Studies have shown that patients with asthma often have GERD (gastroesophageal refx disease) OF are m0 ‘Susceptible to GERD. RATIONALE A history of respiratory disease increases the risk for a ‘ecurrence. In addition, some respiratory diseases may, imitate other disorders. For example, asthma symp- ‘toms may mimic symptoms commonly associated with ‘emphysema or heart failure. 4 Previous surgeries may alter the appearance of the tho- "cand cause changes in respiratory sounds. Trauma‘o ‘the thorax can result in lung tissue changes. J Many allergic responses are manifested with respiratory symptoms such as dyspnea, cough, "or hoarseness. — ‘Clients may need education on controlling the amount of allergens in their environment. ° 2 Information on previous chest xrays, TB skin {influenza immunizations, and so forth is useful for parison with current findings and gives information self-care practices and possible teaching needs. ‘Travel to high-risk areas such as mainland China; Kong; Hanoi, Vietnam; Singapore; of Toronto, Canada, ‘may have exposed the client to SARS (severe acute res: piratory syndrome). : RATIONALE the risk for development of these conditions. Secondhand smoke puts individuals a sk fore sema of hing eancer later in ie. ‘Some pulmonary disorders, such a8 asthma, in families asmoking 1s linked to 2 number of respir Sage, snctuding tun cancer (eee Risk Fane ng Cancer). The sumber ‘of Years a person has san fhe number of cigarettes Per day influence ie “dang din the pa ea to qull? sevetopment of smoking-related respiratory foe seh smoking? Ha rt Information OP ‘smoking behavior and previo, Oblemy, to quit may be helpful later in identifying ae fh smoking cessation. sure ronmental COP sxposue to certain environmental inhalants can vironmental omen you wae gased incidence of certain respiritory iy ve you crea ental itants COMMONIY associate okers? include coal dust, insecticides, eae ae : Pesto fibers, and the like. For example inal fit Histoplasma capsulatum me ra systemic fungal discae. Ths us Mirthe rural midwestern United Sates ig another irritant that can seriowy affect a pers respiratory health. “problems can negatively affect a persons m the usual activities of daily living osed to any €1 Dpreathing? Where 4° reath can be a manifestation of ses Fedlucation about relaxation techniques when determining if respira d be attribured to adverse reactions for example, betaadrenersic 108 Kers) such as atenolol (Tenormi sor) and angiotensin-conver™ tors such as enalapril (Vasotec) oF dre associated with the side cle Gephese medications are cont! ind: tory problems such #5150 foxygen or other respirsto" I! m portant to evaluate kno Tatjons as well as une liens”RISK FACTORS LUNG CANCER Overview Lung cancer is the leading cause of death in the United states and. Europe. Both incidence and mortality omen ne GesPite decreasing mortality rates for most other cancers I ete ana Teche cage Te ena In 2005, there are expected to be joo Pee Proportions (CancerConsultants.com, 1998-2004). ith 73,020 of the dentne os 172:500 new lung cancer cases and 163,510 death In the United Fees abe SC dears eae noe Wien Cneaty peice sa many cette soc Brn tae ate eee a tail cat and tress U2 lung cancer diagnosis is unusual under age 40. For people whose Se toes eed in the early ead Surgery, the S-year survival rate is about 42% but only 15% of cases : isk Reduction Teaching Tips + Cigarette smoking + Do not start smoking, and stop smok- + Genetic predisposition possibly asso- ing ityou do smoke. ‘ ciated with interaction of genetics + Join a smoking cessation program, and smoking + Eata healthy, low-cholesterol diet Beta carotene supplements esp. in with adequate amounts of fruits and presence of heavy smoking, moderate vegetables. alcohol intake + Ifyou smoke, avoid beta carotene Asbestos exposure supplements or diet high in beta Radon exposure carotene, Exposure to workplace pollutants: radioactive ores, mining chemicals _ (€g., arsenic, vinyl chloride, nickel, coal, mustard gas, chloromethyl esters, and fuels such as gasoline) Other environmental exposure: air Pollution, passive tobacco smoke, marijuana smoking of previous lung cancer, 2 ‘silicosis, berylliosis Recurring inflammation that leaves (€g., tuberculosis, some types Pneumonia) in American heritage, espe- men = women’s lung cells may have fon to lung cancer when ed ta tobacco smoke ‘of Hodgkin's disease treated jotherapy, radiation or both ‘who have been treated with y or radiation Limit exposure to air pollution and harmful substances. ‘Wear a mask when exposed to air pollution or dangerous airborne substances.uur sunsine ASSESSMENT OF THEADL Collecting Objective Data: Physical Examination ‘Examination of the thorax and lungs begins when the ‘nurse first meets the client and observes any obvious breathing difficulties, However, complete examination of the thorax and lungs consists of inspection, palpation, Percussion, and auscultation of the posterior and anterior thorax to evaluate functioning of the lungs. Inspection. and palpation are fairly simple skills to acquire; however Practice and experience are the best ways to become pro- ficient with percussion and auscultation. Preparing the Client Have the client remove all clothing from the waist up and Put on an examination gown or drape. The gown should be encouraged to ask questions and to inform hy iner of any discomfort or fatigue he experience, the examination. Try to make sure that the rooin ature is comfortable for the client lin per Equipment + Examination gown and drape + Gloves 5 + Stethoscope * Light source + Mask + Skin marker * Metric ruler Physical Assessment pipe examination of the client, remember these key * Provide privacy for the client. * Keep your hands warm to promote the comfort during examination. onjudgmental regarding client's habits * Particularly smoking, At the same nd inform about risks, suc! 3s and chronic obstructive pulmonity PD), related to habits, Be text continues on page 32" ient’sCWMPTER 14+ ryoscac ann LNG ASSESSMENT 309 jon for nasal flaring and Naval flaing isnot observed. Normally Nasal flaring is seen with labored Dreathing. {hedlaphragm and the external inter. _pirations (especially n small {aul muscles do most of the work of and is indicative of hypoxia reathing, This is evidenced by out. | Pursed lip breathing may be Tan! expansion ofthe abdomen and in asthia, emphysema, oc CHE lower ribs on inspiration and retum physiologic response to help ‘O-resting postion on expiration. down expiration and keep alvet open longer color of face, Ups, and The client has evenly colored skin Ruddy to purple complexion may! ‘one without unusual or prominent seen in clients with COPD of CHE discoloration, result of polycythemia. Cyanosis be seen if client is cold or hypoxl: ‘Cyanosis makes white appear blue-tinged, esp in the perioral, nailbed, and conji tival areas. Dark skin appears dull, and lifeless in the same areas Pink tones should be seen in the Pale or cyanotic nails may nailbeds. There is normally a 160- hypoxia. Early clubbing (18 degree angle between the nail base angle) and late clubbing (greater! and the skin, a 180-degree angle) can occur fro hypoxia, me Lene a 4 on. While the Scapulae are symmetric and non- spinous processes that deviate later=| etarms at her sides, protruding. Shoulders and seapulae allyn the thoracic area may indicate et and observe the arc at equal horizontal postions. The scoliosis, and the shape _ ratio of anteroposterior to transverse Spinal configurations may have ‘of the chest wall diameters 1:2 ‘respiratory implications. Ribs appear- Spinous processes appear ing horizontal atan angle greater tha straight, and thorax appears sym- 45 degrees with the spinal column are me clinicians pre- metric with ribs sloping downward frequently the result of an increased ‘entire thorax first, at approximatcly a 45-degree angle ratio between the anteroposterior of the anterior in relation to the spine transverse diameter (barrel chest). Rey corcustion ‘This condition is commonly the result te antenor and BEIBY_Kyphons can incised ofemphema duc tobypernnation curve of the thoracic of the lungsont Observe use of accessory muscles. Watch as the client breathes and note use. Inspect the client’s positioning. [Note the client’s posture and his abil+ ityto support weight while breathing comfortably. NURSING ASSESSMENT OF TH re apULT js common in older clients vaormal Findings 16-0. It s of lung resiliency may spine) i Gee Abr results from 2 108 oat a loss of skeletal muscle be a normal finding. ‘The size of the thorax, which affects pulmonary function, differs by race. Compared with ‘african Americans, Asians and Native ‘Americans, adult Caucasians have @ larger thorax and greater lung capac- ity (Overfield, 1995). “the client does not use accessory (craperius/shoulder) muscles to assist breathing, The diaphragm is the major muscle at work. This is evidenced by expansion of the lower chest dur- ing inspiration, Client should be sitting up and relaxed, breathing easily with arms at sides or in lap. Abno: rma Fj Yatious thoracic cel®s 1 Contig, ! ition [Trupezius, of shout, spe7is O shoulder, my fused to facttate inspige Of acute and ch on inca ChrONIC airy | [Bon or atelectasis 9 obing i [Client leans forwara sar eed 204 wey PPO Weight and jig ep ' pod positicy ea Aive pulmonary disease oyptt senderness and sen. tion may be performed one Paasoth hands; however, Fi oof palpation is estab. ie 16-11). Use your fingers jsned or tendemess, warmth, fo Pa ee sensations. Start toward tthe level of the left ine a be WH over the apex ofthe let lung) ‘urhand et 0 right, com, seer gings bilaterally. Move sys. atte downward and out to ret ral portions of the lunge efor crepitus. Crepitus, also peutaneous emphysema, is sensation (like bones or ing against cach other) ‘when air passes through exudate. Use your fingers the above sequence when The examiner §; crepitus, CHM TER ig inds no palpable THORACIC AND LUNG ASSESSMENT a ‘Tender of painful areas may indicate inflamed fibrous connective tissue: Pain over the intercostal spaces may be from inflamed pleurae. Pain Over the ribs, especially at the costal chom ral junctions, is a symptom of fract tured ribs Muscle soreness from exercise Of the excessive work of breathing (as i COPD) may be palpated as tenderness, Increased warmth may be related 10 local infection Crepitus can be palpated ifair escapes from the lung or other airways into the subcutaneous tissue as occurs afier an open thoracic injury, around 4 chest tube, or tracheostomy. It als ‘may be palpated in areas of extreme ‘congestion or consolidation. In such situations, mark margins and moni: tor to note any decrease or increase in the crepitant areapSSME 312 UIT m+ NURSING ASSES surface characteristics: war fingers (© iced Palpate si ut on gloves and use Yo" palpate any lesions that you no! Guring inspection. Also feel for any ‘unusual masses, Palpate for fremitus. Following the above sequence, use the ball or ulnar edge of one hand to assess for fremi- tus (vibrations of air in the bronchial tubes transmitted to the chest wall) [As you move your hand to cach area, ask the client to say “ninety-nine.” Assess all areas for symmetry and intensity of vibration, ¥linical Tip: |The ball of the hand is best for assessing tactle fremitus because the area is especially sensitive to vibratory sensation Assess chest expansion. Place your hands on the posterior chest wall with your thumbs at the level of T9 orT10 and pressing together a small skin fold. As the client takes a deep ‘breath, observe the movement of your ‘thumbs (Fig. 16-12). Figure 16-12 Scarung position for ees op THE ADU ymnmetti remyinthe upper tegions of tne MS, trtremius is not palpable on C10 fide, the client may need £0 SPe: weer. decrease in the intensity Of fremitus is normal as the examiner moves toward the base of the lungs. However, fremitus should remain. sym" metric for bilateral positions. ‘When the client takes a deep breath, the examiner's thumbs should move 510 10cm apart symmetrically. snusual palpable masg juated further by a pr nl Jef APPTOPrIate professions” ona qual fremitus is usually ¢ us) or bronchial obst, trapping in emphysema jon, oF pneumothorax (y se fremitus). Diminished jeven with a loud spoken von Bom pronchial tree. rat ction Pleura, ich ay omplete expansion), pneumonia trauma, or pneumothorax (xr pleural space). Decreased cies sion at the base of the lungs Characteristic of chronic obsin pulmonary disease (COPD). This duc to decreased diaphragmarc tion.