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NRS 310:
HEALTH ASSESSMENT
Lecture 5
Fall 2013
Karrie Hendrickson PhD, RN
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CHAPTER 11
Lungs and
Respiratory System
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Concept Overview: Oxygenation
• Processes that facilitate and impair oxygenation.
• Adequate perfusion is necessary to deliver oxygenated blood to
tissues and remove metabolic waste.
• Intracranial regulation supports oxygenation.
• Adequate oxygenation needed to support intracranial function.
• Interrelationship necessary.
Intracranial
Regulation
Perfusion
Metabolism
Oxygenation
Sleep
Motion
Tissue
Integrity
Nutrition
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Anatomy and Physiology
• Respiratory system supplies oxygen to cells and removes carbon
dioxide using processes of ventilation and diffusion:
• Ventilation is the process of moving gases in and out of lungs by inspiration
and expiration.
• Diffusion is the process by which oxygen and carbon dioxide move from
areas of high concentration to areas of lower concentration.
• After inspiration, concentration of oxygen is higher in alveoli than in
pulmonary capillaries, causing oxygen to diffuse across alveolar-capillary
membrane, then carried by erythrocytes to cells.
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A&P
• At cellular level, oxygen
diffuses into cells, and
carbon dioxide diffuses
from cells into capillaries,
where it is carried by
erythrocytes to alveoli.
• Carbon dioxide diffuses
from pulmonary capillaries
to alveoli and is exhaled.
• Cardiovascular system
provides transportation of
oxygen and carbon dioxide
between alveoli and cells.
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Structures in the Thorax: Mediastinum
• Three main structures within thorax or chest:
• Mediastinum and right and left pleural cavities.
• Mediastinum positioned in middle of chest. Within it are:
•
•
•
•
•
Heart
Arch of aorta
Superior vena cava
Lower esophagus
Lower part of trachea
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Structures in the Thorax:
Pleural Cavities
Pleural cavities contain lungs.
These cavities lined with two
types of serous membranes:
Parietal pleura
Visceral pleura
Chest wall and diaphragm are protected by parietal
pleura, and lungs are protected by visceral pleura.
Small amount of fluid lubricates space between
pleurae to reduce friction as lungs move during
inspiration and expiration.
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Structures in the Thorax: The Lungs
• Right lung has three lobes and
left has two.
• Each lobe has a major, oblique
fissure dividing upper and lower
portions.
• However, right lung has a lesser
horizontal fissure dividing upper
lung into upper and middle lobes.
• Each lung extends anteriorly
about 1.5 inches above first rib
into base of neck in adults.
• Posteriorly, lungs’ apices rise to
level of T1 (first thoracic
vertebrae); lower borders expand
down to T12 and, on expiration,
rise to T9.
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External Thorax
• Thoracic cage protects most
of respiratory system and
consists of:
• 12 thoracic vertebrae
• 12 pair of ribs
• Sternum
• Ribs connect to thoracic vertebrae posteriorly:
• First seven ribs also connected to sternum by costal cartilages.
• Costal cartilages of eighth to tenth ribs are connected immediately
superior to ribs.
• Eleventh and twelfth ribs are unattached anteriorly, thus the name
“floating ribs.”
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External Thorax
Sternum is about 7 inches
long and has three
components:
Manubrium
Body
Xiphoid process
Manubrium and body
articulate with first seven
ribs; manubrium also
supports clavicle.
Intercostal) is the area
between ribs. space (ICS
ICS named according to rib
immediately above it; thus,
first ICS is located between
first and second ribs.
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Mechanics of Breathing
Diaphragm and intercostal muscles are primary muscles of
inspiration.
During inspiration, diaphragm contracts and pushes abdominal
contents down, while intercostal muscles push chest wall outward.
Combined efforts decrease intrathoracic pressure, creating
negative pressure within lungs.
During expiration, muscles relax, expelling air as intrathoracic
pressure rises.
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Mechanics of Breathing
Accessory muscles contributing to respiratory effort include:
Anterior:
•
•
•
•
•
Sternocleidomastoid
Scalenus
Pectoralis minor
Serratus anterior
Rectus abdominus
Posterior:
• Serratus posterior superior
• Transverse thoracic
• Serratus posterior inferior
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Mechanics of Breathing
During inspiration, air is drawn through mouth or nose
and passes through pharynx and larynx to reach trachea.
Nose, pharynx, larynx, and intrathoracic trachea make up
upper airway.
Three functions of upper airway:
Conducts air to
lower airway.
Protects lower
airway from foreign
matter.
Warms, filters, and
humidifies inspired air.
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Upper Airway
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Mechanics of Breathing
• Lower airway consists of:
• Trachea
• Right and left main stem bronchi
• Segmental and subsegmental
bronchi
• Terminal bronchioles
• Bronchi are further subdivided into increasingly smaller
bronchioles.
• Bronchioles open into alveolar ducts and terminate in multiple
alveoli, where gas exchanges occur.
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Lower Airway
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Topographic Markers: Anterior Chest Wall
• Nipples
• Suprasternal notch:
• Depression at ventral aspect of
neck, just above manubrium.
• Manubriosternal junction (angle of
Louis):
• Junction between manubrium and
sternum; useful for rib identification.
• Midsternal line:
• Imaginary vertical line through
middle of sternum.
• Costal angle:
• Intersection of costal margins,
usually no more than 90 degrees.
• Clavicles:
• Bones extending out both sides of
manubrium to shoulder; they cover
first ribs.
• Midclavicular lines: MCL
• Imaginary vertical lines on right
and left sides of chest that are
“drawn” through clavicle midpoints,
parallel to midsternal line
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Topographic Markers: Lateral Chest Wall
• Anterior axillary lines:
• Imaginary vertical lines on right and
left sides of chest “drawn” from
anterior axillary folds through
anterolateral chest, parallel to
midsternal line.
• Posterior axillary lines:
• Imaginary vertical lines on right and
left sides of chest “drawn” from
posterior axillary folds along
posterolateral thoracic wall with
abducted lateral arm.
• Midaxillary lines:
• Imaginary vertical lines on right and
left sides of chest “drawn” from axillary
apices; midway between and parallel
to anterior and posterior axillary lines.
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Topographic Markers: Posterior Chest Wall
• Vertebra prominens:
• Spinous process of C7; visible
and palpable with head bent
forward.
• Vertebral line:
• Imaginary vertical line “drawn”
along posterior vertebral spinous
processes.
• Scapular lines:
• Imaginary vertical lines on right
and left sides of chest “drawn”
parallel to midspinal line; pass
through inferior angles of
scapulae in upright patient with
arms at sides.
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ASSESSMENT
QUESTIONS
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General Health History: Present Health Status
• Do you have any chronic illnesses?
• Do you have allergies?
• Do you have difficulty breathing during daily
activities?
• Do you have difficulty
breathing when you sleep?
• In what position do you sleep?
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General Health History:
Present Health Status
• Are you currently taking any oral
medications for a respiratory disorder?
• If so, what are you taking, and how effective have they been?
• Do you use an inhaler?
• What medication is in inhaler?
• What is the purpose?
• How often?
• Do you use oxygen at home?
• Does oxygen relieve symptoms?
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General Health History:
Past Medical History
Have you ever had problems with your lungs?
Have you been diagnosed with respiratory diseases such
as the following:
Asthma
Bronchitis
Bronchiectasis
Emphysema
Lung cancer
Tuberculosis
Pneumonia
Have you ever had an injury to your chest?
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General Health History:
Personal and Psychosocial History
• Do you smoke?
• Have you smoked in the past?
• How often do (did) you smoke?
• Have you ever tried to quit?
• Why do you think you were unsuccessful?
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General Health History:
Family History
• Is there a family history of lung disease?
• Tuberculosis
• Cancer
• Cystic fibrosis
• Emphysema
• Asthma
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General Health History:
Home Environment
• Are there environmental conditions that may affect your
breathing at home?
• Air pollution
• Possible allergens in home, such as pets.
• Type of heating or air conditioning, including air filtering system.
• Hobbies: woodworking, plants, metal work.
• Exposure to smoking of others in home.
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General Health History:
Occupational Environment
• Where do you work?
• Factory
• Outdoors
• In heavy traffic
• Are you frequently exposed to any allergens?
• If you are exposed to irritants, do you wear a mask or
respirator mask?
• Does work area have special ventilation to clear pollutants?
• Do you wear monitor to evaluate exposure?
• Do you have periodic health examinations, pulmonary tests, or
radiographic examinations?
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General Health History: Travel
• Have you recently traveled to foreign countries or areas of
the United States where you may have been exposed to
uncommon respiratory diseases? Examples:
• Histoplasmosis in Southeast and Midwest US
• Schistosomiasis or severe acute respiratory syndrome [SARS] in
Southwest Asia, Caribbean, and Asia?
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Problem-Based History
• Commonly reported problems related to lungs are cough,
shortness of breath, and chest pain with breathing.
• A symptom analysis is completed, which includes:
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Problem-Based History:
Cough
• When did you first notice cough?
• Is cough constant, or does it come and go?
• Has cough changed since you first noticed it?
• Describe your cough.
• Is it dry?
• Productive?
• Hacking?
• Hoarse?
• How often are you coughing up sputum (all of the time or
just periodically)?
• What is color of sputum?
• Consistency of sputum (thick, thin, frothy)?
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Problem-Based History: Cough
Have you noticed if sputum has an odor?
Have you noticed other symptoms:
Shortness of breath?
Chest pain or tightness with breathing?
Hoarseness?
Gagging?
Does coughing tire you out?
Keep you awake at night?
Have you done anything to treat cough such as medications,
fluids, or vaporizer?
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Problem-Based History: Shortness of Breath
How long have you had shortness of breath?
Short of breath all the time, or does it come and go?
Describe your shortness of breath:
Harder to inhale or exhale or difficulty with both?
Do symptoms interfere with your activities?
Does anything seem to trigger episodes or make shortness
of breath worse?
If it occurs at night, in what position do you sleep?
How many pillows do you use?
Does changing your position affect problem?
Have you noticed any other problems when you are short of
breath?
What do you do to relieve symptoms?
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Problem-Based History:
Chest Pain with Breathing
• How long have you had pain in chest with
• breathing?
• When did this start?
• Does pain radiate to other areas such as neck or arms?
• What does pain feel like (viselike, tight, sharp, burning)?
• When it started, was pain associated with injury to ribs or
respiratory infection?
• Pain worse with deep inspiration?
• Does pain interfere with getting enough air?
• Pain Scale: 0-10
• Is there anything that makes pain worse, such as movement or
coughing?
• Have you done anything to treat pain, such as heat, splinting,
or pain medication?
• Have any measures been effective?
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Physical Examination
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Physical Exam: Respiratory System
• INSPECT
• General appearance, posture, breathing effort
• Observe respirations
• Nails, skin, lips
• Anterior and posterior thorax
• AUSCULTATE
• Anterior, Posterior, and Lateral thorax
• Sometimes vocal resonance
• PALPATE
• Trachea, thoracic muscles, expansion of thoracic wall
• Tactile fremitus
• PERCUSS
• For tone and diaphragmatic excursion
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INSPECT
• General appearance, posture, breathing effort
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INSPECT
• Observe respirations
• Rate, breathing pattern, and chest expansion
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INSPECT
• Nails, skin, and lips for color.
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Examination: Posterior Thorax
• Inspect posterior thorax for shape and symmetry, and
muscle development.
• Auscultate posterior and lateral thorax for breath sounds.
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Examination: Anterior Thorax
• Inspect anterior thorax for shape and symmetry, muscle
development, anteroposterior diameter to lateral diameter,
and costal angle.
• Auscultate anterior thorax for breath sounds.
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Adventitious Breath Sounds
• http://www.easyauscultation.com/lung-sounds-reference-guide.aspx
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Examination: Advanced Practice
and Special Circumstances
• Posterior thorax:
• Palpate posterior thoracic muscles for tenderness, bulges, and
symmetry.
• Palpate posterior chest wall for thoracic expansion.
• Palpate posterior thorax wall for vocal (tactile) fremitus.
• Percuss posterior and lateral thorax for tone.
• Percuss thorax for diaphragmatic (respiratory) excursion.
• Auscultate thorax for vocal sounds (vocal resonance).
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Examination: Advanced Practice
and Special Circumstances
• Anterior thorax:
• Palpate trachea for position.
• Palpate anterior thoracic muscles for tenderness, bulges, and
symmetry.
• Palpate anterior chest wall for thoracic expansion.
• Palpate the anterior thorax wall for vocal (tactile) fremitus.
• Percuss anterior thorax for tone.
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Age-Related Variations:
Infants, Children, and Adolescents
• Assessing respiratory status of infants, children, or
adolescents follows sequence as for adult—there are
differences worth noting:
• Infants must be undressed to diaper for exam.
• Keep infant covered when not examining to prevent exposure and
cooling.
• Conduct exam while infant is calm; exam of a crying infant is
difficult.
• By ages of 2 or 3 years, child is usually cooperative.
• Prior to that age, you need to develop a relationship with child to
improve cooperation.
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Age-Related Variations:
Older Adults
• Assessing respiratory status of older adults usually
follows same procedures as other adults, although there
are may be structural and functional differences noted:
• Posterior thoracic stooping or bending or kyphosis may alter thorax wall
configuration and make thoracic expansion more difficult.
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Common Problems and Conditions:
Infections and Inflammatory Conditions – Acute Bronchitis
• Acute bronchitis is inflammation of mucous membranes of
bronchial tree caused by viruses or bacteria.
• Clinical findings:
•
•
•
•
Cough initially nonproductive but may become productive after few days.
Patients may complain of substernal chest pain aggravated by coughing.
Other clinical manifestations include fever, malaise, and tachypnea.
Rhonchi and crackles frequently heard on auscultation, with wheezing
heard after coughing.
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Common Problems and Conditions:
Infections and Inflammatory Conditions – Pneumonia
• Pneumonia is inflammation of terminal bronchioles and alveoli;
may be caused by bacteria, fungi, viruses, mycoplasma, or
aspiration of gastric secretions.
• Clinical findings:
• Viral pneumonia tends to produce a nonproductive cough or
clear sputum.
• Bacterial pneumonia, however, causes productive cough that
may produce white, yellow, or green sputum.
• Other clinical findings associated with pneumonia include
fever, tachypnea, and dyspnea.
• Crackles and wheezes may be heard on auscultation of the
lungs.
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Common Problems and Conditions:
Infections and Inflammatory Conditions – Tuberculosis
• Tuberculosis is a contagious, bacterial infection caused by
Mycobacterium tuberculosis.
• Primarily in lungs, but kidney, bone, lymph node, and meninges can
also be involved.
• Clinical findings:
• Patient usually asymptomatic in early stages of disease; initial
clinical manifestations consist of fatigue, anorexia, weight loss,
fever.
• Characteristic finding later in disease is cough that becomes
increasingly frequent, producing a mucopurulent sputum.
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Common Problems and Conditions:
Infections and Inflammatory Conditions – Pleural Effusion
• Pleural effusion is accumulation of serous fluid in pleural
space between visceral and parietal pleurae.
• Clinical findings:
• Degree of manifestation depends on amount of fluid accumulation
and position of patient.
• If effusion occurs rapidly and if it is large, there may be dyspnea,
intercostal bulging, or decreased chest wall movement.
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Common Problems and Conditions:
Asthma
Asthma is hyperreactive airway disease characterized by:
Bronchoconstriction
Airway obstruction
Inflammation.
Asthma occurs in response to:
Allergens or pollutants
Infection
Cold air
Vigorous exercise
Emotional stress
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Common Problems and Conditions:
Asthma
Clinical findings signs include:
Increased respiratory rate with prolonged expiration
Audible wheeze
Dyspnea
Tachycardia
Anxious appearance
Possible use of accessory muscles
Cough
Prolonged expiration, expiratory and occasionally
inspiratory wheeze, and diminished breath sounds are
common findings with auscultation.
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Common Problems and Conditions:
Chronic Pulmonary Disease – COPD & Emphysema
• Emphysema is destruction of alveolar walls that causes
permanent abnormal enlargement of air spaces.
• Clinical findings:
• Classic appearance of a patient with advanced emphysema is
underweight with barrel chest and short of breath with minimal
exertion.
• Other findings reveal diminished breath and voice sounds, possible
wheezing or crackles on auscultation, and decreased diaphragmatic
excursion on percussion.
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Common Problems and Conditions:
Chronic Pulmonary Disease – Chronic Bronchitis
• Chronic bronchitis characterized by hypersecretion of
mucus by goblet cells of trachea and bronchi resulting in
productive cough for 3 months in each of 2 successive
years.
• Caused by irritants such as cigarette smoke and air
pollution or by infection.
• Clinical findings: Chronic bronchitis
• Symptoms are productive cough, increased mucus
production, and dyspnea.
• Findings on auscultation are rhonchi, sometimes cleared
by coughing.
• When sufficient mucus occludes alveoli, crackles may be
heard.
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Common Problems and Conditions:
Acute or Traumatic Conditions – Pneumothorax
• Pneumothorax results from air in pleural spaces.
• Three types of pneumothorax:
• Closed: May be spontaneous, traumatic, or iatrogenic.
• Open: Occurs following penetration of chest by either injury or
surgical procedure.
• Tension: Develops when air leaks into pleura and cannot escape.
• Clinical findings: Pneumothorax
• Signs vary, depending on amount of lung collapse.
• With minor collapse, patient may be slightly short of breath,
anxious, and have chest pain.
• With large amount of lung collapse, patient may be in severe
respiratory distress, including dyspnea, tachypnea, and cyanosis.
• Decreased chest wall movement on affected side; may also have
paradoxic chest wall movement.
• If severe, may be tracheal displacement toward unaffected side
with a mediastinal shift.
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Common Problems and Conditions:
Acute or Traumatic Conditions – Hemothorax
• Hemothorax results from blood in pleural space caused
by injury to the chest but also may be complication of
thoracic surgery.
• Clinical findings:
• Signs are similar to those described for pneumothorax, although it
is common to note distant muffled breath sounds and dullness with
percussion over affected area.
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Common Problems and Conditions:
Other Pulmonary Conditions – Atelectasis
• Atelectasis refers to collapsed alveoli caused by external
pressure from tumor, fluid, or air in pleural space
(compression atelectasis) or by removal of air from
hypoventilation or obstruction by secretions (absorption
atelectasis).
• Clinical findings:
• Affected lobe has diminished or absent breath sounds.
• Oxygen saturation may decrease to less than 90%.
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Common Problems and Conditions:
Other Pulmonary Conditions – Lung Cancer
• Lung cancer is uncontrolled growth of anaplastic cells in
lung.
• Agents such as tobacco smoke, asbestos, ionizing radiation,
and other noxious inhalants can be causative agents.
• Clinical findings:
• Most common initial symptom reported is a persistent cough.
• Weight loss, congestion, wheezing, hemoptysis, labored breathing, or
dyspnea are other manifestations that occur with advanced disease.
• Lung sounds may be normal or diminished over affected area; if there
is a partial obstruction of airways from tumor, wheezes may be heard.
• Percussion tones may be normal or may be dull over tumor,
particularly if cancer is large or patient has associated atelectasis.
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Question 1
Before caring for the patient, the nurse reviews the test
results. A chest radiographic report shows that there is
atelectasis in the right base. During lung auscultation, what
would the nurse expect to find?
A.
B.
C.
D.
Increased fremitus in the right base.
Diminished breath sounds.
Wheezing throughout.
Symmetrical chest expansion.
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Question 2
The nurse is caring for a patient who is suffering from
chronic obstructive pulmonary disease. He coughs
frequently and produces a thick white sputum. During
auscultation, the stethoscope should be placed:
A. Over the scapula to enhance adventitious lung sounds.
B. So that it is barely touching the skin to avoid auditory
artifact.
C. Over the left lung fields first.
D. In one position long enough to hear an entire inhalationexhalation set.
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Case Study
Sean is a 10-year-old male child who attends a local middle
school. He has two siblings in his home. All of his
immunizations are up to date. He has a history of eczema
and chickenpox. His favorite activities are baseball and
basketball. He loves to go to the movies with his best
friend, Josh. His father smokes inside the home. Sean has
recently had a hospitalization for asthma.
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Case Study (contd.)
Subjective data:
Complains of increased shortness of breath, especially
with exercise.
Mother says he seems to be using the inhaler more.
Mother admits to not having a lot of knowledge regarding
inhaler usage.
Objective data:
Vital signs: T 98.0; P 61; R 17. Height: 4 ft 5 in. Weight
85 lb.
 Lungs: Clear on auscultation, no wheezing present.
 Heart: RRR, no murmurs present.
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Case Study (contd.)
Questions:
1.
2.
3.
What risk factors does Sean have for asthma?
What measures might help to prevent asthma exacerbation?
What should the nurse do in this clinical situation? Prioritize
actions.