Due to Sarah having limited mobility you must pay
attention to her respiratory assessment. Why?
Stroke may disrupt breathing either by (A)
causing a disturbance of central rhythm
generation, (B) interrupting the descending respiratory
pathways leading to a reduced respiratory drive,
or (C) causing bulbar weakness leading to aspiration.
Explain how you will do this assessment.
Respiratory system assessment is the first of a four-part
series. A systematic method of collecting both subjective and
objective data will guide the healthcare clinician to make accurate
clinical judgments and develop interventions appropriate to the
home healthcare environment.
I) Subjective
Data
A focused assessment of the respiratory system includes a review
for common or concerning symptoms including:
- Cough—productive/nonproductive, hoarse, or barking;
- Sputum characteristics—clear, purulent, bloody (hemoptysis),
rust colored, or pink and frothy;
- Dyspnea (shortness of breath) with or without activity,
wheezing, or stridor;
- Chest pain—on inspiration, expiration, or with coughing and
location of pain.
- Ask about associated symptoms such as cold symptoms, fever,
night sweats, and fatigue.
- For positive responses, ask when symptoms started (duration),
location, severity, setting, time of day, alleviating factors (what
helps), and aggravating factors (what makes it worse).
- In addition, ask about smoking history, environmental exposure,
past medical and family history, and current medications
ii) Objective
Data
Inspection
- Visual inspection begins with observation of facial expression,
skin color, moisture, and temperature.
- Skin should be warm and dry, and skin color should be uniform
and consistent with ethnicity.
- Facial expression should be relaxed, without signs of distress
or apprehension.
- Any indication that breathing is a conscious effort may be a
sign that something is wrong.
- Observe nail beds, lips, mouth, ears, and conjunctiva for
oxygen saturation.
- A bluish color indicates cyanosis and hypoxia.
- Clubbing of the fingers may indicate chronic hypoxemia.
- Observe the neck for contraction of the sternomastoid muscles;
any use of neck muscles to breathe signals difficult
breathing.
- With the patient properly draped and sitting upright, observe
the respiratory pattern for a full minute.
- Normal adult respiratory rate is 14 to 20 with a regular rate
and frequency and should be quiet.
Palpation
- Place your index finger in the suprasternal notch at the base
of the trachea.
- The trachea should be midline and slightly moveable.
- Pulling of the trachea to either side of the neck results from
unequal intrathoracic pressure within the chest cavity and may
indicate partial to complete pneumothorax, or other serious
conditions.
- Using the palmar surface of the fingers, palpate the anterior
and posterior chest. It should be free of tenderness, pain, or
masses.
- A cracking sensation on palpation is crepitus, as minute air
collections are displaced with fingertip pressure.
- This occurs when air from the lungs is introduced into the
subcutaneous space, usually with a pneumothorax
Percussion
- Percussion is performed by placing the middle finger of the
nondominant hand against the chest wall.
- The tip of the middle finger on the dominant hand is used to
strike the distal phalanx of the middle finger between the cuticle
and the first joint.
- Percussion is helpful to determine the density of the
underlying lung tissue and identify the position of the diaphragm
during inspiration and expiration.
- Percuss the posterior chest in each intercostal space, avoiding
the ribs and scapula, comparing one side with the other, using the
side-to-side ladder pattern, striking in each place twice
- Percussion sounds should be low-pitched, hollow, and long in
duration, or resonant.
- In contrast, dullness occurs when fluid or solid tissue
replaces the normally air filled lung and are thud-like with medium
pitch and duration.
- Dull tones may indicate pneumonia, pleural effusion, or
atelectasis.
- Very loud, lower pitch, and longer percussion sounds,
hyperresonance, when unilateral may indicate emphysema or
pneumothorax
Auscultation
- Ask the patient to breathe slowly and deeply through their open
mouth.
- Listen in each area for at least one full breath. In the person
unable to sit up without help—percuss the upper lung and ascultate
the dependent lung on each side.
- Vesicular breath sounds are soft and generated by airflow of
normal lungs.
- Bronchial breath sounds are normally heard over the larger
airways and trachea.
- Bronchial breath sounds occurring over lateral or posterior
chest walls may indicate consolidation, as in pneumonia.
- Bronchovesicular breath sounds normally heard between the
scapula are abnormal if heard over peripheral lung fields and
indicate lung tissue is dense, possibly due to consolidation,
infection, or compression.