Care For A Client With Respiratory Disorders 2

CARE FOR A
CLIENT WITH
RESPIRATORY
DISORDERS
Prepared by:
Anthony C. Barrera, RN
Learning Objectives
Anatomic and Physiologic Overview of the Respiratory System
 Composed of the upper and lower respiratory tracts

 Upper respiratory tract warms and filters inspired air
 Lower respiratory tract accomplishes gas exchange or
diffusion
 Gas exchange involves delivering oxygen to the tissues
through the bloodstream and expelling waste gases, such as
carbon dioxide, during expiration
 Respiratory system depends on the cardiovascular system for
perfusion, or blood flow through the pulmonary system
Anatomy of the Respiratory System
Upper Respiratory Tract
 Nose
 Paranasal sinuses
 Pharynx, tonsils, and
adenoids
 Larynx
 Trachea
Nose
 Passageway for air to pass to and from the lungs

 Filters impurities and humidifies and warms
 Composed of an external and an internal portion
 Each nasal cavity is divided into three passageways:
Superior Turbinate
Middle Turbinate
Inferior Turbinate
Paranasal Sinuses
 Four pairs of bony cavities
Frontal
Ethmoid
Sphenoid
maxillary
 Serve as a resonating chamber in
speech
 Common site of infection
Pharynx, Tonsils, Adenoids
Pharynx
 Connects the nasal and oral cavities to the larynx
 Passageway for the respiratory and digestive tracts
 Divided into three regions:
Nasal
Oral
Laryngeal
Pharynx, Tonsils, Adenoids
Adenoids or Pharyngeal Tonsils

 Located in the roof of the nasopharynx
 Encircle the throat
Larynx
 The epiglottis forms the entrance to the larynx
 Connects the pharynx and the trachea
 Consists of epiglottis, glottis, thyroid cartilage,
cricoid cartilage, arytenoid cartilage, and vocal
cords
 Major function is vocalization
 Protects the lower airway
 “watchdog of the lungs”
Trachea
 Also known as windpipe
 Composed of smooth
muscle
 Serves as the passage
between the larynx and the
right and left main stem
bronchi through the hilus
Lower Respiratory Tract
 Lungs
Pleura
Mediastinum
Bronchi and
bronchioles
Alveoli
Anterior view of the lungs

Lungs
Pleura
 A serous membrane that
lined the lungs and wall of
thoracic cavity
 Consists of Visceral and
parietal pleura
Lungs
Mediastinum
 Located at the middle of the thorax, between the pleural sacs
that contain the two lungs
 Extends from the sternum to the vertebral column and
contains all of the thoracic tissue outside the lungs
Lungs
Bronchi and Bronchioles

 Bronchi have several
divisions: lobar,
segmental, and
subsegmental.
 Lined with cells that have
surfaces covered with cilia
Lungs
Lungs
 Bronchioles contain submucosal
glands
 Bronchioles branch into terminal
bronchioles, and become
respiratory bronchioles
 Respiratory bronchioles then lead
into alveolar ducts and sacs and
then alveoli
Lungs
Alveoli
 Oxygen and carbon dioxide
exchange takes place
 The lung is made up of about 300
million alveoli
 3 types of alveolar cells: type I,
Type II, and alveolar
macrophages
Function of the Respiratory System
 Oxygen Transport
- Oxygen is supplied to, and carbon dioxide
is removed from, cells by way of the
circulating blood through the thin
walls of the capillaries
 Respiration
- process of gas exchange between the
atmospheric air and the blood and
between the blood and cells
of the body
 Gas Exchange
- The air we breathe is a gaseous mixture
consisting mainly of nitrogen (78%),
oxygen (21%), argon (1%), and trace
amounts of other gases including
carbon dioxide, methane, and
helium, among other gases
 Pulmonary Diffusion and Perfusion
- Pulmonary diffusion refers to gas exchange
in the alveolar-capillary membrane.
- Pulmonary perfusion refers to the actual
 Ventilation
- Inspiration and expiration
- Involves mechanics ventilation, that is, air
pressure variances, resistance to airflow,
and lung compliance .
Lung Volume and Lung Capacity
LUNG VOLUME
Term and Symbol Normal Value
Tidal Volume (VT or TV) 500 mL
Inspiratory Reserve Volume (IRV) 3000 mL
Expiratory Reserve Volume (ERV) 1100 mL
Residual Volume (RV) 1200 mL
Lung Volume and Lung Capacity
LUNG CAPACITY
Term and Symbol Normal Value
Vital Capacity (VC) 4600 mL
Inspiratory Capacity (IC) 3500 mL
Functional Residual Capacity (FRC) 2300 mL
Total Lung Capacity (TLC) 5800 mL
Note: Spirometer is an instrument that can be used at the bedside

to measure volumes
Assessment of the
Respiratory System
Common Symptoms
 Dyspnea
 Cough
 Sputum production
 Chest pain
 Wheezing
 Hemoptysis
Common Symptoms
 Dyspnea  Defined as a feeling of discomfort while

breathing
 Dyspnea and tachypnea accompanied by
progressive hypoxemia may signal ARDS
 Orthopnea may be found in patient with
heard disease and COPD
 Stridor may be heard
Common Symptoms
To help determine the cause of dyspnea, the nurse should
 Dyspnea ask the following questions:
Common Symptoms
Dyspnea Scale and Patient’s Report of Current and
 Dyspnea Recent Dyspnea
Common Symptoms
Dyspnea Scale and Patient’s Report of Current and
 Dyspnea Recent Dyspnea
Common Symptoms
 Cough  A reflex that protects the lungs

 Results from irritation or inflammation of
the mucous membranes anywhere in the
respiratory tract
 Common causes include asthma,
gastrointestinal reflux disease, infection,
and side effects of medications
Common Symptoms
 Sputum  Reaction of the lungs to any constantly

recurring irritant and often results from
production persistent coughing
 A thick and yellow, green, or rust colored
sputum is a common sign of a bacterial
infection
 Thin, mucoid sputum frequently results
from viral bronchitis
Common Symptoms
 Chest pain  Lung disease does not always cause thoracic

pain
 Pleuritic pain from irritation of the parietal
pleura is sharp and seems to “catch” on
inspiration
 Assess the onset, quality, intensity, and
radiation of pain and identifies and explores
precipitating factors and their relationship
Common Symptoms
 Wheezing  A high-pitched, musical sound which is

continuous, meaning it is heard on either
expiration (asthma) or inspiration
(bronchitis)
 A major finding in a patient with
bronchoconstriction or airway narrowing
Common Symptoms
 Hemoptysis  Expectoration of blood from the respiratory

tract
 Onset is usually sudden, and it may be
intermittent or continuous
 Determine the source of the bleeding
History Taking
 Family History Assessment Specific to Genetic
Respiratory Disorders
 Various conditions that affect gas exchange and
respiratory function are influenced by genetic factors
 Some are known to have a direct inherited pathway while
others have a strong familial association, but the exact
inheritance pattern is not entirely clear
Physical Assessment of the Respiratory System
 Inspects for clubbing of the fingers and notes skin color
 Clubbing a sign of lung disease that is found in patients

with chronic hypoxic conditions, chronic lung infections,
or malignancies of the lung
 Central cyanosis is assessed by observing the color of the
tongue and lips. Peripheral cyanosis results from
decreased blood flow to the body’s periphery
Physical Assessment of the Respiratory System
 In clubbing, the distal phalanx of each
finger is rounded and bulbous. The nail
plate is more convex, and the angle
between the plate and the proximal nail
fold increases to 180 degrees or more.
The proximal nail fold, when palpated,
feels spongy or floating. Among the
many causes are chronic hypoxia and
lung cancer.
Physical Assessment of the
Upper Respiratory Structure
1. Nose
2. Sinuses
3. Mouth and Pharynx
4. Trachea
Nose
 Inspect the external nose for lesions, asymmetry, or inflammation
 Examine the internal structures of the nose, and inspect the mucosa for
color, swelling, exudate, or bleeding
 Inspect the septum for deviation, perforation, or bleeding
 Inspect the inferior and middle turbinates
Sinuses
 Inspect the frontal and maxillary sinuses by transillumination
Sinuses
 Palpate the frontal and maxillary sinuses for tenderness
Mouth and Pharynx
 Inspect anterior and posterior pillars, tonsils, uvula, and posterior
pharynx for color, symmetry, and evidence of exudate, ulceration, or
enlargement
 If a tongue blade is needed to depress the tongue to visualize the
pharynx, it is pressed firmly beyond the midpoint of the tongue to
avoid a gagging response.
Trachea
 Palpate directly the trachea and check its position and mobility
 The trachea is normally in the midline as it enters the thoracic inlet
behind the sternum
Physical Assessment of the Lower
Respiratory Structure and Breathing
Positioning
 To assess the posterior thorax and the lungs, the patient should be in a
sitting position with arms crossed in front of the chest and hands
placed on the opposite shoulders.
 If the patient is unable to sit, with the patient supine, the nurse should
roll the patient from side to side to complete the posterior examination
 To assess the anterior thorax and lungs, the patient should be either
supine or sitting.
Thoracic Inspection
 Inspect the skin over the thorax for color and turgor and for evidence
of loss of subcutaneous tissue
 Note asymmetry and chest deformity, if present.
 Four main chest deformities: barrel chest, funnel chest (pectus
excavatum), pigeon chest (pectus carinatum), and kyphoscoliosis
Thoracic Inspection (Four Main Deformities)
 Barrel chest
Results from overinflation of the lungs
Occurs with aging
Hallmark sign of emphysema and COPD
 Funnel chest (pectus excavatum)
Results from depression in the lower portion of the sternum
Occur with rickets or Marfan syndrome
 Pigeon Chest (Pectus Carinatum)
Results from anterior displacement of the sternum
Occur with rickets, Marfan syndrome, or severe kyphoscoliosis.
 Kyphoscoliosis
Characterized by elevation of the scapula and a corresponding S-
shaped spine
Normal Chest Barrel Chest

Normal Chest Funnel Chest

Normal Chest Pigeon Chest

Normal Spine Kyphoscoliosis

Thoracic Inspection (Locating Thoracic Landmarks)
Anterior View
Posterior View
Lateral View
Thoracic Inspection (Breathing Pattern and Respiratory Rate)
 Observe the rate, depth, and symmetry during respiration
 Respirations are quiet with a regular rate, depth, and rhythm
 Normal pattern associated with breathing is known as eupnea
 Episodes of apnea occur repeatedly during sleep, secondary to
transient upper airway blockage, is called obstructive sleep apnea
Thoracic Inspection (Types of Breathing Pattern and Rate)
Thoracic Inspection (Use of Accessory Muscles)
 Observe the use of
sternocleidomastoid,
scalene, and trapezius
muscles during inspiration
Thoracic Inspection (Use of Accessory Muscles)
 Observe the use of abdominal and internal intercostal muscles during
expiration
Thoracic Palpation
 Palpates the thorax for
tenderness, masses, lesions,
respiratory excursion, and
vocal fremitus
 Perform direct palpation on
area of pain or if lesions are
apparent
Thoracic Palpation
Respiratory Excursion
 Estimates thoracic expansion and may discloses
significant information about thoracic movement
during breathing.
Thoracic Palpation
Anterior
Respiratory
Excursion
Thoracic Palpation
Posterior
Respiratory
Excursion
Thoracic Palpation
Tactile Fremitus
 Describes vibrations of the chest wall that result
from speech detected on palpation.
 Normally, sounds generated by the larynx travel
distally along the bronchial tree to set the chest
wall in resonant motion
Thoracic Palpation
Tactile Fremitus
Thoracic Palpation
Tactile Fremitus
 Factors influencing the normal tactile fremitus:
1. Thickness of the chest wall
2. Pitch
3. Closeness to the large bronchi
Thoracic Palpation
Tactile Fremitus
 Air doesn’t conduct
sound well; however, a
solid substance such as
tissue does, provided
that is has elasticity
and is not compressed.
Thoracic Percussion
 Percussion usually begins with the posterior thorax overlying the lung
apices
 Determine whether underlying tissues are filled with air, fluid, or solid
material
 Percussion is also used to estimate the size and location of certain
structures within the thorax
 Dullness over the fluid-filled lung or solid tissue
Thoracic Percussion
Thoracic Percussion
Thoracic Percussion
Characteristics of Percussion Sounds
Sound Examples
Flatness Large pleural effusion
Dullness Lobar pneumonia
Resonance Simple chronic bronchitis
Hyperresonance Emphysema, pneumothorax
Tymphany Large pneumothorax
Thoracic Percussion
Diaphragmatic Excursion
Use to assess the position and motion of the diaphragm
Position of diaphragm is different during inspiration and
expiration
Maximal excursion of the diaphragm may be as much as 8
to 10 cm (3 to 4 inches) in healthy men, but for most
people, it is usually 5 to 7 cm (2 to 2.75 inches)
Thoracic Percussion
Diaphragmatic Excursion
Thoracic Auscultation
 Assess the flow of air through the bronchial tree and evaluate the
presence of fluid or solid obstruction in the lung
 Auscultate for normal breath sounds, adventitious sounds, and voice
sounds
 Place the diaphragm of the stethoscope against the bare skin of the
chest and auscultate in a systematic sequence similar to that used for
percussion.
Breath Sounds
 Normal breath sounds are identified as vesicular,

bronchovesicular, and bronchial (tubular) breath sounds.
 Breath sounds of the patient with emphysema are faint
or often completely inaudible.
Breath Sounds
Adventitious Sounds
 Divided into two categories: crackles and wheezes
 Duration of the sound is the important distinction to
make in identifying the sound as discontinuous or
continuous
Breath Sound Description Etiology
Crackles
Crackles in general Nonmusical, discontinuous Secondary to fluid in the airways or
popping sounds that occur alveoli or to delayed opening of
during inspiration (may also be collapsed alveoli during inspiration.
heard on expiration) Associated with heart failure and
pulmonary fibrosis
Crackles
Coarse crackles Discontinuous popping sounds heard in Associated with obstructive
early inspiration and throughout expiration; pulmonary disease
harsh, moist sound originating in the large
bronchi; can be heard over any lung region;
do not vary with body position
Crackles
Fine crackles Soft, high-pitched, discontinuous Associated with interstitial
popping sounds heard in mid to late pneumonia, restrictive pulmonary
inspiration; sounds like hair rubbing disease (e.g., fibrosis); fine crackles
together; originates in the alveoli, in early inspiration are associated
especially in dependent areas; may vary with bronchitis or pneumonia
with body position
Wheezes
Wheezes in Continuous, musical, high-pitched, Associated with bronchial wall
general shrill sound usually heard on expiration oscillation and narrowed airway
but may be heard on inspiration diameter or partially obstructed
depending on the cause airway.
Associated with chronic bronchitis
or bronchiectasis
Wheezes
Rhonchi Deep, lower-pitched rumbling sounds, Associated with secretions or
snoring quality, heard primarily during tumor; variant of a wheeze; caused
expiration; may clear with coughing by air moving through narrowed
tracheobronchial passages
Breath Description Etiology
Sound
Friction Rubs
Pleural Discontinuous, low-pitched, rubbing or grating sound, like Secondary to
friction two pieces of leather being rubbed together (sound inflammation and loss of
rub imitated by rubbing thumb and finger together near the lubricating pleural fluid
ear). between the visceral and
Heard during inspiration and expiration. May subside parietal pleurae
when patient holds breath; coughing will not clear sound.
Best heard in axillae and bases of lungs
Other Breath Sounds

Stridor Continuous, high-pitched, musical Narrowing of the upper
sound, heard over the neck respiratory tract; immediate
intervention is warranted
Voice Sounds
 A normal voice sound heard through the stethoscope as
the patient speaks is known as vocal resonance
 With normal physiology, the sounds are faint and
indistinct
Voice Sounds
 Pathology that increases lung density, such as
pneumonia and pulmonary edema, alters this normal
physiologic response and may result in the following
sounds:
• Bronchophony
• Egophony
Assessment Findings in Common Respiratory Disorders








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CARE FOR A

 Composed of the upper and lower respiratory tracts

 Passageway for air to pass to and from the lungs

Adenoids or Pharyngeal Tonsils

Anterior view of the lungs

Bronchi and Bronchioles

Note: Spirometer is an instrument that can be used at the bedside

 Dyspnea  Defined as a feeling of discomfort while

 Cough  A reflex that protects the lungs

 Sputum  Reaction of the lungs to any constantly

 Chest pain  Lung disease does not always cause thoracic

 Wheezing  A high-pitched, musical sound which is

 Hemoptysis  Expectoration of blood from the respiratory

 Clubbing a sign of lung disease that is found in patients

Normal Chest Barrel Chest

Normal Chest Funnel Chest

Normal Chest Pigeon Chest

Normal Spine Kyphoscoliosis

 Normal breath sounds are identified as vesicular,

Breath Sound Description Etiology

Other Breath Sounds

Assessment Findings in Common Respiratory Disorders

Assessment Findings in Common Respiratory Disorders

Assessment Findings in Common Respiratory Disorders

Assessment Findings in Common Respiratory Disorders

Assessment Findings in Common Respiratory Disorders

Assessment Findings in Common Respiratory Disorders

Assessment Findings in Common Respiratory Disorders

Assessment Findings in Common Respiratory Disorders

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