Family History  no signs of clubbing, generally be

- History of pulmonary disease- TB, a pink color - with the healthy nail plate
emphysema, cancer, asthma, cystic being pink, and the nail being white in
color as it grows off the nail bed. 
fibrosis
CLUBBING OF FINGERS
Personal and Social History
 change in the normal nail bed.
 Smoking/ Tobacco use- smoking start
 is a symptom of disease, often of the
date, pack year history (no. of packs/day
heart or lungs which cause chronically
times the number of years in smoking)/
low blood levels of oxygen
second hand smoke. Is patient still
 In clubbing, the distal phalanx of each
smoking or he quits smoking.
finger is rounded and bulbous. Nail plate
 Use of Electronic Nicotine Delivery
is more convex and the angle between
System (ENDS)-E-cigarretes, e-pens, e-
the plate and the proximal nail fold
pipes,
increases to 180 degrees or more
 Work environment – nature of work,
 Seen in patients with chronic hypoxia,
exposure to environmental hazards
chronic lung infections, congenital heart
(chemicals, vapors, dust, allergen,
disease, endocarditis and inflammatory
asbestos, work hours, exposure to
bowel disease.
extreme heat or cold
 Home environment – location,
CYANOSIS
exposure to allergens, pets, plants,
 Bluish color of the skin and mucous
exposure to cleaning agents,
membranes caused by low oxygen levels
pesticides, fertilizers, air-conditioning
in the red blood cells or problems
system
getting oxygenated blood to your body
 Recent travelling
 A very late sign of hypoxia and often a
 Issues on diet, exercise, sleep,
threatening sign
recreational habits
 The presence or absence of cyanosis is
determined by the amount of
PHYSICAL ASSESSMENT OF THE
unoxygenated hemoglobin
RESPIRATORY SYSTEM (Part 2)
 It appears when there is at least 5g/dl of
 The general appearance gives clues to
unoxygenated hemoglobin
respiratory status. A thorough physical
 Causes of cyanosis are anemia,
assessment includes IAPP.
polycythemia vera, internal hemorrhage,
Problems with the lungs, Blood clot in
INSPECTION OF GENERAL
the arteries of the lungs
APPEARANCE
 Assessment of cyanosis is affected by
 The nurse inspect for normal and
room lighting, patient’s skin color
abnormal findings such as presence of
clubbing of the fingers and cyanosis  Central cyanosis- is observe on the
tongue and lips. This indicates a
NORMAL FINDINGS decrease in oxygen tension in the blood.
Skin  Peripheral cyanosis- results to decreased
 Pink, no cyanosis or pallor present blood flow to the periphery (fingers, tip
Nails
of the noes, toes, and earlobes) due to
vasoconstriction from exposure to cold
 and does not indicate a systemic
problem
PALLOR
 Pale looking
 caused by reduced blood flow and
oxygen or by a decreased number of red
blood cells or hemoglobin. It can occur
all over your skin or appear more
localized.
 Usually seen in lower palpebral
conjunctiva, tip and dorsum of the
tongue, soft palate, nail beds, palmar or
plantar creases, general body skin.
UPPER RESPIRATORY STRUCTURES
 Penlight and tongue blades, nasal
speculum is necessary,
Nose and Sinuses
 Inspect for the lesions, asymmetry or
inflammation
 Gently tilt the head backward and gently
push the tip of the nose upward in order
to examine the internal structures
 Inspect for color, swelling, exudate or
bleeding
 Nasal mucosa is normally redder than
oral mucosa
 Swollen and hyperemic if patient has
common cold
 Pale and swollen due to allergic rhinitis
 Inspect the septum for deviation,
perforation or bleeding
 Inspect the inferior and middle
turbinates. In chronic rhinitis, nasal
polyps may develop
 Palpate the frontal and maxillary sinuses
for tenderness
 Gentle apply thumb pressure in an
upward fashion at the supraorbital ridge
(frontal sinuses) and in the check area
adjacent to the nose
 Tenderness is a sign of inflammation
 Frontal and maxillary can be inspected
by transillumination (passing a strong
light through a bony area to inspect the
cavity. If the light fails to penetrate, the
cavity is likely containing fluid or pus.
MOUTH AND PHARYNX
 Instruct the client to open the mouth
wide and take a deep breath as this
flattens the posterior tongue and allows
a full view of the anterior view and
posterior tonsils, uvula and posterior
pharynx
 Inspect for color, symmetry and
evidence of exudates, ulceration or
enlargement
 If tongue blade is needed to depress the
tongue to visualize the pharynx ,it is
pressed firmly beyond the midpoint of
the tongue to avoid gag response.
TRACHEA
 Direct palpation is used to assess the
position and mobility of the trachea.
This is performed by placing the thumb
and index finger of one hand on either
side of the trachea just above the sternal
notch
 Trachea is highly sensitive and palpating
too firmly may trigger coughing or
gagging reflex
 Trachea should be in the midline
normally and abnormal if it is deviated
into one side.
 Pleural effusion, hemothorax,
Pneumothorax, or tension pneumothorax
can deviate the trachea away from the
affected side (toward the opposite side)
 Trachea is pulled toward the affected
side to patients with atelectasis, fibrosis,
tumors on the neck.
ASSESSMENT OF THE
LOWERRESPIRATORY STRUCTURES
POSITIONING from trauma may indicate a respiratory
 Sitting position with arms crossed in distress.
front of the chest and hands placed on
the opposite shoulders. This position
separates the scapulae widely and
exposes more lung area for assessment. CHEST WALL ABNORMALITIES
 If the patient is unable to sit, with the BARREL CHEST
patient supine, roll the patient form side  Due to overinflation of the lungs which
to side to complete the posterior increases the antero-posterior diameter
examination. of the lungs
 To assess the anterior thorax and lungs,  A barrel chest means a broad, deep
patient should be supine or sitting, it chest that resembles the shape of a
allows easier displacement of the barrel. A man with a barrel chest have
patient’s breast tissue and chest a large rib cage, round torso and great
examination. upper body strength. A barrel chest
usually relates to osteoarthritis as you
CHEST INSPECTION age which can stiffen the joints where
a. Observe the he uses of diaphragm, the ribs attach to the spine. The ribs
intercostal and accessory muscles with
become fixed in their most expanded
breathing.
position, causing the appearance of a
 Intercostal retractions (sucking in of the
barrel chest
muscles and skin between ribs during
 It occurs with aging and a hallmark sign
inspiration) usually mean that the
of emphysema and COPD
patient is making a larger effort at
 In patient with emphysema the ribs are
inspiration than normal
more widely spread and the intercostal
 Frequent use of accessory muscles
spaces tend to bulge on expiration
indicates respiratory problem.
indicating that lungs have lost their
 Observe for use of the abdominal
elasticity and the diaphragm is flattened
muscles during passive expiratory
phase. Labored breathing maybe
FUNNEL CHEST/PECTUS EXCAVATUM
accompanied by interrupted speech
 A funnel shape depression on all or part
pattern as he or she gulps for air.
of the sternum. This may compress the
b. Look at the diameter of the chest, from
heart and great vessels resulting to
front to back (antero-posterior diameter) of
murmurs that may interfere with
the chest.
respiratory and cardiac function
 Increased antero-posterior diameter of
 Funnel chest may occur with rickets and
the chest is due to overexpansion or
Marfan syndrome
inflation of the lungs from COPD and
kyphosis (curvature of the spine)
PIGEON CHEST/PECTUS CARINATUM
c. Look for Chest deformities.
 A pigeon chest occurs as a result of the
 These are important in helping to
anterior displacement of the sternum,
determine the reason for respiratory
which increases the anteroposterior
distress. Khyposcoliosis or flail chest
diameter/ Displaced sternum that
protrudes in front of the abdomen that
 increases the front to back diameter of
the chest
 the breastbone to push outward instead
of being flush against the chest. 
 the tissue that connects the breastbone to
the ribs grows too much. Another cause
might be when parts of the bone itself
grow too much. Sometimes it happens
following open heart surgery. Pigeon
chest seems to run in families
 Treatment options include chest-wall
bracing and/or surgery
 This may occur with rickets, Marfan’s
syndrome and severe kyphoscoliosis
THORACIC KYPHOSCOLIOSIS
 Characterized by elevation of the
scapula and a corresponding S-shaped
spine/ Characterized by spinal curvature
to one side and rotate vertebra
 It causes difficulty in assessing
respiratory status because of the rotation
distorts the lung tissue
d. Look for Posture.
 Patients with obstructive pulmonary
disease often sit and prop themselves up
on outstretched arms or lean forward
with their elbows on a table in an effort
to elevate their clavicles
e. Note for masses, scars that indicate trauma
or surgery.
 A scar may signify old injuries to the
chest and provide clues to possible
sources of distress
f. The respiratory Rate and Depth of the
respiration
 It should be counted over at least 15
seconds among healthy or stable patients
and a full minute over a critical ill
patients
 Deep rapid, shallow respiration may
indicate compensation for acidosis.
Shallow respiration at 40breaths/min is
an indication of severe respiratory
distress
NORMAL BREATHING PATTERNS AND
RESPIRATORY RATES
General appearance
 Breathing is quiet and easy without
apparent effort
Respiratory rate
 <1 y/o=30-40
 1-5yo=25-35
 5-12=20-25
 12-20/ minute- normal adult
Breathing Pattern
EUPNEA
 Smooth and regular breathing, quiet
and passive with symmetric chest
expansion and Regular in depth and
rhythm
ALTERED BREATHING PATTERN AND
RESPIRATORY RATES
 Changes in RR and rhythm may be the
first sign of clinical deterioration in
patients who are acutely ill.
 Labored breathing is an important factor
of respiratory distress. As part of the
inspection, the nurse should determine if
the patients is using the accessory
muscles such as sternocleidomastoid,
scalene muscles, and trapezius muscles
during inspiration and the abdominal
and intercostal muscle during expiration.
 Bulging of the intercostal spaces
during expiration implies obstruction of
expiratory airflow as in Emphysema
 Mark retraction on inspiration (if
asymmetric) implies blockage of a
branch of bronchi tree.
 Asymmetric bulging of the intercostal
spaces is created by an increase in
pressure within the hemithorax as a
result of air trapping within the pleural
cavity where it is not normally present
 (ex. Pneumothorax) or the fluids within
the pleural space (Pleural effusion)
 These muscles provide additional
support to assist the breathing effort
during times of exertion (Bickly, 2013)
BRADYPNEA
 Decrease RR usually below 12
breath/min with normal depth and
regular rhythm
 CNS depression caused by sedation,
tissue damage or Diabetic coma,
intracranial pressure, brain injury and
drug overdose such as narcotics
TACHYPNEA
 Shallow breathing with a respiratory rate
greater than 20 breath/minute
 Seen in patients with restrictive lung
disease, pain, fever, obesity or anxiety,
Pneumonia, Pulmonary edema,
metabolic acidosis, severe pain, rib
fracture and septicemia
HYPOVENTILATION
 very slow, shallow respiration resulting
to increased PaCO2 level in the blood.
 COPD. Neuromuscular disorders -
Amyotrophic lateral sclerosis, muscular
dystrophies (Duchenne and Becker
dystrophies), diaphragm paralysis,
Guillain-Barré syndrome, myasthenia
gravis, Chest wall deformities
Kyphoscoliosis,thoracoplasty
HYPERVENTILATION
 increased rate and depth breathing that
results in decreased PaCO2 level
 inspiration and expiration nearly equal
in duration
 associated with exertion, anxiety and
metabolic acidosis
KUSSMAUL’S BREATHING
 Deep rapid breathing. RR is greater than
20 and labored breath sounds
 Metabolic acidosis or DKA
APNEA
 Period of cessation of breathing/
Absence of breathing/temporary pauses
of breathing
 Apnea may occurs briefly during other
breathing disorders such as sleep apnea
 Life threathening is sustained
OBSTRUCTIVE SLEEP APNEA
 Occurs repeatedly during sleep
secondary to transient upper airway
blockage
HYPERPNEA
 Deep rapid breathing
 Can occur during or after exercise or
result from pain, anxiety or metabolic
acidosis
 Indicate hypoxia or hypocalcemia in a
coma patient
CHEYNE-STOKES BREATHING
 Regular cycle where the rate and depth
of breathing increase, then decrease until
apnea (about 20 seconds occurs)
 marked rhythmic, waxing and waning
(weakening or disappearing) respirations
from very deep and very shallow
breathing and temporary apnea.
 Seen in heart failure, kidney failure or
CNS damage
BIOT’S BREATHING
 Period of normal breathing (3-4 breaths)
followed by a varying period of apnea
(usually 10-60 seconds)
 shallow breaths interrupted by apnea
 associated with respiratory depression
due to drug overdose and brain injury
 An ominous sign of severe CNS damage
APNEUSTIC BREATHING
 prolonged, gasping inspiration followed
by a very short and inefficient expiration
 is an abnormal pattern
of breathing characterized by deep,
gasping inspiration with a pause at full
inspiration followed by a brief,
insufficient release.
APNEUSTIC CENTER
  sends signals for inspiration for long and
deep breaths.
 It controls the intensity of breathing and
is inhibited by the stretch receptors of
the pulmonary muscles at maximum
depth of inspiration, or by signals from
the pnuemotaxic center.
 It increases tidal volume
h. Duration of inspiration and expiration
 Helps to determine the presence of
obstructive lung disease. Expiration is
more than 1 ½ times long as inspiration
 Expiration even though is
physiologically longer than inspiration,
on auscultation over lung fields it will
be shorter. The air moves away from
alveoli towards central airway
during expiration, hence you can hear
only early third of expiration
Inspiration Expiration Ratio
 refers to the ratio of inspiratory time
:expiratory time.
 In normal spontaneous breathing, the
expiratory time is about twice as long as
the inspiratory time.
 This ratio is typically changed in
asthmatics due to the prolonged time
of expiration. They might have an
I:E ratio of 1:3 or 1:4.

i. Observation of thoracic expansion.
 Chest expansion is about 3 inches
occurs from maximal expiration to
maximal inspiration. ,
 Compare the expansion with the upper
chest of that to the lower chest. Observe
the movement of the diaphragm to
determine whether the patient has
obstructive lung disease is concentrated
on expanding the lower chest and using
the diaphragm properly.
 Expansion on side of the chest vs. the
other side due to atelectasis due to
mucus plugs may cause unilaterally
diminished chest expansion because
the air is unable to move equally
through the pulmonary bed.
 Flail chest results from broken bone ribs
that are unable to maintain the integrity
of the chest wall during respiration.
Abnormal chest expansion may occur in
flail chest because the chest collapsed
instead of expanding during inspiration
 Pulmonary embolus, pneumonia, pleural
effusion, pneumothorax, COPD or any
problem associated with chest pain may
lead to diminished chest expansion
 Endotracheal or nasotracheal tube
positioned beyond the trachea can
diminished expansion on one side of the
chest
Normal Chest Size
Men’s Size: S-34-36 (86-91cm), M-37-39 (94-
99cm, L-40-42 (102-107cm), XL-43-46 (109-
117)
CHEST EXPANSION TEST
 Assessment of chest expansion with
deep inspiration helps identify the side
of abnormality
 Take measurements at the end of
deep inspiration and expiration.
 Take a tape and encircle chest around
the level of nipple. Take measurements
at the end of deep inspiration and
expiration.
 Normally, a 2-5" of chest
expansion can be observed.
 For the upper expansion and
lower expansion, the values are 1.4 cm,
3.1 cm, 5.1 cm and 1.0 cm, 2.7 cm and
4.3 cm respectively.
 It was concluded that chest
expansion of both upper and
lower thoracic increase with age
increases until the 3rd decade of life,
and then steadily declines after this
  Any lung or pleural disease can give rise
to a decrease in overall chest expansion
such chronic fibrotic disease,
consolidation, effusion, collapse or
pneumothorax
RESPIRATORY
EXCURSION/SYMMETRY OF CHEST
EXPANSION
 The nurse assesses the patient for range
and symmetry of excursion.
 Posterior assessment
 Have patient seated erect or stand with
arms on the side. Stand behind patient.
Place both hands posteriorly at the level
of T 9-T10, slide hands medially to pinch
a small amount of skin between your
thumbs.
 Have patient slowly take a deep breath
and expire. Watch the symmetry of
movement of the hemithorax.
Simultaneously, feel the chest
expansion.
 For anterior assessment- place the
thumbs along side the costal margin of
the chest wall and instruct the patient to
inhale deeply. Place your hands
over upper chest and apex and repeat
the process. Next, stand in front and lay
your hands over both apices of the lung
and anterior chest and assess chest
expansion
 The nurse observes movement of the
thumbs during inspiration and
expiration. This movement is normally
symmetric
 Normal- Chest expansion is symmetrical.
Both sides take off at the same time and to
the same extent.
 Abnormal- Asymmetrical chest expansion
is abnormal. The abnormal side expands less
and lags behind the normal side. Any form
of unilateral lung or pleural disease can
cause asymmetry of chest expansion.
 Asymmetric excursion may be due to
fractured ribs, splinting secondary to
pleurisy, trauma, or unilateral bronchial
obstruction.
DIAGPHRAGMATIC Excursion
 Is the movement of the thoracic
diaphragm during breathing
 to assess the position and motion of the
diaphragm, instruct the client to take a
deep breath and hold it while, the
maximal descent of the diaphragm is
percussed.
 Normal DE should be 3-5 cm but can
increase in healthy clients to 7-8 cm, this
measures the contraction of the
diaphragm. It is performed by asking the
patient to exhale and hold it.
 Maximal excursion of the diaphragm is
3-4 inches or 8-10cm or 5-7 cm (2-2.75
inches
 Decrease diaphragmatic excursion
indicates pleural effusion, Trauma or
cervical cord or phrenic nerve damage
due surgery (high C-spine injuries
involving C3-C5, phrenic nerve injury
during cardiac surgery)
 Increase diaphragmatic excursion
indicates Atelectasis or pregnancy
because the diaphragm is position high
in the thorax.
CHEST PALPATION
 Place the palm over the thorax. The
chest wall should be smooth, warm and
dry
 Palpate for tenderness, bulging,
retractions of the chest
 If there are reported pain in area if
lesions are apparent or superficial direct
palpation will be perform.
TACTILE FREMITUS
  The ability to feel the sound on the chest
wall. Tactile fremitus is more easily
palpated over the large bronchi
 Describes vibrations of the chest wall
that result from speech detected on
palpation/ the sensation of sound
vibrations produced when the patients
speaks.
 To assess the tactile fremitus, the
nurse ask the patient to say 99 or
“one, one, one” while moving his/her
hands over the posterior surfaces of
the chest wall. Tactile fremitus should
be symmetrical/ Place your open palms
on both sides of the client’s back
without touching his back with your
fingers.
 Diminished or absent tactile fremitus
due to an increase in air per unit volume
of lung, because air impedes the
transmission of sound (in Emphysema,
atelectasis
 Increase Fremitus- Increase in
vibration is felt due to consolidation of
the lung (Lung consolidation occurs
when the air that fills the small airways
in your lungs is replaced may be
replaced with: a fluid, such as pus,
blood, or water. a solid, such as stomach
contents or cell ) caused by fluid-filled
or solid structures
 due to Pneumonia and tumor of the
lungs
CHEST PERCUSSION TONES
 Chest Percussion is done if or when
lungs are filled with air, fluid or solid
material
 to percuss the chest, the HCP presses
one finger from the non-dominant hand
against the chest and uses a finger tip
from the dominant hand to strike the
knuckle pressed against the chest.
 Healthy lung tissue is resonant
 Percussion normally begins in
Posterior thorax. The nurse percusses
across each shoulder top locating the 5
cm width of resonance overlying the
lung apices.
 To perform percussion anterior chest,
begin in the supraclavicular area and
proceeds downward, form one ICS to
the next
 Dullness noted to the left sternum
between 3rd and 5th ICS is a normal
finding because of the location of the
heart
1. Resonant
 heard over normal lung tissue
 Long, loud, low pitch
 Simple chronic bronchitis
2. Hyper resonant
 abnormal sound heard during percussion
in adults
 Long, Very loud lower pitch sound
 Hyperinflated lung/air trapping such
emphysema and Pneumothorax
3. Flat
 heard over airless tissue/ a part of the
body that contains no air.
 Short, soft, high pitch, extremely dull
 Atelectasis, and extensive pleural
effusion
4. Dull
 Medium in intensity and pitch
 occurs over dense lung tissue such as
tumor and consolidation. Due to Lobar
pneumonia, pulmonary edema and
hemorrhage
4.Tympanic
 Loud, high pitch, moderate length,
musical drum like sound
 Gastric air bubble, air in the intestine
 indicates large tension pneumothorax
and asthma.
CHEST AUSCULTATION
  Auscultate the anterior, posterior and
lateral thorax. Auscultation helps to
assess the flow of air through the
bronchial tree and to evaluate the
presence of fluid or solid obstruction in
the lungs
 We auscultate normal breath sounds and
adventitious sounds
 Place the diaphragm of the stethoscope
firmly on the chest wall as the patient
breath slowly and deeply through the
mouth.
 Auscultate the chest started to the apices
to the base and along midaxillary lines.
The sequence of auscultation is similar
in doing percussion.
 Listen to two full inspiration and
expiration at each anatomic location for
valid interpretation of the sound heard.
 The location, quality, and intensity of
the breath sounds are determined by
auscultation.
Normal Breath Sounds
Vesicular
 low pitch sound and heard all over the
chest and heard best in the bases of
lungs except over the upper sternum and
between the scapulae
 best heard on (prolong) inspiration and
shortened during expiration
Broncho vesicular
 Moderate pitch with moderate amplitude
created by air moving through larger
airway
 Heard when pt inhales or exhales
equally
 heard between the scapulae and lateral
to the sternum at the first and second
ICS
Bronchial
 High pitch and loud sounds created by
air moving through the trachea.
 Heard loudest when patient exhales just
above the clavicles on each side of the
sternum, over the manubrium
Tracheal
 Harsh, high pitch sound
 Heard when patient inhale or exhales/
inspiratory and expiratory sounds are
about equal.
 Above supraclavicular notch, over the
trachea
ADVENTITIOUS Breath Sounds
Crackles/rales in general
 Soft high pitch, discontinuous popping
sounds that occur during inspiration
(usually heard in inspiration and may
also be heard in expiration)
 Usually don’t clear with coughing
 caused by collapse or fluid filled alveoli
 Associated with heart failure and
pulmonary fibrosis
Classified by Fine or Coarse
Fine Crackles
 discontinuous popping sound heard in
late inspiration; sounds like hair rubbing
together, originates in the alveoli
 intermittent, non-musical, soft, high
pitch, short crackling popping sounds,
heard during inspiration
 Causes- associated with interstitial
pneumonia and restrictive pulmonary
disease (fibrosis)
Coarse Crackles
 Discontinuous popping sound heard
in early inspiration
 Intermittent, loud, low pitch, bubbling or
gurgling sounds heard during inspiration
at bases of lower lung lobes
 Harsh moist sound originating in the
large bronchi
 air passing through fluid or mucus in
any air passage.
  Asthma, Bronchitis, or Obstructive
pulmonary disease
WHEEZE (Sibilant)
 continuous, high pitched musical squeak
or whistling sound occurring on
EXPIRATION and inspiration when air
moves through a narrowed or partially
obstructed airway
 May clear with coughing
 Bilateral wheezes is an indication of
bronchoconstriction which can be
treated with short acting bronchodilator
like albuterol
 Unilateral wheezes indicate a foreign
body obstruction which requires
bronchoscopy
 Asthma, chronic bronchitis,
bronchiectasis and build-up of
secretions.
Sonorous Wheeze (Rhonchi)
 Deep, low pitch rumbling sounds heard
primarily during expiration
 Cause by air moving through narrowed
tracheobronchial passages
Pleural friction rub
 Harsh, crackling sound like two pieces
of leather rubbing together (rubbing
thumb and finger together near the ear)
 Heard during inspiration and expiration
 Best heard over the lower lateral anterior
surface of the thorax
 May subside when patients hold their
breath; coughing will not clear the sound
 Cause by rubbing of inflamed pleural
surfaces, loss of lubrication pleural
fluid.
Gurgling/rhonchi
 continues, low pitch, snoring quality
 best heard on expiration, but could be
heard in both inspiration and expiration
 Cause: air passes through a narrow
passages due to swelling and
secretion/blocks the large airways
VOICE SOUNDS
Voice Resonance
 The sound heard through the
stethoscope when the patient talks
 Assess voice sound when abnormal
breath sounds are auscultated
 The vibrations produced in the larynx
are transmitted to the chest wall as they
passes to the through the bronchi to the
alveolar tissue
 Voice are evaluated by having the
patient repeat “99” or “1, 1, 1” while the
nurse listens with the stethoscope in
corresponding areas of the chest from
the apices to the base
 Normal- faint and indistinct
 Abnormal- increase lung density such as
in Pneumonia and Pulmonary edema.
ABNORMAL VOICE RESONANCE
Bronchopony
 a voice resonance that is more intense
and clearer than normal
Egophony
 describes voice sounds that are distorted.
It is best appreciated by having the
patient repeat the letter E
 It transforms the sound into clearly A
rather than E
Whispered Pectoriloquy
 Describes the ability to clearly and
distinctly hear whispered sounds that
should not normally be heard.
  POSITIVE- 10mm or more
 HIV patients- 5mm is POSITIVE
 + Mantoux test signifies exposure to
Mycobacterium Tubercle Bacilli
 Mantoux Test will be positive for clients
who have received BCG
PULSE OXIMETRY
 To determine o2 saturation in the blood
 Can detect hypoxemia or hypoxia
 95-100%
 The pulse oximeter sensor is place in the
index finger or earlobe.
 The sensor should be covered with
DIAGNOSTIC opaque material. The result is affected
EVALUATION/PROCEDURES by sunlight.
Non Invasive Sputum exam
 To determine the appearance of the
Pulmonary Function Test sputum
 Is routinely used in patients with  Rusty sputum- pneumococcal
respiratory conditions pneumonia
 Is performed to assessed respiratory  Greenish sputum- Pseudomonas
function and the extent of dysfunction, infection
response to therapy and screening test in  Blood tinged- PTB
hazardous industries such as coal mining  Culture and Sensitivity- to detect the
exposure to asbestos actual microorganisms causing
 Used prior to surgery for thoracic and respiratory infection
upper abdominal surgical procedures,  Cytologic exam- to assess for presence
obese patients of CA.
 A test that measures lung volumes,  AFB staining-
ventilatory function, to determine the - to detect PTB
capacity of the lungs to exchange O2 Nursing considerations
and CO2  Collect sputum early in the
MORNING. Sputum usually
Incentive Spirometry accumulates in the lungs during sleep
 To prevent and treat atelectasis and can easily be coughed in the
 Semi fowlers position morning
 Done to enhance deep inhalation  Advise the patient to rinse mouth with
 Instruct the client to take in a slow, easy plain water. Do not used mouthwash
deep breath from the mouthpiece. that may destroy microorganisms
 Sterile container should be used. To
prevent contamination
Skin Test/Mantoux Test  Sputum specimen for C and S is
 purified protein derivative (PPD) collected before the first dose of
skin test is a test that determines if you antibiotic.
have exposure to tuberculosis (TB). TB  For AFB- collect sputum for 3
is a serious infection, usually of the consecutives morning
lungs, caused by the bacteria
Mycobacterium tuberculosis. ABG analysis
 PPD is used  to assess ventilation and acid base
 Route: ID balance
 48-72 hrs
  It helps to monitor patients response to
therapy
 Radial Artery is the common site for
withdrawal of specimen
 Allen’s Test is done to assess for
adequacy of collateral circulation of the
hand
 Use 10 ml heparinized syringed to draw
the blood specimen. To prevent blood
clotting.
 Place the specimen in a container with
ice. To prevent hemolysis. If hemolysis,
OXYGEN and CO2 are release and
cannot be measure accurately.
AVOID INACCURATE ABG VALUES
 Be sure to use proper technique
 Avoid delays in getting the sample to
the laboratory
 Don’t draw blood for ABG ANALYSIS
within 15-20 minutes of a procedure
such as suctioning or administering
respiratory treatment
 Remove air bubbles from the syringe
because they could affect the oxygen
level in the blood
 Don’t get venous blood in the syringe
because it could affect the CO2 and O2
levels and pH
IMAGING STUDIES
CHEST X-RAY
 Instruct the client to hold his breath and
not to do breathing
 Remove metals from the chest.
INVASIVE Procedure
THORACENTESIS
 Aspiration of fluid or air from the
pleural space
Nursing Interventions Before the procedure
 Secure written consent- invasive
 Take V/S- aspiration of air/fluid from
the pleural space cause Hypovolemic
shock
 Position: upright, leaning on the over
bed table/Sitting position
 Topical anesthesia is used at the site of
needle insertion
 Pressure sensation is felt on insertion
site
Nursing interventions Post Procedure
 Apply pressure to the puncture site
 Turn the client on the unaffected side.
To prevent leakage of fluid in the
thoracic cavity
 Bed rest. To prevent postural
hypotension
 Check for expectoration of blood. Notify
the doctor. Indicates trauma to the lung
 Monitor for complications:
 Shock, Pneumothorax, and Respiratory
arrest
Bronchoscopy
 Direct inspection and observation of
the larynx, trachea, and bronchi using
bronchoscope.
USES:
 To collect secretions
 To determine pathologic process and
collect specimen for biopsy
 To remove aspirated foreign object and
excise small lesions.
Nursing Intervention before the Procedure
 Informed consent. Invasive procedure
 Atropine sulphate and valium as ordered
 Topical anesthesia sprayed in the throat
followed by local anesthesia in the
larynx
 NPO 6-8 hrs. To prevent aspiration.
 Remove dentures prostheses and contact
lenses. To prevent airway obstruction.
Nursing intervention after Procedure
 Side lying position- to promote drainage
of secretions from the mouth
 Check for cough and gag reflex before
giving fluid. To prevent aspiration
 Prepare suction device at the bedside
 Watch for cyanosis, hypotension,
tachycardia, arrhythmias, dyspnea and
hemoptysis. And notify the physician.
 These are signs of perforation of
bronchial tree

LUNG SCAN
 Following injection of radioisotope,
scans are taken with a scintillation
camera.
 Measures the blood perfusion through
the lungs
 Confirms pulmonary embolism and
other blood flow abnormalities
 Instruct the client to remain still during
the procedure

BIOPSY OF THE LUNG

 Transbronchoscopic biopsy- done
during bronchoscopy

 Percutaneous needle biopsy- done

with the use of aspiration needle

 Open lung biopsy- done during

surgery

LYMP node BIOPSY- to assess metastatic

CA