Lewis et al: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition Key Points: Chapter 26:

Nursing Assessment: Respiratory System

STRUCTURES AND FUNCTIONS 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 upper respiratory tract includes the nose, pharynx, adenoids, tonsils, epiglottis, larynx, and trachea. The lower respiratory tract consists of the bronchi, bronchioles, alveolar ducts, and alveoli. In adults, a normal tidal volume (VT), or volume of air exchanged with each breath, is about 500 ml. Ventilation involves inspiration (movement of air into the lungs) and expiration (movement of air out of the lungs). ABGs are measured to determine oxygenation status and acid-base balance. ABG analysis includes measurement of the PaO2, PaCO2, acidity (pH), and bicarbonate (HCO3) in arterial blood. Arterial oxygen saturation can be monitored continuously using a pulse oximetry probe on the finger, toe, ear, or bridge of the nose. The respiratory center in the brainstem medulla responds to chemical and mechanical signals from the body. A chemoreceptor is a receptor that responds to a change in the chemical composition (PaCO2 and pH) of the fluid around it. Mechanical receptors are stimulated by a variety of physiologic factors, such as irritants, muscle stretching, and alveolar wall distortion. The respiratory defense mechanisms include filtration of air, the mucociliary clearance system, the cough reflex, reflex bronchoconstriction, and alveolar macrophages.

ASSESSMENT During nursing assessment, a cough should be evaluated by the quality of the cough and sputum.

During physical examination, the nose, mouth, pharynx, neck, thorax, and lungs should be assessed and the respiratory rate, depth, and rhythm should be observed. When listening to the lung sounds, there are three normal breath sounds: vesicular, bronchovesicular, and bronchial. Adventitious sounds are extra breath sounds that are abnormal and include crackles, rhonchi, wheezes, and pleural friction rub.

DIAGNOSTIC STUDIES A chest x-ray is the most commonly used test for assessment of the respiratory system, as well as the progression of disease and response to treatment.

Bronchoscopy is a procedure in which the bronchi are visualized through a fiberoptic tube and may be used for diagnostic purposes to obtain biopsy specimens and assess changes resulting from treatment. Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Pulmonary function tests (PFTs) measure lung volumes and airflow. The results of PFTs are used to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators. Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.