RESPIRATORY SYSTEM

INTRODUCTION

Judgment must be used in determining whether all or part of the history and physical
examination will be completed based on problems presented by the patients and the degree of
respiratory distress. If respiratory distress is severe, only pertinent information should be
obtained and a thorough assessment should be deferred until the patient’s condition stabilizes.

DEFINITION – Correct diagnosis depends on an accurate health history and a through physical
examination. A respiratory assessment can be done as a part of a comprehensive physical
examination or as an examination in itself.

ANATOMY AND PHYSIOLOGY:

The primary purpose of the respiratory system is gas exchange, which involves the transfer of oxygen and
carbon dioxide between the atmosphere and the blood. The respiratory system is divided into two parts;

 The upper respiratory tract .

 The lower respiratory tract.

The upper respiratory tract includes the nose, pharynx, adenoids, tonsils, epiglottis , larynx, and
trachea. The lower respiratory tract consist of the bronchi, bronchioles, alveolar ducts, and
alveoli.

Upper respiratory tract

1. Nose :
The nose made of bone and cartilage, is divided into two nares by the nasal
septum.
The interior of nose is shaped into rolling projections called turbinates.
That increase the surface area for warming and moistening air.
The internal nose opens directly into the sinuses.
The nasal cavity connects with the pharynx.
Breathing through the narrow nasal passages (rather than mouth breathing)
provides protection for the lower airway.
2. Epiglottis:
The epiglottis is a flap of tissue at the base of the tongue.
During swallowing, the epiglottis covers the larynx, preventing solids and liquids
from entering the lungs.
Conditions such as a stroke, prolong intubation , or level of consciousness may
alter the swallowing ability
 3. Oropharynx:
After passing through the oropharynx, air moves through the laryngopharynx and
the larynx
4. Larynx:
Larynx where the vocal cords are located, air passes through it

Lower respiratory tract:

1. Trachea:
Largest tube in the respiratory tract .
Consist of tracheal rings of hyaline cartilage
The trachea is a cylindric tube about 5 inches(10-12 cm) long and 1 inch(1.5-2.5
cm) in diameter.
The support of U-shaped cartilages keeps the trachea open but allows the adjacent
esophagus to expand for swallowing.
2. Bronchi:
Trachea branches off into two bronchial tubes, a left and the right main bronchus.
The bronchi branch off into smaller sections inside the lungs, called bronchioles
These bronchioles give rise to the air sac in the lungs called the alveoli
3. Lungs:
The lungs are the largest organ in the lower respiratory tract.
The lungs are suspended within the pleural cavity of the thorax
The pleurae are two thin membrane, one cell layer thick, which surrounds the
lungs.

FUNCTION –

1. Oxygen transport:
Oxygen supplied to, and carbon dioxide is removed from, cells by way of the circulating
blood through the thin walls of the capillaries.
Oxygen diffuses from the capillaries through the capillaries wall to the interstitial fluid.
At this point, it diffuses through the membrane of tissue cells, where it is used by
mitochondria for cellular respiration
2. Respiration:
After these tissue capillary exchange, the blood enters the systemic venous circulation
and travels to the pulmonary circulation
The oxygen concentration in blood within the capillaries of the lungs is lower than then
in the lungs alveoli.
3. Ventilation :
 Ventilation requires movement of the walls of the thoracic cage and of its floor, the
diaphragm
The effect of these movements is alternately to increase and decrease the capacity of the
chest.
When the capacity of the chest is increased, air enters through the trachea (inspiration)
and moves into the bronchi, bronchioles, and alveoli and inflates the lungs.
When the chest wall and diaphragm returns to its previous position (expiration), the lungs
recoil and force the air out through the bronchi and trachea.

4. Pulmonary Diffusion and Perfusion

Pulmonary diffusion is the process by which oxygen and carbon dioxide are exchanged
from areas of high concentration to low concentration at the air blood interface.
Pulmonary perfusion is the actual blood flow through the pulmonary vasculature. The
blood is pumped into the lungs by the right ventricle through the pulmonary artery.

HISTORY COLLECTION:

A respiratory history contains information about a clients present condition and previous
respiratory problems.
Interview the client and his/her family, and focus on the clinical manifestation of the
chief complaint, events leading up to the current condition, past health history, family
history and psychosocial history.

Biographical and demographical data

Begain the history by obtaining demographical data include the clients name, age,
gender, and living situation.
Demographical data are usually recorded on an agency assessment form.
Note the clients biologic age and compare it with the clients appearance.

CURRENT HISTORY

Chief complaints

The chief complaints help to establish priorities for intervention and to assess the client’s level of
understanding of the current condition. Common respiratory complaints include:

Dyspnea(shortness of breath): distressful sensation of uncomfortable breathing. Most common

complaints of people with respiratory problems. Person may become accustomed to sensation
and not recognized its presence.
Cough: the cough is a protective reflex action that clears the airway by a high pressure, high
velocity, flow of air. Coughing is effective in removing secretion only above the subsegmental
level(large or main airway).

sputum production: material coughed up from lungs. Contain mucus, cellular debris, or
microorganism and may contain blood or pus. Amount, color, and constituents of sputum are
important diagnostic cure

chest pain: described on a continuum from discomfort during inspiration to intense, sharp pain,
at the end of inspiration. Pain is usually aggravated by deep breathing and coughing.

Wheezing: may or may not be heard by patients. May be describe as chest tightness.

Hemoptysis: coughing up of blood; either gross, frankly bloody sputum or blood–tinged

sputum. Precipitating events should be investigated.

Fatigue: sence of overwhelming tiredness not completely relieved by sleep or rest.

Past health history

In addition to the presenting problem and associated symptoms, the history should also focus on
the past health as well. Specific questions are asked about childhood illnesses, immunization
(include the most recent influenza and pneumonia vaccine)

Medications: Obtain detailed information regarding both prescribed and over the counter
medications because many products affect the respiratory system the client may routinely require
antibiotics , bronchodilators , or steroid for respiratory tract infection. Specify the route of
administration (pill, liquid , or inhalation) many respiratory medications are inhaled through a
metered dose inhaler (MDI) or mini nebulizer . some medications can affect smell and taste ,
these includes metronizadole , local anesthetics , clofribate, some antibiotics, some antineoplastic
, allopurinol , phenylbutazone , levodopa , codeine, morphine,carbamazepine , lithium and
trifluoperazine.

Allergies: Question the client about the history of any allergies and timing of manifestations to
help identify a possible allergic basis for the condition . has the client been tested for allergies ?
when? Ask about precipitating and aggravating factors , such as food , medications, pollen ,
smokes, fumes, animal dander. Ask the client to describe the allergic , manifestations
experienced (chest tightness, wheezing , cough , rhinitis , watery eyes, scratchy throat) and their
severity. Determine the age at which allergies first occurred and whether they have become
progressively more severe.
Surgical history and other treatment:

Discuss the client history of any procedure or surgery that pertains to the upper or lower
respiratory system , such as biopsies , or procedures to directly visualize the structure. The nurse
should determine if the patient has been hospitalization for a respiratory problem(intubation due
to respiratory problem, postural drainage).

Nutritional history

Weight loss is the symptom of many respiratory problems. Maintaining a nutritious diet is
important for clients with chronic respiratiory disease which can result in decrease in lung
capacity and greater workload for the lungs and cardiovascular system . the added workload
increases calorie , expenditure and weight loss may occur . clients may become anorectic
because of the effects of medications and fatigue . the client may not have enough energy to
consume the needed calories to maintain body weight . ask the client to recall intake for the last
24 hours . assess the amount of protein , kilocalories , and sodium intake .

Elimination pattern

Healthy elimination habits depend on the ability to reach a toilet when necessary. Activity
intolerance secondary to dyspnea could result in incontinence. Especially females, with a cronic
cough may be troubled with urinary incontinence during paroxysms of coughing.

Activity- exercise patterns:

The nurse should determine if the patients activity is limited by dyspnea at rest or during
exercise. The nurse should also note weather the patient housing poses a problem that increases
social isolation.

Value- belief pattern

The nurse should determine the patients adherence to the management regimen. Reason for
lacking of adherence should be explore, including conflict with culturally specific beliefs, failure
to note benefits.
PHYSICAL EXAMINATION

Hypoxia is a result of respiratory conditions may precipitate subtle neurologic alterations such
as restlessness , fatigue , disorientation, and personality changes .tachycardia usually
accompanies respiratory problems as the body attempts to compensate for decreased oxygen
delivery . anorexia and weight loss are seen in Many chronic respiratory conditions.

General Assessment

Assess the client level of consciousnesss and orientation note the skin and lip colour . assess the
nail colour , nail beds , and presence of cubbing ,which occurs as compensatory measure for
chronic hypoxia. The shamroth technique is useful assessment for the presence of clubbing.

NOSE AND PARANASAL SINUSES

External Nose

Inspect and palpate the external nose for deviations, from normal alignment , symmetry , colour,
discharge , nasal flaring , lesions,, and tenderness . the client should able to breath quietly
through the nose rather than breath through mouth . check the nasal canals for petency by asking
the clients to occlude one naris with a finger and breath through the open naris while closing the
mouth. Ask the client to tip the head back, and inspect the outer nares, for crusting , bleeding , or
dryness , which should be absent.

Internal Nose

Next inspect the vestibules with the penlight while the clients head is tipped back , normal
findings include coarse hairs, dark red nasal mucosa , clear passage without discharge , and
midline septum , further examination of the internal nose requires the use of nasal speculum and
is not conducted unless indicated . inspection may be hampered by nasal congestion.

Paranasal Sinuses

Palpate and percuss the frontal and maxillary sinuses to assess for swelling and tenderness ,
which are normally absent . palpate the frontal sinuses simultaneously placing the thumbs above
the eyes just under the ridge of the eyes orbits , and apply gentle pressure and palpate the
maxillary sinuses by using side of nose just under the zygomatic bones, direct percussion over
the eyebrows .
Smell

The senses of taste and smell are closely related smell is perceived mainly via the olfactory
nerves ,although the trigeminal nerves many conditions can affect taste and smell , such as viral
infections , normal ageing , head injuries, and local obstructions .smell impairement may be 1.
Hyposmia(a decrease in smell sensitivity ) or 2. Anosmia( bilateral and complete absence of
smell sensitivity ). Assess smell by having the client identify various odours by testing each
nostrils separately.

THORAX AND LUNGS

Accurate physical examination of thorax and lungs requires being familiar with the anatomic
landmarks of the posterior , anterior, and lateral thorax, use these landmarks to identify the
underlying structures, particularly the lobes of the lung and the heart . when performing
inspection , palpation , percussion and auscultation of the respiratory system the examiner should
compare one side of the thorax to the other side to helpm determine the presence or absence of
abnormalities.

Inspection

Notes the client rate , rhythm , and depth of respiration. The normal respiratory rate for an adult
is 14 to 20 breaths per minute . the assessing respiratory patterns figure on the website describes
examples of normal and abnormal respiratory patterns. Observe for signs of respiratory distress ,
such as nasal flaring or retractions, and bulging of intercostals or sternocleidomastoid muscles to
facilitate breathing . inspect the chest wall configuration by comparing the anteroposterior (AP)
diameter to the transverse (lateral) diameter is normally twice the AP diameter ,

Palpation

Palpate the trachea for midline position and slight diversity . palpate the chest wall for
symmetrical thorasic excursion during inspiration and expiration assessment of thorasic
excursion . palpate costal angle (angle at the base of the rib) the costal angle should be less than
90 degrees, acostal angle greater than 90 degrees with an AP/lateral diameter ratio of 1:1
indicates an abnormal barrel chest wall shape , as seen in clients says “ ninety nine” compare the
intensity of vibrations on both sides for symmetry.

Percussion

Percussion over healthy lung tissue produces a resonant (low pitched ,hollow) sound . the pitch
and qualities of other percussion sounds can be summerized as 1. Tympany(high pitched,
hollow, drum like) flat(high pitched, soft) dull ( medium pitched, thundlike )
Auscultation

Lung auscultation provides critical assessment data in terms of client respiratory health .
auscultate in a pattern that compares the right side of the thorax to the left side , auscultate all
areas of the lungs over a bare chest in order to achive accurate findings . at each auscultation
location , listen for a full respiration as the clients breaths through the mouth auscultate for type
or character of breath sounds and the presence of adventitious (extra) sounds. The characteristics
of normal breath sounds illustrate a normal anartomic location .of these sounds
bronchovesicular or bronchial breath sounds heard it the peripheral lung fields can indicate
consolidation of the lung resulting from inflammation and infection .absent or diminished breath
sounds can also indicate lung disease .

Characteristics of normal breath sound

pitch amplitud duration quality Normal location

e
Bronchial High Loud Inspiration Harsh , Trachea and larynx
(tracheal) < expiration hollow,
tabular
Bronchovesicula moderat Moderate Inspiration = mixed Over major bronchi
r e expiration where fewer alveoli
are located posterior,
between scapulae,
especially on right,
anterior, around
upper sternum in first
and second
intercostal spaces.
Vesicular Low Soft Inspiration>ex Rustlin Over peripheral lung
piration g ,like fields where air
sound follows through
of wind smaller bronchioles
in trees. and alveoli.
DIAGNOSTIC TESTING

Noninvasive tests

Diagnostic procedure facilitate the assessment and diagnosis of client trespiratory disorders .
commonly available diagnostic tests include pulmonary function tests , arterial blood gas
analysis , pulse oximetry , ventilation perfusion scan ,x-ray and sputum cultures .

Pulse oximetry

The pulse oxymeter passes a beam of light through the tissue , and a sensor attached to the finger
tip , toe , or ear lobe measures , the amount of light absorbed by the oxygen , saturated
haemoglobin . the oximeter then gives a reading of percentage of haemoglobin that is saturated
with oxygen (sao2) sao2 is closely correlated with the saturations obtained from the pulse
oximeter it is greater than 70% .

Pulmonary function testing

Pulmonary function tests provide information about respiratory fiunction by measuring lung
volumes, lung mechanics, and diffusion capabilities, of the lungs, its performed in pulmonary
function laboratory can measure respiratory volumes, capacities . its done outside the laboratory
are modified to include ventilation tests of forced expiratory volume , vital capacity , and
maximal voluntary ventilation measures refers to the table pulmonary function test (PFT)
recording and results that indicate obstructive and restrictive lung disease .

Comparing oxygen saturation to partial pressure of arterial oxygen

Oxygen saturation(%) Pao2(mmHg) Clients status

50 25 life threatening hypoxemia
75 40 Moderate hypoxemia
90 55 Mild hypoxemia
Chest x-ray

Chest x ray provide information about the chest that may not be available through other
assessment means and may not be able to illustrate graphically the cause of respiratory
dysfunction .chest film may reveals the abnormalities when there are no physical manifestations
of pulmonary disease . chest x ray studies may be performed for variety of reasons including the
following as part of routine screening procedure , when pulmonary disease is suspected ,to
monitor te status of respiratory disorders and abnormalities (pleural, atelectasis, tubercular
lesions) and to confirm endotracheal or tracheostomy tube placement.

Ventilation perfusion scan

Ventilation perfusion (V/Q ) scan are used to assess the lung ventilation and lung perfusion .

V/Q scan are used confirm pulmonary embolism , pulmonary infraction, emphysema, fibrosis,
and bronchietasis . although pulmonary angiography is the most specific diagnostic tool for
pulmonary emboli , it is invasive and less dangerous . quantitative perfusion scans may be
helpful in preoperative assessment Of clients undergoing surgical resection of malignancy.

Computed tomography and magnetic resonance imagning

Computed tomography (CT) provides more sophisticated tomography than is possible with
conventional x ray equipment . the (CT) scan is particularly helpful in identifying peripheral
(pleural) or mediastinal disorders . special techniques can be used to view pulmonary nodules .
thin cuts of CT scans are used to diagnosing interstitial lung disorders such as pulmonary
fibrosis and bronchietasis . spiral or helical CT scan of the chest is an invasive to the lung scan
for identifying pulmonary emboli.

Magnetic resonance imaging (MRI) employs magnetic fields rather than radiation to create
images of the body structures . MRI used in more definitive than CT because it creates more
detailed images of anatomic structures.

INVASIVE TEST

Laryngoscopy
Laryngoscopy is a visual examination of the laynx and is used to diagnosed laryngeal papillomas
, nodules , polyps and cancer. Laryngoscopy can be performed during bronchoscopy. Or as a
separate procedure .

Bronchoscopy

Bronchoscopy is test used for diagnostic and therapeutic uses . a flexible fiberoptic
bronchoscope or rigid bronchoscope permits visualization of the larynx and trachea and bronchi
. a bronchoscopy is useful for the diagnostic detection of tumors , inflammations, or strictures
as well as to obtain tissue biopsies . therapeutic uses of bronchoscopy include removal of
retained secretions or foreign bodies blocking air passage and to control bleeding within the
bronchus.

Thoracocentesis and pleural fluid analysis

Thoracocentesis is an invasive procedure that involves insertion of needle into the pleural space
for removal of pleural fluid or air pleural fluid is removed to therapeutically relieve pain or
shortness of breath . caused by excessive pleural pressure. A thoracocentesis and pleural fluid
analysis can also be diagnostic tool to detect various disorders. Such as inflammatory,
infectious , or cancerous conditions.

Biopsy

Biopsy of the lung or pleura require a surgical excision of the tissue the tissue is examined for
abnormal cellular structures cancers cells or infections.

LABORATORY TEST

Sputum culture

An infectious process can lead to excessive production of mucus commonly called sputum
assessment of sputum by bacteria , fungi, or cellular elements guides the treatment of the
underlying infections . if possible sputum should be collected before antimicrobial treatment is
begun.
Nose and throat culture

The throat and nose normally contains many organisms using a flexible sterile cotton swab ,
cultures , of these areas are taken to identify certain pathogens such as streptococcus species ,
bordetella pertusis , cornybacterium diphtheria , haemophillus influenza , or respiratory syncytial
virus (RSV) bacteria in the nose and throat can be identified by culture during assessment of the
upper airway . some bacteria are normally present ( streptococci , staphylococci , pneumococci ,
haemophillus influenzae, and klebstella pneumonia, )other organisms are abnormal those
causing diphtheria , or tuberculosis . the culture should be collected before antimicrobial
treatment is began.

Arterial blood gases

The ABG analysis involves the use of arterial rather than venous , blood to measure pao2, paco2
and PH directly. Bicarbonate concentration (HCO3) and sao2 are calculated as well . pao2 reflects
the efficiency of gas exchange , whereas paco2 reflects the effectiveness of alveolar ventilation .
the acid base status of the body is indicated by the PH of arterial blood . ABG analysis is helpful
in the assessment of the clients. Who are acutely ill with either pulmonary disorders , who
require an artificial airway , who are dependent on mechanical ventilation , or who are
experiencing chronic respiratory disease.

Arterial supply

The bronchial arteries supply nutrition to the bronchial tree and to the pulmonary tissues.

1. On theright side, there is one bronchial artery which arises either from the third posterior
intercostal artery.

2. On the left side, there are two bronchial arteries both of which arise from the descending
thoracic aorta, the upper opposites fifth thoracic vertebra.

Deoxygenated blood is brought to the lungs by the pulmonary arteries and oxygenated blood is
returned to the heart by the pulmonary veins.

Venous drainage of the lungs

The venous blood from the first one or two divisions of the bronchi is carried by bronchial veins.
Usually there are two bronchial veins on each other side.
The right bronchial veins drain into the azygos vein.

The left bronchial veins drain into the hemiazygos vein.

Lymphatic drainage

There is two set of lymphatics

1. Superficial vessels drain the peripheral lung tissue lying beneath the pulmonary pleura.

2. Deep lymphatics drain the bronchial tree, the pulmonary vessels and the connectives
tissue septa.

Nerve supply

a. Parasympathetic nerve is derived from the vagus.

b. Sympathetic nerves are derived from second to fifth spinal segments.