.Respiratory Assessment Research Paper
Respiration—the process of exchanging oxygen (O2) and carbon dioxide (CO2)—involves ventilation, oxygenation, and gas transport; the ventilation/perfusion (V/Q) relationship; and control of breathing. Respiration is regulated by chemical and neural control systems, including the brainstem, peripheral and central chemoreceptors, and mechanoreceptors in skeletal muscle and joints.
A dynamic process, ventilation is affected by the respiratory rate (RR) and tidal volume—the amount of air inhaled and exhaled with each breath. Pulmonary ventilation refers to the total volume of air inspired or expired per minute.Respiratory Assessment Research Paper
Not all inspired air participates in gas exchange. Alveolar ventilation—the volume of air entering alveoli taking part in gas exchange—is the most important variable in gas exchange. Air that distributes to the conducting airways is deemed dead space or wasted air because it’s not involved in gas exchange. (See Oxygenation and gas transport.)
Ultimately, effective ventilation is measured by the partial pressure of CO2 in arterial blood (Paco2). All expired CO2 comes from alveolar gas. During normal breathing, the breathing rate or depth adjusts to maintain a steady Paco2 between 35 and 45 mm Hg. Hyperventilation manifests as a low Paco2; hypoventilation, as a high Paco2. During exercise or certain disease states, increasing breathing depth is far more effective than increasing the RR in improving alveolar ventilation.Respiratory Assessment Research Paper
Lung recoil and compliance
The lungs, airways, and vascular trees are embedded in elastic tissue. To inflate, the lung must stretch to overcome these elastic components. Elastic recoil—the lung’s ability to return to its original shape after stretching from inhalation—relates inversely to compliance. Lung compliance indirectly reflects lung stiffness or resistance to stretch. A stiff lung, as in pulmonary fibrosis, is less compliant than a normal lung.Respiratory Assessment Research Paper
With reduced compliance, more work is required to produce a normal tidal volume. With extremely high compliance, as in emphysema where there is loss of alveolar and elastic tissue, the lungs inflate extremely easily. Someone with emphysema must expend a lot of effort to get air out of the lungs because they don’t recoil back to their normal position during expiration. In both pulmonary fibrosis and emphysema, inadequate lung ventilation leads to hypercapnic respiratory failure.Respiratory Assessment Research Paper
Respiratory failure
Respiratory failure occurs when one of the gas-exchange functions—oxygenation or CO2 elimination—fails. A wide range of conditions can lead to acute respiratory failure, including drug overdose, respiratory infection, and exacerbation of chronic respiratory or cardiac disease.
Respiratory failure may be acute or chronic. In acute failure, life-threatening derangements in arterial blood gases (ABGs) and acid-base status occur, and patients may need immediate intubation. Respiratory failure also may be classified as hypoxemic or hypercapnic.
Clinical indicators of acute respiratory failure include:
partial pressure of arterial oxygen (Pao2) below 60 mm Hg, or arterial oxygen saturation as measured by pulse oximetry (Spo2) below 91% on room air
Paco2 above 50 mm Hg and pH below 7.35
Pao2 decrease or Paco2 increase of 10 mm Hg from baseline in patients with chronic lung disease (who tend to have higher Paco2 and lower PaO2 baseline values than other patients).
In contrast, chronic respiratory failure is a long-term condition that develops over time, such as with COPD. Manifestations of chronic respiratory failure are less dramatic and less apparent than those of acute failure.Respiratory Assessment Research Paper
Three main types of respiratory failure
The most common type of respiratory failure is type 1, or hypoxemic respiratory failure (failure to exchange oxygen), indicated by a Pao2 value below 60 mm Hg with a normal or low Paco2 value. In ICU patients, the most common causes of type 1 respiratory failure are V/Q mismatching and shunts. COPD exacerbation is a classic example of V/Q mismatching. Shunting, which occurs in virtually all acute lung diseases, involves alveolar collapse or fluid-filled alveoli. Examples of type 1 respiratory failure include pulmonary edema (both cardiogenic and noncardiogenic), pneumonia, influenza, and pulmonary hemorrhage. (See Ventilation and perfusion: A critical relationship.)Respiratory Assessment Research Paper
Type 2, or hypercapnic, respiratory failure, is defined as failure to exchange or remove CO2, indicated by Paco2 above 50 mm Hg. Patients with type 2 respiratory failure who are breathing room air commonly have hypoxemia. Blood pH depends on the bicarbonate level, which is influenced by hypercapnia duration. Any disease that affects alveolar ventilation can result in type 2 respiratory failure. Common causes include severe airway disorders (such as COPD), drug overdose, chest-wall abnormalities, and neuromuscular disease.Respiratory Assessment Research Paper
Type 3 respiratory failure (also called perioperative respiratory failure) is a subtype of type 1 and results from lung or alveolar atelectasis. General anesthesia can cause collapse of dependent lung alveoli. Patients most at risk for type 3 respiratory failure are those with chronic lung conditions, excessive airway secretions, obesity, immobility, and tobacco use, as well as those who’ve had surgery involving the upper abdomen. Type 3 respiratory failure also may occur in patients experiencing shock, from hypoperfusion of respiratory muscles. Normally, less than 5% of total cardiac output flows to respiratory muscles. But in pulmonary edema, lactic acidosis, and anemia (conditions that commonly arise during shock), up to 40% of cardiac output may flow to the respiratory muscles.Respiratory Assessment Research Paper
Signs and symptoms of respiratory failure
Patients with impending respiratory failure typically develop shortness of breath and mental-status changes, which may present as anxiety, tachypnea, and decreased Spo2 despite increasing amounts of supplemental oxygen.
Acute respiratory failure may cause tachycardia and tachypnea. Other signs and symptoms include periorbital or circumoral cyanosis, diaphoresis, accessory muscle use, diminished lung sounds, inability to speak in full sentences, an impending sense of doom, and an altered mental status. The patient may assume the tripod position in an attempt to further expand the chest during the inspiratory phase of respiration. In chronic respiratory failure, the only consistent clinical indictor is protracted shortness of breath.
Be aware that pulse oximetry measures the percentage of hemoglobin saturated with oxygen, but it doesn’t give information about oxygen delivery to the tissues or the patient’s ventilatory function. So be sure to consider the patient’s entire clinical presentation. Compared to SpO2, an ABG study provides more accurate information on acid-base balance and blood oxygen saturation. Capnography is another tool used for monitoring patients receiving anesthesia and in critical care units to assess a patient’s respiratory status. It directly monitors inhaled and exhaled concentration of CO2 and indirectly monitors Paco2.Respiratory Assessment Research Paper
Treatment and management
In acute respiratory failure, the healthcare team treats the underlying cause while supporting the patient’s respiratory status with supplemental oxygen, mechanical ventilation, and oxygen saturation monitoring. Treatment of the underlying cause, such as pneumonia, COPD, or heart failure, may require diligent administration of antibiotics, diuretics, steroids, nebulizer treatments, and supplemental O2 as appropriate.
For chronic respiratory failure, despite the wide range of chronic or end-stage pathology present (such as COPD, heart failure, or systemic lupus erythematosus with lung involvement), the mainstay of treatment is continuous supplemental O2, along with treatment of the underlying cause.
Nursing care
Nursing care can have a tremendous impact in improving efficiency of the patient’s respiration and ventilation and increasing the chance for recovery. To detect changes in respiratory status early, assess the patient’s tissue oxygenation status regularly. Evaluate ABG results and indices of end-organ perfusion. Keep in mind that the brain is extremely sensitive to O2 supply; decreased O2 can lead to an altered mental status. Also, know that angina signals inadequate coronary artery perfusion. In addition, stay alert for conditions that can impair O2 delivery, such as elevated temperature, anemia, impaired cardiac output, acidosis, and sepsis.Respiratory Assessment Research Paper
As indicated, take steps to improve V/Q matching, which is crucial for improving respiratory efficiency. To enhance V/Q matching, turn the patient on a regular and timely basis to rotate and maximize lung zones. Because blood flow and ventilation are distributed preferentially to dependent lung zones, V/Q is maximized on the side on which the patient is lying.
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Regular, effective use of incentive spirometry helps maximize diffusion and alveolar surface area and can help prevent atelectasis. Regular rotation of V/Q lung zones by patient turning and repositioning enhances diffusion by promoting a healthy, well-perfused alveolar surface. These actions, as well as suctioning, help mobilize sputum or secretions.Respiratory Assessment Research Paper
Nutritional support
Patients in respiratory failure have unique nutritional needs and considerations. Those with acute respiratory failure from primary lung disease may be malnourished initially or may become malnourished from increased metabolic demands or inadequate nutritional intake. Malnutrition can impair the function of respiratory muscles, reduce ventilatory drive, and decrease lung defense mechanisms. Clinicians should consider nutritional support and individualize such support to ensure adequate caloric and protein intake to meet the patient’s respiratory needs.Respiratory Assessment Research Paper
Patient and family education
Provide appropriate education to the patient and family to promote adherence with treatment and help prevent the need for readmission. Explain the purpose of nursing measures, such as turning and incentive spirometry, as well as medications. At discharge, teach patients about pertinent risk factors for their specific respiratory condition, when to return to the healthcare provider for follow-up care, and home measures they can take to promote and maximize respiratory function.
This lesson examines a nursing approach to respiratory assessment. We will review the respiratory system’s structure and function and describe how to perform a history and physical focusing on this system, making use of subjective data, objective data, and documentation of the assessment process.Respiratory Assessment Research Paper
The Respiratory System
You are a new nurse excited to get started in your new job in the emergency room. The first patient of the day is a young man in his late 20s, who is complaining of shortness of breath. For a second you freeze. You try to think back to nursing school and where to start with a respiratory assessment.
The respiratory system’s purpose is supplying oxygen to and removing carbon dioxide from the body. To this end, your patient must be able to perform the actions of inspiration (breathing in) and expiration (breathing out).
Normal breathing should be quiet and require little effort. The respiratory rate in a healthy adult patient ranges from 12-20 breaths per minute at rest. The oxygen saturation (a measure of how much oxygen is in the blood) should be above 92.
Inspection
After taking a thorough family history and reviewing your patient’s current medications, ask your patient about his energy level, ability to perform activities, smoking status, vaccination status, and current symptoms, such as chest pain, shortness of breath, or wheezing.Respiratory Assessment Research Paper
Objective Data: Physical Examination
Looking at your patient and observing him as he breathes is the first step. Take note of the rate, rhythm (should be regular), depth, and effort of breathing (should be easy with minimal effort).
Look at the chest’s shape: a normal-shaped chest is wider than it is deep; however, older adults or those with chronic obstructive pulmonary disorder (COPD) may develop a barrel chest (measures longer front to back than side to side).Respiratory Assessment Research Paper
Look at the color of the mucus membranes of the mouth, skin, and nail beds.
Additionally, take note of the patient’s mental status, as diminished mental functioning may be a sign of hypoxia (too little oxygen in the blood).
Palpation and Percussion
The second step involves putting hands on the patient to feel whether their respiratory anatomy is normal or abnormal.
Testing chest expansion involves placing your hands palm down on your patient’s back with your thumbs at the level of the 10th ribs on each side and your fingers spread. Ask him to breathe deeply; your hands should move symmetrically.Respiratory Assessment Research Paper
Feel for tactile fremitus (vibrations from the lungs that you can feel through the skin). Ask your patient to say ninety-nine with your palms on his back. You should feel an even, slight vibration. Increased fremitus in a certain area suggests consolidation, an area of concentrated liquid, in the lung, as in pneumonia. Decreased fremitus suggests an obstruction to air flow.
You may also feel for crepitus, a course, crackling sensation that suggests air trapped under the skin. This may happen after trauma or surgery.
The percussion step involves using the middle finger of your dominant hand to firmly and quickly tap the middle finger of your nondominant hand against your patient’s chest. This creates vibrations that help you determine whether the underlying tissues are healthy. The following sounds give you clues:
Flatness – A short, soft, high-pitched sound, similar to how it would sound if you tapped your thigh. This indicates fluid.
Dullness – A thud-like sound. This also suggests fluid.
Resonance – A loud, hollow sound. This indicates air and is a healthy sound to hear over the lungs.
Hyperresonance – A very loud, lower-pitched round, similar to what you would hear over the stomach. This suggests the lung is hyper-inflated.Respiratory Assessment Research Paper
Tympany – A high-pitched, drum-like sound. This suggests excess air.
A changing respiratory rate (RR) measurement is cited as an early indicator of patient deterioration (Dougherty and Lister, 2015), but there are other respiratory signs that can be observed in conjunction with it.
In normal breathing a fairly steady rate, inspiratory volume and depth of chest movement are maintained, with equal expansion and symmetry. In the resting state normal breathing is relaxed, regulating the gas exchange in the lungs to maintain homoeostasis and balance pH changes and metabolism.
When there is an increased demand on the respiratory system from an acute episode, such as a chest infection, or long-term conditions, such as chronic obstructive pulmonary disease, the respiratory rhythm and chest movement change. These changes are compensatory mechanisms as a direct result of a chemical imbalance; and the primary cause may be mechanical, metabolic or neurological. The changes result in an increase or decrease in RR, depth of breathing and pattern of breathing.Respiratory Assessment Research Paper
Changes in rhythm and chest movements are made through feedback mechanisms to the central respiratory control centres of the brain. A range of receptors provide information that is interpreted in the higher respiratory centre, modulating RR and chest movement (Feldman and Del Negro, 2006); these receptors are:
Peripheral chemo receptors found in the carotid artery detect changes in PaO2 in the blood as well as PaCO2 and pH;
Central chemo receptors in the ventral medullary surface of the medulla oblongata in the brain detect pH changes;
Preceptors are stretch receptors located in the smooth muscle of the main airways and parenchyma. They respond to excessive stretching of the lung during inspiration and send signals to the apneustic centre of the pons (located in the brain stem); the pons controls inspiration and expiration.Respiratory Assessment Research Paper
Respiratory rhythm and chest movement
Normal
In relaxed normal breathing the RR is 12-20 breaths per minute (bpm) (Royal College of Physicians, 2017). Chest expansion on inspiration should be the same or similar on each breath. The chest wall is symmetrical, accessory (neck and shoulder) muscles are not used, diaphragm muscles are functioning, and there is no paradoxical movement – the chest and abdomen move in the same direction on inspiration and expiration.
Abnormal
There are several reasons why respiratory rhythm and chest movement may change. Abnormality in respiratory rhythm may be related to changes in the patient’s metabolic state; for example, a patient with diabetic ketoacidosis may exhibit signs of rapid, deep breaths. Such breathing (often called Kussmaul’s breathing) aims to reduce the level of CO2 in the blood to maintain a normal pH and re-establish a homeostatic state.Respiratory Assessment Research Paper
Patients with chest pain may have rapid but shallow breaths because deep breaths cause discomfort; in patients with rib fractures adequate pain relief is paramount to restore a normal depth and rate of breathing
The ability to carry out and document a full respiratory assessment is an essential skill for all nurses. The elements included are: an initial assessment, history taking, inspection, palpation, percussion, auscultation and further investigations. A prompt initial assessment allows immediate evaluation of severity of illness and appropriate treatment measures may warrant instigation at this point. Following this, a comprehensive patient history will be elicited. Clinical examination of the patient follows and involves inspection, palpation, percussion and auscultation. At this point, consideration must be given to preparation of a light, warm, quiet, private environment for examination and suitable patient positioning. Inspection is a comprehensive visual assessment, while palpation involves using touch to gather information. The next stages are percussion and auscultation. While percussion is striking the chest to determine the state of underlying tissues, auscultation entails listening to and interpreting sound transmission through the chest wall via a stethoscope. Finally, further investigations may be necessary to confirm or negate suspected diagnoses.Respiratory Assessment Research Paper
If you’re a med-surf nurse, you probably don’t care for pediatric patients often. But when the occasion arises, are you confident of your pediatric knowledge base?
In children, little things can mean a lot. For instance, did you know that a 1-mm occlusion (as from mucus or edema) in a child’s respiratory tract increases airway resistance 16%, causing immediate respiratory compromise?
To help ensure proper diagnosis, aid early preventive treatment, and promote improved outcomes, you need to be familiar with normal pediatric assessment findings. If you’re alert for subtle or seemingly minor details, you can help your patient avoid the lasting effects of hypoxia, or—worst case scenario—loss of life. This article provides a basic review of pediatric respiratory assessment. (If you’re a pediatric nurse, think of it as a quick refresher course.)Respiratory Assessment Research Paper
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Pediatric points of difference
Keep in mind these essential facts about a child’s respiratory system:
• At birth, the respiratory system isn’t fully developed. Consequently, respiratory de compensation occurs more rapidly in children and recovery takes longer.
• Alveoli keep expanding and replicating until about age 4. The lungs develop completely between ages 5 and 6, and alveolar maturation reaches adult capacity during adolescence.
• Age and respiratory rate have an inverse relationship: the younger the child, the faster the respiratory rate.
• Preterm infants have weak respiratory muscles. They also experience periodic breathing, marked by episodes of rapid breathing and apnea, which may lead to hypoxia.
• Children breathe mainly through the nose until about age 4 weeks (or in some cases, up to several months).
• A child’s diaphragm is flatter than an adult’s.Respiratory Assessment Research Paper
• Infants and children have smaller airways than adults, leading to increased airway resistance, which manifests as a rapid respiratory rate.
• Because of increased airway resistance and nasal breathing, children are at high risk for airway obstruction, even with minimal amounts of mucus or edema. (See Common respiratory disorders in children in pdf format available by clicking download now.)
• Infants and children have abnormally large tongues, which can cause airway obstruction.
• Children have thinner chest walls than adults and therefore louder breath sounds.
• A child’s chest has cartilaginous structures that increase lung compliance (and also promote cooperation during auscultation).
Make age-appropriate alterations
Gear your respiratory assessment not just to the child’s age and size but also to cognitive and functional status. One way to gauge cognitive status is to maintain a steady dialogue during the exam.
With a child who’s too young to provide a medical history or describe symptoms, direct your questions to the parent or other accompanying adult. Ask open-ended questions to help elicit a full description of the problem.
Try to get an older child or adolescent to describe the symptom or concern in his or her own words. Ask about the history of the problem, including when it began; its location, quality, severity, and timing (frequency); whether it has changed or progressed (and if so, how); and what makes the symptom better or worse.
Use the right stethoscope
Be sure to use a stethoscope with a smaller bell and diaphragm than an adult stethoscope—especially for an infant or toddler. If you use a stethoscope that’s too large, you will have a harder time isolating respiratory sounds and may miss important findings.
Put the child at ease
If appropriate, have the child sit on the parent’s lap during the exam to promote calm and quiet. To put the child at ease, make the exam go more smoothly, and promote more accurate findings, let the child “help” with the exam. Explaining what you’re doing (in simple terms, of course) also helps calm the child. Consider role-playing, too; for instance, let the child handle the stethoscope while holding it against your chest or a parent’s or doll’s chest.Respiratory Assessment Research Paper
Initial inspection
Check for nasal flaring, which indicates accessory muscle use in an infant or toddler. Look for signs of respiratory effort, retractions, bulging of intercostal muscles, and head bobbing (an attempt to take in more air).
Chest auscultation
You should be able to auscultate a child’s chest fairly easily. (See Comparing normal and abnormal breath sounds in pdf format available by clicking download now.) Before auscultating, clear the nasal passages of a small child, if needed, to prevent distorted nasal sounds, which may be misinterpreted as abnormal (adventitious) breath sounds.
Timing is important: Auscultate at the start of the exam, when the child is most attentive and cooperative. Perform auscultation on a bare chest. (Clothing distorts the quality of respiratory sounds.) Hold the diaphragm of the stethoscope firmly against the child’s chest; to promote cooperation, have the child help with this maneuver.
Move the stethoscope from side to side to compare areas. Evaluate the child’s breath sounds along both the anterior and posterior chest walls. Listen for one full cycle of inspiration and expiration in all chest areas. Keep in mind that for both children and adults, the normal inspiratory-to-expiatory ratio is 1:2. An abnormal ratio may signal respiratory distress. In children with restrictive disease, the ratio may be 1:1; in those with acute upper airway obstruction, it may be 2:2 to 4:2. Such diseases as cystic fibrosis and acute asthma increase expiatory time. To differentiate the breath sounds you’re hearing, you may need to listen for several minutes.Respiratory Assessment Research Paper
Speak for the child
Remember—when assessing a pediatric patient, the smallest red flag could signal respiratory distress and warrants further investigation. Infants and young children can’t verbalize their symptoms; it’s your responsibility to conduct a full assessment accurately and report your findings promptly to the attending clinician or practitioner. You’re not just the child’s nurse; in many cases, you’re the child’s voice.Respiratory Assessment Research Paper
