MEDICAL–SURGICAL

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NCM112 T
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NURSING ELLANO M

(RESPIRATORY SYSTEM) TOPIC 2: ASSESSMENT, DIAGNOSTICS, AND LABORATORIES

MAJOR SIGNS AND SYMPTOMS OBSERVED IN
CLIENTS WITH RESPIRATORY DISORDERS
SPUTUM
1
 Refers to phlegm that is actually coughed up or
DYSPNEA
expectorated from the lungs, trachea, or bronchi. It is
 Subjective feeling of difficult or labored breathing,
collected and examined in medical tests (like sputum
breathlessness, shortness of breath. culture) to check for infection.
 It is a symptom common to many pulmonary and
cardiac disorders, particularly when there is
decreased lung compliance or increased air way
resistance.

SPUTUM COLOR CHART

CHEST PAIN
COUGH  Chest pain or discomfort may be associated with
 Cough is a reflex that protects pulmonary or cardiac disease.
the lungs from the accumulation  Chest pain associated with pulmonary conditions
of secretions or the inhalation of may be sharp, stabbing, and intermittent, or it may
foreign bodies. be dull, aching, and persistent.
 Cough results from irritation of  The pain usually is felt on the side where the
the mucous membranes pathologic process is located, but it may be referred
anywhere in the respiratory tract. elsewhere—for example, to the neck, back, or
 The stimulus that produces a abdomen.
cough may arise from an
infectious process or from an WHEEZING
airborne irritant, such as smoke, smog, dust, or a  Wheezing is a high-pitched, musical sound heard
gas. mainly on expiration (asthma) or inspiration
(bronchitis).
SPUTUM PRODUCTION  It is often the major finding in a patient with
PHLEGM VS SPUTUM bronchoconstriction or airway narrowing.
PHLEGM
 Refers to thick mucus produced in the lungs and RHONCHI
airways, especially during illness.  Rhonchi are low pitched continuous sounds heard
 It is not normally expelled, unless there's a
over the lungs in partial airway obstruction.
respiratory problem.  Depending on their location and severity, these
 Term is often used generally to describe mucus in
sounds may be heard with or without a stethoscope.
the chest.

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 TOPIC 2: ASSESSMENT, DIAGNOSTICS, AND LABORATORIES

HEMOPTYSIS  What do you do to relieve the shortness of breath?

 Expectoration of blood  How well does it work?
from the respiratory  Ask the patient with a cough these questions:
tract o When did the cough start?
 Hemoptysis is a o Is the cough productive?
symptom of both o If the cough is chronic, has it
pulmonary and cardiac o Changed recently? If so, how?
disorders. o What makes the cough better?
 The onset of o What makes it worse?
hemoptysis is usually o What medications are you taking?
sudden, and it may be intermittent or continuous.
 When a patient produces sputum, ask him to
 Signs, which vary from blood-stained sputum to a
estimate the amount produced in teaspoons or some
large, sudden hemorrhage, always merit
other common measurement. Also ask him these
investigation.
questions:
o At what time of day do you cough most often?
PHYSICAL ASSESSMENT
o What’s the color and consistency of the sputum?
(ASSESSING RESPIRATION)
o If sputum is a chronic problem, has it changed
CLUBBING OF THE FINGERS
recently? If so, how?
 It is a sign of lung disease
that is found in patients
PHYSICAL EXAMINATION (INSPECTION)
with chronic hypoxic
UPPER RESPIRATORY STRUCTURES
conditions, chronic lung
infections, or malignancies 1. Nose and Sinuses
of the lung. 2. Mouth and Pharynx
 This finding may be manifested initially as 3. Trachea
sponginess of the nail bed and loss of the nail bed
angle.

CYANOSIS
 A bluish coloring of the skin,
is a very late indicator of
hypoxia.
 The presence or absence of
cyanosis is determined by the
amount of unoxygenated
hemoglobin in the blood.
 Cyanosis appears when there is at least 5 g/dL of
unoxygenated hemoglobin.

PAST HEALTH, FAMILY AND SOCIAL HISTORY

 Child hood illnesses
 Immunizations
 Chronic medical condition
 Injuries
 Hospitalizations
 Surgeries
 Allergies
 Current medications (including over-the-counter
medications and herbal remedies)
 Related to or exacerbated by tobacco smoking
 Smoking history (including exposure to second-
hand smoke)
 When the patient quit smoking or is still smoking
 Anxiety
 Role changes
 Family relationships
 Financial problems
 Employment status
 Strategies the patient uses
WHAT CAN YOU ASK THE PATIENT?
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 TOPIC 2: ASSESSMENT, DIAGNOSTICS, AND LABORATORIES

SWOLLEN SINUSES RATES AND DEPTHS OF RESPIRATION

TYPES DESCRIPTIONS
EUPNEA
 Normal, breathing at 12-18
breath/min
 Slower than normal rate (<10
BRADYPNEA breath/min), with normal depth an
regular rhythm
 Associated with increased
intracranial pressure, brain injury,
and drug overdose
 Rapid, shallow breathing (>24
breaths/min).
TACHYPNEA  Associated with pneumonia,
pulmonary edema, metabolic
acidosis, septicemia, severe pain,
and rib fracture.
HYPOVENTILATION
 Shallow, irregular breathing

HYPERPNEA  Increase depth of respiration

 Increased rate and depth of
breathing that results in
HYPERVENTILATION decreased PaCO2 level.
 Inspiration and expiration are
nearly equal in durations.
 Called Kussmaul's respiration if
associated with diabetic
LOWER RESPIRATORY STRUCTURE AND ketoacidosis or renal origin.
 Period of cessation of breathing;
BREATHING
APNEA time duration varies; apnea may
THORACIC INSPECTION occur briefly during other
 Chest Configuration breathing disorders, such as with
 Breathing Pattern and Respiratory Rates sleep apnea; life-threatening it
sustained.
THORACIC PALPATION  Regular cycle where the rate and
depth of breathing increase, then
 Respiratory Excursion
decrease until apnea (usually
 Tactile Fremitus
CHEYNE–STOKES about 20 seconds) occurs.
 Duration of apnea may vary and
THORACIC PERCUSSION progressively lengthen; therefore
 Diaphragmatic Excursion it is timed and reported.
 Associated with heart failure and
THORACIC AUSCULTATION damage to the respiratory center
(drug-induced, tumor, trauma).
 Breath Sounds
 Periods of normal breathing (3-4
 Voice Sounds
BIOT’S breaths) followed by a varying
RESPIRATION period of apnea (usually 10-60
seconds).
 Also called “cluster breathing.”
 Associated with some nervous
system disorders.

MORANO BREATH SOUNDS 3

 TOPIC 2: ASSESSMENT, DIAGNOSTICS, AND LABORATORIES

pitched, whistle-like sounds

Locations heard during inspiration and
Intensity of Pitch of expiration caused by air bronchospasm,
Duration of Where
Types Expiratory Expiratory wheezes passing through narrowed asthma, and buildup
Sounds Heard
Sound Sound or partially obstructed of secretions
Normally
Entire lung airways; may clear with
Vesicular field except coughing.
Inspiratory *FRICTION RUBS*
over the
sounds last  Harsh, crackling
Relatively expiratory
longer than Soft sound, like two pieces
low one’s upper
expiratory of leather being rubbed
sternum and
ones. together (sound
between the
scapulae. imitated by rubbing
Often in the thumb and finger
1st and 2nd together near the ear).
Broncho- interspaces  Heard during
vesicular Inspiratory are about inspiration alone or
and equal during both inspiration
expiratory Intermediate Intermediate anteriorly and expiration. Secondary to
sounds are and between Pleural  May subside when inflammation and
about equal. the scapulae friction rub patient holds breath; loss of lubricating
(over the coughing will not clear pleura fluid.
main sound.
bronchus).  Best heard over the
Bronchial Expiratory lower lateral anterior
sounds last Over the surface of the thorax.
Relatively  Sound can be
longer than Loud manubrium,
high enhanced by applying
inspiratory if heard all
ones. pressure to the chest
Tracheal Inspiratory wall with the
and Over the diaphragm of the
Relatively stethoscope.
expiratory Very Loud trachea in
high
sounds are the neck
about equal. CHARACTERISTICS OF PERCUSSIONS SOUNDS

ABNORMAL (ADVENTITIOUS) BREATH SOUNDS Sound

Relative Relative Relative Location Examples
Intensity Pitch Duration Example
Large pleural
BREATH Flatness Soft High Short Thigh
DESCRIPTION ETIOLOGY effusion
SOUNDS Lobar
Dullness Medium Medium Medium Liver
*CRACKLES* pneumonia
Soft, high-pitched, Simple chronic
 Secondary to fluid in the Resonance Loud Low Long Normal lung
discontinuous popping sounds bronchitis
airways of alveoli or to Hyper- Emphysema,
that occur during inspiration Very loud Lower Longer None normally
delayed opening of resonance pneumothorax
Crackles in (while usually heard on Gastric air
collapsed alveoli.
general inspiration, they may also be bubble or Large
 Associated with heart Tympany Loud High
heard on expiration); may or puffed-out pneumothorax
failure and pulmonary
may not be cleared by check
fibrosis.
coughing.
Discontinuous popping sounds
Coarse heard in early inspiration; Associated with obstructive
ASSESSMENT FINDINGS IN COMMON
crackles harsh, moist sound originating pulmonary disease. RESPIRATORY DISORDERS
in the large bronchi.
Associated with interstitial Tactile
Discontinuous popping sounds Disorder Percussion Auscultation
pneumonia, restrictive Fremitus
heard in late inspiration;
Fine pulmonary disease (e.g., Consolidation Bronchial breath sounds, crackles,
sounds like hair rubbing
crackles fibrosis); fine crackles in early (e.g., Increased Dull bronchophony, egophony,
together; originates in the pneumonia) whispered pectoriloquy.
inspiration are associated with
alveoli. Normal to decreased breath
bronchitis or pneumonia. Bronchitis Normal Resonant
sounds, wheezes
*WHEEZES*
Decreased intensity of breath
 Associated with bronchial Emphysema Decreased Hyperresonant sounds, usually with prolonged
wall oscillation and expiration.
changes in airway Asthma (severe Normal to Resonant to
Wheezes
Usually heard on expiration but diameter. attack) decreased hyperresonant
Wheezes in
may be heard on inspiration  Associated with chronic Pulmonary
Normal Resonant
Crackles at lung bases, possibly
general edema wheezes
depending on the cause. bronchitis or
bronchiectasis. Decreased to absent breath
sounds, bronchial breath sounds
 Associated with
and bronchophony, egophony, and
secretions or tumor. Pleural effusion Absent Dull to flat
whispered pectoriloquy above the
Deep, low-pitched rumbling effusion over the area of
Sonorous sounds heard primarily during compressed lung.
wheezes expiration; caused by air Pneumothorax Decreased Hyperresonant Absent breath sounds
(ronchi) moving through narrowed Atelectasis Absent Flat
Decreased to absent breath
tracheobronchial passages. sounds

Sibilant Continuous, musical, high- Associated with

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 TOPIC 2: ASSESSMENT, DIAGNOSTICS, AND LABORATORIES

DIAGNOSTIC EVALUATION
(DIAGNOSTIC PROCEDURES)
PULMONARY FUNCTION TESTS
 PFTs can measure either volume or capacity.
 These tests aid diagnosis in patients with suspected
respiratory dysfunction. NURSING CONSIDERATIONS
 The practitioner orders these tests to:  For some tests, the patient will sit upright and wear a
o Evaluate ventilatory function through spirometric nose clip.
measurements.  Explain that they may receive an aerosolized
o Determine the cause of dyspnea. bronchodilator.
o Assess the effectiveness of medications, such o He may need to receive the bronchodilator more
as bronchodilators and steroids. than once to evaluate the drug’s effectiveness.
o Determine whether a respiratory abnormality  Emphasize that the test will proceed quickly if the
stems from an obstructive or restrictive disease patient follows directions, tries hard, and keeps a
process. tight seal around the mouthpiece or tube to ensure
o Evaluate the extent of dysfunction. accurate results.
 Instruct the patient to loosen tight clothing so he can
TERM USED SYMBOL DESCRIPTION REMARKS breathe freely.
Vital capacity Forced vital capacity  Tell the patient that he/she must not smoke or eat a
Forced vital performed with a is often reduced in
FVC large meal for 4 hours before the test.
capacity maximally forced COPD because of
expiratory effort. air trapping.
Volume of air
Forced ARTERIAL BLOOD GAS STUDIES
exhaled in the
expiratory
specified time  A practitioner will
volume A valuable clue to
FEV1 during the
(qualified by the severity of the
subscript
(usually performance of
expiratory airway
typically order an
FEV1) forced vital
indicating the
capacity; FÊV1 is
obstruction. ABG analysis as one
time interval in
seconds)
volume exhaled in of the first tests to
1 second.
Ratio of timed
assess respiratory
Another way of
forced FEV1/FVC FEV, expressed as
expressing the status because it
expiratory %, usually a percentage of
volume to FEV1/FVC the forced vital
presence or helps evaluate gas
absence of airway
forced vital % capacity.
obstruction. exchange in the
capacity
Mean forced lungs.
expiratory flow
Forced An indicator of large
FEF200-1200 between 200 and
expiratory flow
1200 mL of the
airway obstruction NURSING CONSIDERATIONS
FVC.  Blood for an ABG analysis should be drawn from an
Mean forced
Forced
expiratory flow Slowed in small arterial line if the patient has one.
midexpiratory FEF25-75%
flow
during the middle airway obstruction o If a percutaneous puncture is necessary, the site
half of the FVC.
Mean forced must be chosen carefully.
Slowed in
Forced end expiratory flow o The brachial, radial, or femoral arteries can be
FEF75-85% obstruction of
expiratory flow during the terminal
smallest airways
portion of the FVC. used.
Volume of air
expired in a
 After the sample is obtained, apply pressure to the
Maximal An important factor
voluntary MVV
specified period
in exercise puncture site for 5 minutes and tape a gauze pad
(12 seconds)
ventilation
during repetitive
tolerance firmly in place (Don’t apply tape around the arm; it
maximal effort. could restrict circulation).
o Regularly monitor the site for bleeding, and
SPIROMETRY check the arm for signs of complications, such
 Spirometry is a breathing test that measures how as swelling, discoloration, pain, numbness, and
well your lungs work, specifically: tingling.
o How much air you can inhale and exhale (lung  Make sure you note on the slip whether the patient is
volumes). breathing room air or oxygen.
o How fast you can blow air out (airflow rates). o If oxygen, document the number of liters.
o If the patient is receiving mechanical ventilation,
document the fraction of inspired oxygen.

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 TOPIC 2: ASSESSMENT, DIAGNOSTICS, AND LABORATORIES

o Also include the patient’s temperature on the

slip; results may be
corrected if the
patient has a fever or
hypothermia.
 Keep in mind that certain
conditions may interfere
with test results — for
example, failing to
properly heparinize the syringe before drawing a
blood sample or exposing the sample to air.
o Venous blood in the sample may lower PaO2
levels and elevate PaCO2 levels. SPUTUM STUDIES
 These are laboratory tests performed on sputum —
PULSE OXIMETRY the thick mucus you cough up from the lungs (not
 Pulse oximetry is a noninvasive method of saliva) — to help diagnose and monitor lung or
continuously monitoring the oxygen saturation of airway diseases.
hemoglobin (SaO2).  These studies can include cultures to identify
 When oxygen saturation is measured with pulse bacteria or fungi, cytology to detect abnormal cells,
oximetry, it is referred to as SpO2. and other tests to assess the presence of specific
pathogens like Mycobacterium tuberculosis.

SaO2 SpO2
S – Saturation S – Saturation
a – Arterial p – Arterial
O2 – Oxygen O2 – Oxygen
Direct measurement from Indirect estimate from a
arterial blood (lab or pulse oximeter using light
blood gas machine). absorption.

NURSING
CONSIDERATIONS
 Place the probe or clip NURSING CONSIDERATIONS
over the finger or other  Encourage the patient to increase his fluid intake the
intended sensor site so night before sputum collection to aid expectoration.
that the light beams and  To prevent foreign particles from contaminating the
sensors are opposite specimen, instruct the patient not to eat, brush his
each other. teeth, or use a mouthwash before expectorating.
 Protect the transducer from exposure to strong light. o He may rinse his mouth with water.
o Check the transducer site frequently to make
 When the patient is ready to expectorate, instruct
sure the device is in place and examine the skin him to take three deep breaths and force a deep
for abrasion and circulatory impairment. cough.
 Before sending the specimen to the laboratory,
CULTURES make sure it’s sputum, not saliva.
 Throat cultures may be performed to identify o Saliva has a thinner consistency and more
organisms responsible for pharyngitis.
bubbles (froth) than sputum.
 Throat culture may also assist in identifying
organisms responsible for infection of the lower
IMAGING STUDIES
respiratory tract.
1. X-Ray
 Nasal swabs may be performed for the same
purpose. 2. CT scan
3. MRI
4. Fluoroscopic Studies
5. Pulmonary Angiography
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 TOPIC 2: ASSESSMENT, DIAGNOSTICS, AND LABORATORIES

6. Radioisotope Diagnostic Procedure (Lung Scan)

4
HOW IT’S DONE?


CT SCAN
CT is an imaging method in which the lungs are
scanned in successive layers by a narrow-beam x-
5 1. A catheter (thin tube) is inserted into a large vein
(often in the groin or arm) and guided into the
pulmonary artery.
ray. 2. A contrast dye (iodine-based) is injected.
 The images produced provide a cross-sectional view 3. X-ray images or fluoroscopy records how the dye
of the chest. flows through the lung arteries.
 A contrast agent is sometimes used to highlight 4. Blockages or narrowing appear as areas where dye
blood vessels and to allow greater visual doesn’t flow normally.
discrimination.
NURSING CONSIDERATIONS
 Tell the patient who will perform the test and where
and when it will take place.
o Explain that the test takes about 1 hour and
allows confirmation of pulmonary emboli.
 Tell the patient he must fast for 6 hours before the
test or as ordered.
o The patient may continue prescribed drug
regimen unless the practitioner orders otherwise.
NURSING CONSIDERATIONS  Explain that he/she may be given a sedative, such
 Ask the patient if he has ever had an allergic as diazepam, as ordered.
reaction to contrast media, shellfish, or iodine. o The patient may also be given diphenhydramine
 If he has, notify the practitioner before the (Benadryl) to reduce the risk of a reaction to the
procedure. dye.
 Tell the patient that, if a contrast dye will be used, he  Explain the procedure to the patient.
should fast for 4 hours before the test. o The doctor will make a percutaneous needle
 Explain that they’ll lie on a large, noisy, tunnel- puncture in an antecubital, femoral, jugular, or
shaped machine. subclavian vein.
 If a contrast dye will be used, tell the patient that  Explain the procedure to the patient.
he/she may experience transient nausea, flushing, o The doctor will make a percutaneous needle
warmth, and a salty taste when the dye is injected puncture in an antecubital, femoral, jugular, or
into his arm vein. subclavian vein.
 Tell the patient that the equipment may make o The patient may feel pressure at the site.
him/her feel claustrophobic. o The doctor will then insert and advance a
catheter.
PULMONARY ANGIOGRAPHY
 After catheter insertion, check the pressure dressing
 A pulmonary angiography is another
for bleeding and assess for arterial occlusion by
test used to check for PE.
checking the patient’s temperature, sensation, color,
 A flexible tube is threaded through the
and peripheral pulse distal to the insertion site.
upper thigh or arm to blood vessels in
 After the test, monitor the patient for hypersensitivity
your lungs.
to the contrast medium or to the local anesthetic.
 Dye is injected into the blood vessels,
o Keep emergency equipment nearby and watch
allowing x-ray pictures to show how
for dyspnea.
blood flows through the blood vessels
in your lungs.
ENDOSCOPIC PROCEDURES
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 TOPIC 2: ASSESSMENT, DIAGNOSTICS, AND LABORATORIES

 Explain that the doctor will introduce the

bronchoscope tube through the patient’s nose or
 Bronchoscopy mouth into the airway.
 Thoracoscopy  Then the doctor will flush small amounts of
 Thoracentesis anesthetic through the tube to suppress coughing
and gagging.
 Explain to the patient that he/she will be asked to lie
on the side or sit with the head elevated at least 30
degrees until the gag reflex returns; food, fluid, and
oral drugs will be withheld as well until this time.
 Report bloody mucus, dyspnea, wheezing, or chest
BRONCHOSCOPY pain to the practitioner immediately.
 A bronchoscope is used to view the airways and o A chest X-ray will be taken after the procedure
check for any abnormalities. and the patient may receive an aerosolized
bronchodilator treatment.
 Monitor for subcutaneous crepitus around the
patient’s face and neck, which may indicate tracheal
or bronchial perforation.
 Watch for breathing problems from laryngeal edema
or laryngospasm; call the practitioner immediately if
you note labored breathing.
 Observe the patient for signs of hypoxia,
PURPOSES OF BRONCHOSCOPY pneumothorax, bronchospasm, or bleeding.
 To examine tissues or collect secretions.  Keep resuscitative equipment and a tracheostomy
 To determine the location and extent of the tray available during the procedure and for 24 hours
pathologic process and to obtain a tissue sample for afterward.
diagnosis.  Before the procedure, a signed consent form is
 To determine whether a tumor can be resected obtained from the patient.
surgically.  Food and fluids are withheld for 6 hours before the
 To diagnose bleeding sites. test to reduce the risk of aspiration when the cough
reflex is blocked by anesthesia.
FIBEROPTIC BRONCHOSCOPE
 It is a thin, flexible bronchoscope that can be THORACOSCOPY
directed into the segmental bronchi which allows
increased visualization of the peripheral airways.

RIGID BRONCHOSCOPE
 It is a hollow metal tube with a light at its end.

ENDOSCOPIC
THORACOSCOPY
NURSING CONSIDERATIONS  Like bronchoscopy,
 Tell the patient that he/she will receive a sedative, thoracoscopy uses
such as diazepam (Valium), midazolam, or fiberoptic instruments
meperidine (Demerol). MORANO 8
 TOPIC 2: ASSESSMENT, DIAGNOSTICS, AND LABORATORIES

and video cameras for visualizing thoracic

structures.  A biopsy is a medical
 Unlike bronchoscopy, thoracoscopy usually requires procedure where a doctor
the surgeon to make a small incision before inserting takes a small sample of
the endoscope. tissue or cells from the
 A combined diagnostic-treatment procedure, body so it can be examined
thoracoscopy includes excising tissue for biopsy. under a microscope.

THORACENTESIS PURPOSES
 Also known as pleural fluid aspiration 1. To diagnose diseases
 Thoracentesis is used to: 2. To check how severe a disease is
o Obtain a sample of pleural fluid for analysis 3. To monitor the effectiveness of treatment
o Relieve lung compression
o Obtain a lung tissue biopsy specimen. TYPES OF BIOPSY
PLEURAL BIOPSY

LUNG BIOPSY

NURSING CONSIDERATIONS
 Tell the patient that his/her vital signs will be taken
and then the area around the needle insertion site
will be shaved.
 Explain that the doctor will clean the needle insertion
site with a cold antiseptic solution, then inject a local
anesthetic.
o Tell the patient that he/she may feel a burning
sensation as the doctor injects the anesthetic. PLEURAL BIOPSY
 Explain to the patient that after his skin is numb, the
doctor will insert the needle.
o The patient will feel pressure during needle
insertion and withdrawal.
o The patient will need to remain still during the
test to avoid the risk of lung injury.
o The patient should try to relax and breathe
normally during the test and shouldn’t cough,
breathe deeply, or move. NURSING CONSIDERATIONS
 Emphasize that he should tell the doctor if he  After the procedure, recovery and home care are
experiences dyspnea, palpitations, wheezing, similar to those for bronchoscopy and thoracoscopy.
dizziness, weakness, or diaphoresis; these  Nursing care involves monitoring the patient for
symptoms may indicate respiratory distress. shortness of breath, bleeding, and infection.
o After withdrawing the needle, the doctor will  In preparation for discharge, the patient and family
apply slight pressure to the site and then an are instructed to report pain, shortness of breath,
adhesive bandage. visible bleeding, redness of the biopsy site, or
 Tell the patient to report fluid or blood leakage from purulent drainage (pus) to the health care provider
the needle insertion site as well as signs and immediately.
symptoms of respiratory distress.  Patients who have undergone biopsy are often
anxious be cause of the need for the biopsy and the
BIOPSY 9
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potential findings; the nurse must consider this in providing post-biopsy care and teaching.

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