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Pulmonary assessment and disorders ch 33 34 35 36 osborn 2012
- 1. Copyright ©2010 by Pearson Education, Inc.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Complete Assessment
• History
– Biographic and demographic data
– Chief complaint
– Past medical history
– Family history
– Risk factors
– Social history
- 2. Copyright ©2010 by Pearson Education, Inc.
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Complete Assessment
• Components of Physical Exam
– Inspection
– Auscultation
– Percussion
– Pain
– Genetic and gerontological considerations
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Social History
• Patients’ lifestyles and habits and
• Risk for developing pulmonary disease
• Current and previous work settings
• Home environment
• Social settings
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Gerontological Considerations
• aging decreases respiratory function
• lower arterial oxygen values,
• increase risk of pneumonia
• Risk of aspiration may increase with aging
• Aging may affect patient comfort needs
during the examination
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Genetic Considerations
• Cystic fibrosis (CF): genetic disorder,
typically diagnosed in childhood
• CF has serious pulmonary complications –
thick mucus builds up in lungs
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Initial assessment activity
• General appearance:
– Posture, facial expression and movements
– Changes in mental status
– Respiratory rates shallow breathing, irregular
patterns of breathing
– Size and shape of the thorax, asymmetry
– Diminished movement of rib cage, use of
accessory muscles
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Color and appearance of skin
– Pallor may indicate decreased oxygen-
carrying capacity of the blood due to anemia
– Central cyanosis, where the mouth, lips, and
mucous membranes are blue-tinged,
indicates hypoxia in adults
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Inspection of the neck
– Appearance of veins, trachea and
musculature may indicate chronic cardiac or
pulmonary disease, pneumothorax
– Goiter or lesions may obstruct the upper
airway
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Inspection
• Palpation of skin and extremities
– Edema of lower extremities
– Skin temperature and moisture
– Clinical reference points
– Chest excursion
– Tactile fremitus
– Tenderness
– Crepitus
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Clinical Reference Points
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Occupational Impact on
Respiratory Disease
• Exposure to airborne particles, vapors,
and irritants
• Can result in acute or chronic respiratory
disease in susceptible individuals
• Early recognition, diagnosis, and treatment
of occupational asthma can prevent
pulmonary complications
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Auscultating Breath Sounds
• Patient should be upright
• Use the diaphragm of the stethoscope
• Begin at C7 posteriorly and anteriorly from
above the clavicles
• Move steadily from right to left upper and
lower
• Compare breath sounds bilaterally
• Do not auscultate over clothing
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Diaphragm - best for higher
pitched sounds, like breath
sounds and normal heart
sounds.
Bell - is best for detecting
lower pitch sounds, like some
heart murmurs, and some
bowel sounds. It is used for
the detection of bruits, and for
heart sounds (for a cardiac
exam, listen with the
diaphragm, and repeat with
the bell).
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Medical Surgical Nursing: Preparation for Practice
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Figure 33.1 In a respiratory assessment, it is important to palpate and count ribs and interspaces to
accurately record the location of lesions or adventitious breath sounds.
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Auscultating Breath Sounds
Figure 33.2 Lobes of the lung—anterior.
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Medical Surgical Nursing: Preparation for Practice
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Auscultating Breath Sounds
Figure 33.3 Lobes of the lung—posterior
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Tracheal Breath Sounds
• Auscultated over the trachea
• Loud and high pitched
• Cause: airflow through tubular trachea
• Best heard over the neck and trachea
• Occurs during upper airway obstruction
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Medical Surgical Nursing: Preparation for Practice
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Bronchial Breath Sounds
• Anterior: heard on either side of sternum,
over main stems of the bronchus from 2nd
to 4th intercostal spaces
• Posterior: best heard lateral to the spine
between 3rd and 6th intercostal spaces
• Loud, harsh, less turbulent and lower than
tracheal sounds
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Medical Surgical Nursing: Preparation for Practice
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Bronchial Breath Sounds
• Pause between inspiration and expiration;
expiration is heard for a longer time than
inspiration
• Sounds over smaller airways are low
pitched and softer
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Bronchovesicular Breath Sounds
• Heard during inspiration and expiration
• Midway in Pitch and loudness between
vesicular and bronchial breath sounds
• Best heard in 1st and 2nd intercostal
spaces of anterior chest, between
scapulae of the posterior chest
• Represent air movement in the moderate
airways between the bronchi and the
smaller airways
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Medical Surgical Nursing: Preparation for Practice
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Vesicular Breath Sounds
• Heard over most of the thorax
• Soft and low pitched, rustling, from air
moving through small airways
• Heard longer during expiration, which
generally lasts twice as long as inspiration
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Medical Surgical Nursing: Preparation for Practice
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Adventitious Breath Sounds
• Decreased or no sounds where normal
sounds should occur
• Breath sounds occurring in abnormal
locations
• Diminished breath sounds demonstrate
decreased airflow and potentially
decreased oxygen exchange
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Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Adventitious Breath Sounds
• Adventitious/extra sounds:
– Represent pathologic conditions of heart or
lungs
– Indicate disrupted airflow due to airway
spasm, fluid, or secretions
– Crackles (rales-term not used as much),
Wheezes, Stridor, Friction rubs
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Crackles
• Caused by fluid in the airways
• Intermittent or discontinuous, nonmusical, or
popping sounds
• Caused by fluid, inflammation, infection, or
secretions
• Crackles are described as either fine or coarse
• Occur when closed airways snap open during
inspiration
• Softer, gentler sound may also be heard on
inspiration
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Wheezes
• Heard equally during inspiration and expiration
• High-pitched musical sounds
• Caused by air flowing across strands of mucus,
swollen pulmonary tissue that narrows the airway,
bronchospasm
• Rhonchi (term for secretions in airways-not used as
much)
• Inspiratory/expiratory, continuous/ discontinuous,
mild/moderate/severe
• Asthma, allergies, reactive airway disease
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Medical Surgical Nursing: Preparation for Practice
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Stridor
• Heard only during inspiration as air attempts to flow
across an obstruction
• Heard without stethoscope as high-pitched, crowing
sound
• With stethoscope, best heard over large airways,
e.g., trachea or bronchus
• Report to the health care provider immediately
• Indicates airway obstruction requiring
intervention
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Pleural Friction Rubs
• Low-pitched, creaking or squeaking sounds
• Occur when inflamed pleural surfaces rub
together
• Heard on inspiration
• Pitch usually increases with chest expansion
• Have the patient hold breath to distinguish
between pleural and pericardial friction
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Medical Surgical Nursing: Preparation for Practice
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Adventitious Lung Sounds
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Medical Surgical Nursing: Preparation for Practice
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Travel and Area of Residence
• An important aspect of the history in
diagnosing potential respiratory problems
• Exposure to region-specific infectious
diseases
• Exposure to environmental conditions, e.g.
high altitudes
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Medical Surgical Nursing: Preparation for Practice
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High-Altitude Pulmonary Edema
(HAPE)
• HAPE – can occur with travel to altitudes
greater than 5,000 feet
• Increasing altitude → decreasing
atmospheric pressure → decreasing
available O2
• Rapid onset of hypoxemia may result
• Compensatory increased respiratory rate
may contribute to fatigue
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Medical Surgical Nursing: Preparation for Practice
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High-Altitude Pulmonary Edema
(HAPE)
• This causes further respiratory
insufficiency
• Initial compensatory mechanisms –
pulmonary vascular vasoconstriction
• Later, inflammatory mediators cause
vasodilation
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Medical Surgical Nursing: Preparation for Practice
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Percussion
• Assess presence of air, fluid, solid mass in
underlying tissues
• Normal lungs produce a resonant, low-pitched clear
sound
• Hyperresonance indicates airways are hyperinflated
or air is present outside of lung tissue
• Dullness indicates that air is absent
– Pneumonia, pleural effusion, hemothorax, solid
tumors
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Medical Surgical Nursing: Preparation for Practice
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Pain
• Pain during respiration may decrease tidal
volumes
• Pain management enables participation in
rehabilitative activities
• Also promotes deep breathing to prevent
pneumonia and atelectasis
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Standard of Care
• For patients with cardiac and respiratory
illness, standard is:
– Continuous or intermittent observation of the
patient’s oxygen saturation
– End-tidal carbon dioxide levels
– Peak flow is utilized to trend treatment
effectiveness in patients with asthma
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Assessment of Arterial Oxygen
Levels
• ABG’s
• Pulse oximetry
• Physical assessment
• FiO2 will increase the PaO2 four times
(normal patient)
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Pulse Oximetry
• Measures O2 saturation of hemoglobin
• Reflects light off the hemoglobin
molecules
• Measures the absorption of light by
hemoglobin
• Normal range is from 95% to 100%
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Factors Interfering with
Pulse Oximetry
• Nail polish
• Automated BP cuffs, hemodialysis fistulas,
or arterial lines interfere with blood flow
• Shock and hypovolemia
• Patient movement, ambient light, and
venous pulsations may also cause
inaccurate readings
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Peak Flow Meters
• Track trends in a patient’s condition,
evaluate air movement to determine
severity of asthma exacerbation
• Measure the peak expiratory flow rate
• Normal values based on age and body
size
• Severity scale: Utilizes red, yellow, and
green zones to determine the severity of
decrease in peak flow
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Arterial Blood Gas Studies (ABG)
• Provide information on arterial oxygen and
carbon dioxide levels
• Oxygen saturation, bicarbonate, and blood
pH are also calculated
• CO2 is major determinant of respiratory
alkalosis/acidosis
• Bicarbonate level is determinant of
metabolic acidosis/alkalosis
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Capnography
• Measurement of exhaled CO2
• Some utilize paper treated to detect the
presence of acid such as CO2
• Others use spectrography, generate
waveform readings
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Capnography
• Useful in determining ventilatory status,
readiness for extubation
• Also used to determine pulmonary vessel
perfusion in patients with pulmonary
embolus
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Capnography Monitor
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Medical Surgical Nursing: Preparation for Practice
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Medical Surgical Nursing
Preparation for Practice
CHAPTER
Caring for the Patient
with Upper Airway Disorders
34
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Facial Bones
• Mandible
• Maxilla
• Zygoma
• Temporal bones
• Frontal bone
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Mandible
• U-shaped bone
• Together with the maxilla, largest and
strongest bone of the face
• Forms lower jaw, holds the lower teeth in
place
• Articulates with temporal bones at the
temporomandibular joint
• Only mobile bone of the facial skeleton;
motion is essential for mastication
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Nursing Management for
Mandibular Fractures
• Determine patient’s nutritional requirements and
knowledge deficits
• Oral nutrition with high-protein liquid diet and calories
is essential
• Avoid weight loss if possible to ensure nutritional
adequacy for healing
• Nasogastric or oral gastric tube supports nutrition if
patient has extensive facial swelling
• Observe for nausea and vomiting, intervene to
prevent aspiration
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Maxilla
• Largest component of the middle third of
the facial skeleton
• Attaches laterally to the zygomatic bones
• Key bone in the midface, provides
structural support
• Fractures less frequently than mandible or
nose due to strong structural support
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Classification System of
Maxillary Fractures
• Le Fort I Fracture (horizontal)
• Le Fort II Fracture (pyramidal)
• Le Fort III Fracture (transverse)
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Zygoma
• A paired bone, commonly called the
cheekbone
• Articulates with maxilla, temporal,
sphenoid, and frontal bones
• Forms prominence of the cheek
• The masseter muscle is suspended from
the zygomatic arch
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Temporal Bone
• Situated at the sides and base of the skull
• Houses cochlear and vestibular end
organs, facial nerve, carotid artery, jugular
vein
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Nursing Management for
Temporal Bone Fractures
• Care is conservative
• Assess for nerve damage and hearing loss
• Test for otorrhea; may indicate a CSF leak
• Monitor lumbar drain if inserted
• If facial nerve injury is present, provide eye
care
• Institute CSF leak precautions – HOB 30o , no
straining, bending or lifting
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Frontal Bone
• Makes up the forehead, upper edge and
roof of the orbit
• Forms the anterior portion of the cranium
• Frontal sinus – air-filled cavity between
lamina of the frontal bone
• Serves as a mechanical barrier to protect
the brain