Assessment of Oxygenation
Subjective Data
 Past History
– Upper resp infections
– Lower resp problems (asthma, TB, pneumonia,
COPD)
– Related illness that affect resp system – AIDS,
CHF
– Immunizations, TB skin tests, CXRs
– Allergies
– Medications
Subjective Data
 Family History
– Focus on resp illnesses
 Personal and social history
– Occupational history
 Factory, chemical plants, coal mines, farming, heavy traffic are all high
risk for respiratory system
– Smoking history
 How long? How much? (pk yrs = # pks/day X # years)
– Substance abuse
 ETOH – risk for aspiration pneumonia
 IV drugs and AIDS risk for pnuemonia
– Activity Tolerance
 SOB or fatigue with daily activities? How far/fast can you walk?
Subjective Data
 Specific Symptoms
– Cough
 How long?
 Onset (gradual, sudden);
 When (a.m., all day?)
 How often? Productive? How much?
 Color (yellow/green – bacteria; frothy pink –
pulmonary edema)
 Odor?
 Blood?
Subjective Data
 Specific Symptoms
– Shortness of breath (SOB)
 Precipitating factors, severity, duration
 Effect of position (lying down? Upright?)
 Association with other symptoms (chest pain, cough)
 What makes it better/worse (rest, oxygen, inhalers,
meds)
 Effect on activities?
– Chest pain
 PQRST (does breathing affect the pain?)
Objective Data
 Mouth, nose, pharynx, neck, heart
 Lungs and thorax
Objective Data: Inspection
 Note position (upright, leaning on table?)
 Evidence of respiratory distress/quality of
respirations
 Nasal flaring, accessory muscles, intercostal
retraction or bulging
 Shape and symmetry of chest
 Normal AP:transverse ratio is 1:2 – 5:7
 Barrel chest: increased AP diameter in relation to
transverse
Objective Data: Inspection
 Respiratory rate (N = 12 – 20)
 Respiratory pattern
 Tachypnea – rapid, shallow, > 24/min
 Bradypnea – slow (< 10/min)
 Hyperventilation – increased rate and depth
 Hypoventilation – shallow
 Cheyne-Stokes
Objective Data: Inspection
 Skin color
– Cyanosis (indicative of deoxygenated blood)
 Nails
– Clubbing (increased angle between base of nail
and fingernail to 180 degrees or more
– Usually accompanied by increased depth, bulk
and sponginess of end of fingers
Objective Data: Palpation
 Symmetric expansion
 Tactile fremitus
 Palpable vibration generated by vocal cords “99”
 Using palmar base of fingers, palpate from side to
side
 Increased when lung is fluid-filled/more dense
 Decreased when lung is farther from hand or if
hyper-inflated
 Absent over areas of collapse (pneumothorax,
atelectasis)
Objective Data: Percussion
 To assess density or aeration
 Dull over areas of consolidation (e.g.
pneumonia)
 Hyper-resonance over areas of hyperinflation (e.g. asthma, COPD)
Objective Data: Auscultation
Normal breath sounds
 Vesicular
– Soft, low pitch, gentle rustling
– Heard over peripheral lungs
 Bronchial
– Loudest, high pitch, like air through hollow pipe
– Over trachea and larynx
 Bronchovesicular
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–
–
–
Medium pitch and louness
Mix of above qualities
Anteriorly – over bronchi, either side of sternum
Posteriorly – between scapula
Objective Data: Auscultation
 Abnormal/adventitious breath sounds
– Discontinuous sounds
 Crackles (fine)
 Crackles (coarse)
 Pleural friction rub
– Continuous sounds
 Rhonchi
 Wheeze
 Stridor
Objective Data: Auscultation
 Discontinuous sounds
– Crackles (fine)
 Short, crackling, popping sound at end-inspiration
 When collapsed alveoli or bronchioles snap open
 Associated with pneumonia, early pulmonary edema,
atelectasis
– Crackles (coarse)
 Short, low-pitched bubbling sounds, mostly during inspiration
 Caused by air passing through airway that is intermittently
occluded with secretions in larger airways
 Associated with pnuemonia, pulmonary edema
– Pleural friction rub




Creaking, grating sound (like leather being rubbed together)
During inspiration and/or expiration
Due to inflamed pleural surfaces rubbing together
Associated with pleurisy, pneumonia
Objective Data: Auscultation
 Continuous sounds
– Rhonchi
 Low pitch, snoring, moaning sound mostly on expiration
 Air passing through large airways with secretions
 COPD, pneumonia
– Wheeze
 High pitched squeaking sound, mostly on expiration
 Sometimes audible without stethescope
 Caused by air passing through narrowed airways (d/t spasm, swelling,
tumors, secretions)
– Stridor
 High pitch crowing sound; often audible without stethescope
 Caused by partial obstruction of larynx or trachea
 Associated with croup, epiglottitis, laryngeal edema or spasm (post
extubation)
Diagnostic Tests
 Sputum studies
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–
–
–
C&S
Gram stain (classifies as gram + ve or – ve)
AFB (acid fast bacilli) – for TB
Cytology – examination for abnormal cells
 Bronchoscopy
– Bronchi visualized with fiberoptic tube inserted through nose into
airways
– Can take biopsy, remove foreign bodies, mucus plugs
– NPO and sedation pre-test
– Post procedure: NPO until gag returns; assess for laryngeal
edema,, hemorrhage (if bx taken), recovery from sedation
Diagnostic Tests
 Pulmonary Function tests
– Measures lung volumes and airflow
 Arterial blood gases (ABGs)