Assessment of Oxygenation Subjective Data Past History Upper

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 hyperinflated § 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 – 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 – – 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)