"ASSESSMENT OF RESPIRATORY FUNCTION".pdf

"ASSESSMENT OF RESPIRATORY FUNCTION".pdf

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  BY DOLISHA WARBI
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  ASSESSMENT INCLUDE: 1. Arespiratory assessment is an external assessment of ventilation that includes observations of the rate, depth and pattern of respirations. 2. An accurate assessment of respiration depends on recognizing normal thoracic and abdominal movements. 3. On inspiration, the diaphragm contracts, causing abdominal organs to move downward and forward, increasing the vertical space of the chest cavity. 4. At the same time, the ribs lift upward and outward, and the sternum lifts outward to aid the transverse expansion of the lungs. 5. On expiration, the diaphragm relaxes upward, the ribs and sternum return to their relaxed position, and the abdominal organs return to their original position. 6. Assess the patient for signs and symptoms of respiratory changes: ØComplaints of shortness of breath (dyspnea). ØBluish or cyanotic appearance of the nail beds, lips, mucous membranes and skin. ØRestlessness, irritability, confusion, decreased level of consciousness. ØPain during inspiration and expiration. ØLabored or difficult breathing. ØOrthopnea.
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  ØUse of accessorymuscles. ØAbnormal breath sounds such as wheezes, rhonchi or rales. ØInability to breathe spontaneously. ØThick, frothy, blood-tinged or copious sputum production. ØParadoxical chest wall movement
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  7. Assess thepatient for factors that influence the character of respirations: ØActivity ØAnxiety ØAcute pain ØGastric distention ØMedications ØBody position ØPresence of abdominal incisions or dressings ØFever Nurses important in collected the history of the respiratory patient to attain all level of information about his presence and previous condition. 1) Identification data example age sex religions, IP number address etc. 2) Present chief complain. 3) History of present illness. 4) Treatments history. 5) Pass medical or surgical history. 6) Family or social economic status history, etc.
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  Method involves---- ØInspection ØPalpation ØPercussion ØAuscultation INSPECTION: Posture- Anyvariation of thorax such as scoliosis, kyphosis, funnel/barrel chest, pigeon chest. Rate, rhythm and depth of respiratory excursion and expansion of chest wall- normal R.R =12-22 brt/min. Inspection of fingers and toes for any clubbing as a signs of chronic hypoxia or other. PALPATION: Expansion of the chest. Vocal fremitus-vibration with palms of the hand on the chest (when patient is ask to repeat 99) Any part complain of pain or where there is swelling.
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  PERCUSSION: The middle fingerof the left hand is placed on the chest, and the middle phalanx is struck with the tip of the middle finger of the right hand with a patient in supine position. Sound heard can be flattened, dullness, resonance, hyperresonance and tempany, which may indicate the disorder of respiratory tract. AUSCULTATION: Involve listening a chess sound with stethoscope by listening to the lungs while the patient breathed through an open mouth ü to determine the character of the breath sound. ü character of spoken and whisper voice. ü presence of adventitious sound example: Crackles, Wheezes. A. Test to evaluate respiratory function: i. Primary function test (PFTs)-Test lungs volume, diffusion capacity. ii. Pulse oximetry. iii. Capnography- measure exhaled CO2 incase of mechanical ventilation patient. iv. Arterial blood gas analysis (ABG) – PaO2, PaCO2, and PH value.
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  B. Test toidentify the causative organisms. i. Sputum studies. ii. Throat swab/culture. C. Test to evaluate anatomic structure: i. Radiographic imaging. ii. Chest x ray. iii. Fluoroscopy. iv. Computed Tomography. v. Bronchoscopy. vi. Laryngoscopy. vii. Thoracoscopy. viii. Thoracentesis. ix. Biopsy.
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  Many types ofrespiratory disorder, which required intensive care, such as pneumonia, pulmonary embolism, drug overdose and respiratory distress. Nursing management of patient with respiratory disorder in intensive care: qDIAPHRAGMATIC BREATHING – Teach the patient to breathe slowly and deeply through the note, letting the abdomen protrude as far as possible. qCHEST PHYSIOTHERAPHY – It is performed by respiratory therapies and nurses to manage breathing physically by removing secretion and improve ventilation. qPOSTURAL DRAINAGE – Auscultation of the chest is done before and after the procedure to assess the effectiveness of treatment. Prescribed broncodilators, water and saline may be nebulized to dilutes the bronchioles, the thickness of mucus and sputum and combat edema of the bronchial wall. It is done by assumes a sitting position and bends slightly forward-This permit strong coughing. Flex the knee and hips to improve relaxation and reduce the strains on the abdominal muscle while coughing.
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  qCHEST PERCUSSION isdone by tapping air between the patient’s thorax and caregiver’s hand in an alternating rhythmic manner over the lung segments in which the secreation are to be drained. qBREATHING RETAINING – Instruct a patient to breathe slowly and rhythmically in a relaxed manner, and to exhale completely to empty the lungs. Instruct to breathe through nose, because these filters humidifiers and warm the air. qProvide an instructions for an adequate dietary intake to promote gas exchange and increase energy level. qClearing upper every obstruction- It can be done by CPR procedure. AFTER INTUBATION – • Cheek for chess symmetry and expansion. • Auscultate breath sound. • Obtain order for chest X ray to check for tube placement. • Monitor for sign and symptom of aspiration. • Administer oxygen concentration as per doctor at order. • Secure the tube with tape and mark the proximal end of maintenance position. • Use sterile suction to prevent contaminations and infection.
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  AFTER REMOVAL (EXTUBATION)– • Keep masks ready. • Give100% oxygen for a few breaths. • Insert a new sterile suction catheter inside a tube. • Have the patient inhale removed the tube suctioned the airway through the tube as it is pulled out. • Monitor respiratory rate. • Monitor oxygen level-pulse oximeter. • Keep patient NPO. • Provide mouth care. • Breathing exercise. ü Provide instruction to family and patient for treasures to make care by explaining the procedure. ü Suctioning the patient. ü Cleaning the skin around the stoma. ü Providing oral hygiene and assessing for complications.
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  ü Monitor colorsecretion breathing pattern and state of consciousness. ü Perform suctioning, postural drainage and ambulation. ü Monitor vital signs. ü Prevent infection. ü Use clean humidifier when circulatory is change. ü Report malfunction or strange noises immediately. ü Adjust the volume and pressure of alarm if needed.