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Complete Assessment
• History
– Biographic and demographic data
– Chief complaint
– Past medical history
– Family history
– Risk factors
– Social history
Copyright ©2010 by Pearson Education, Inc.

Medical Surgical Nursing: Preparation for Practice
Upper Saddle River, New Jersey 07458
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa All rights reserved.
Complete Assessment
• Components of Physical Exam

– Inspection
– Auscultation
– Percussion
– Pain
– Genetic and gerontological considerations

Social History
• Patients’ lifestyles and habits and

• Risk for developing pulmonary disease
• Current and previous work settings
• Home environment
• Social settings

Gerontological Considerations
• aging decreases respiratory function

• lower arterial oxygen values,
• increase risk of pneumonia
• Risk of aspiration may increase with aging
• Aging may affect patient comfort needs
during the examination

Genetic Considerations
• Cystic fibrosis (CF): genetic disorder,

typically diagnosed in childhood
• CF has serious pulmonary complications –
thick mucus builds up in lungs

Inspection
• Initial assessment activity

• General appearance:
– Posture, facial expression and movements
– Changes in mental status
– Respiratory rates shallow breathing, irregular
patterns of breathing
– Size and shape of the thorax, asymmetry
– Diminished movement of rib cage, use of
accessory muscles
Inspection
• Color and appearance of skin

– Pallor may indicate decreased oxygen-
carrying capacity of the blood due to anemia
– Central cyanosis, where the mouth, lips, and
mucous membranes are blue-tinged,
indicates hypoxia in adults

Inspection
• Inspection of the neck

– Appearance of veins, trachea and
musculature may indicate chronic cardiac or
pulmonary disease, pneumothorax
– Goiter or lesions may obstruct the upper
airway

Inspection
• Palpation of skin and extremities

– Edema of lower extremities
– Skin temperature and moisture
– Clinical reference points
– Chest excursion
– Tactile fremitus
– Tenderness
– Crepitus

Clinical Reference Points

Occupational Impact on
Respiratory Disease
• Exposure to airborne particles, vapors,
and irritants
• Can result in acute or chronic respiratory
disease in susceptible individuals
• Early recognition, diagnosis, and treatment
of occupational asthma can prevent
pulmonary complications

Auscultating Breath Sounds
• Patient should be upright

• Use the diaphragm of the stethoscope
• Begin at C7 posteriorly and anteriorly from
above the clavicles
• Move steadily from right to left upper and
lower
• Compare breath sounds bilaterally
• Do not auscultate over clothing
Diaphragm - best for higher
pitched sounds, like breath
sounds and normal heart
sounds.
Bell - is best for detecting

lower pitch sounds, like some
heart murmurs, and some
bowel sounds. It is used for
the detection of bruits, and for
heart sounds (for a cardiac
exam, listen with the
diaphragm, and repeat with
the bell).

Figure 33.1 In a respiratory assessment, it is important to palpate and count ribs and interspaces to
accurately record the location of lesions or adventitious breath sounds.

Figure 33.2 Lobes of the lung—anterior.

Figure 33.3 Lobes of the lung—posterior

Tracheal Breath Sounds
• Auscultated over the trachea

• Loud and high pitched
• Cause: airflow through tubular trachea
• Best heard over the neck and trachea
• Occurs during upper airway obstruction

Bronchial Breath Sounds
• Anterior: heard on either side of sternum,

over main stems of the bronchus from 2nd
to 4th intercostal spaces
• Posterior: best heard lateral to the spine
between 3rd and 6th intercostal spaces
• Loud, harsh, less turbulent and lower than
tracheal sounds

Bronchial Breath Sounds
• Pause between inspiration and expiration;

expiration is heard for a longer time than
inspiration
• Sounds over smaller airways are low
pitched and softer

Bronchovesicular Breath Sounds
• Heard during inspiration and expiration
• Midway in Pitch and loudness between
vesicular and bronchial breath sounds
• Best heard in 1st and 2nd intercostal
spaces of anterior chest, between
scapulae of the posterior chest
• Represent air movement in the moderate
airways between the bronchi and the
smaller airways
Vesicular Breath Sounds
• Heard over most of the thorax

• Soft and low pitched, rustling, from air
moving through small airways
• Heard longer during expiration, which
generally lasts twice as long as inspiration

Adventitious Breath Sounds
• Decreased or no sounds where normal

sounds should occur
• Breath sounds occurring in abnormal
locations
• Diminished breath sounds demonstrate
decreased airflow and potentially
decreased oxygen exchange

Adventitious Breath Sounds
• Adventitious/extra sounds:
– Represent pathologic conditions of heart or
lungs
– Indicate disrupted airflow due to airway
spasm, fluid, or secretions
– Crackles (rales-term not used as much),
Wheezes, Stridor, Friction rubs

Crackles
• Caused by fluid in the airways
• Intermittent or discontinuous, nonmusical, or
popping sounds
• Caused by fluid, inflammation, infection, or
secretions
• Crackles are described as either fine or coarse
• Occur when closed airways snap open during
inspiration
• Softer, gentler sound may also be heard on
inspiration
Wheezes
• Heard equally during inspiration and expiration
• High-pitched musical sounds
• Caused by air flowing across strands of mucus,
swollen pulmonary tissue that narrows the airway,
bronchospasm
• Rhonchi (term for secretions in airways-not used as
much)
• Inspiratory/expiratory, continuous/ discontinuous,
mild/moderate/severe
• Asthma, allergies, reactive airway disease
Stridor
• Heard only during inspiration as air attempts to flow
across an obstruction
• Heard without stethoscope as high-pitched, crowing
sound
• With stethoscope, best heard over large airways,
e.g., trachea or bronchus
• Report to the health care provider immediately
• Indicates airway obstruction requiring
intervention

Pleural Friction Rubs
• Low-pitched, creaking or squeaking sounds
• Occur when inflamed pleural surfaces rub
together
• Heard on inspiration
• Pitch usually increases with chest expansion
• Have the patient hold breath to distinguish
between pleural and pericardial friction

Adventitious Lung Sounds

Travel and Area of Residence
• An important aspect of the history in

diagnosing potential respiratory problems
• Exposure to region-specific infectious
diseases
• Exposure to environmental conditions, e.g.
high altitudes

High-Altitude Pulmonary Edema
(HAPE)
• HAPE – can occur with travel to altitudes
greater than 5,000 feet
• Increasing altitude → decreasing
atmospheric pressure → decreasing
available O2
• Rapid onset of hypoxemia may result
• Compensatory increased respiratory rate
may contribute to fatigue
High-Altitude Pulmonary Edema
(HAPE)
• This causes further respiratory
insufficiency
• Initial compensatory mechanisms –
pulmonary vascular vasoconstriction
• Later, inflammatory mediators cause
vasodilation

Percussion
• Assess presence of air, fluid, solid mass in
underlying tissues
• Normal lungs produce a resonant, low-pitched clear
sound
• Hyperresonance indicates airways are hyperinflated
or air is present outside of lung tissue
• Dullness indicates that air is absent
– Pneumonia, pleural effusion, hemothorax, solid
tumors

Pain
• Pain during respiration may decrease tidal

volumes
• Pain management enables participation in
rehabilitative activities
• Also promotes deep breathing to prevent
pneumonia and atelectasis

Standard of Care
• For patients with cardiac and respiratory

illness, standard is:
– Continuous or intermittent observation of the
patient’s oxygen saturation
– End-tidal carbon dioxide levels
– Peak flow is utilized to trend treatment
effectiveness in patients with asthma

Assessment of Arterial Oxygen
Levels
• ABG’s
• Pulse oximetry
• Physical assessment
• FiO2 will increase the PaO2 four times
(normal patient)

Pulse Oximetry
• Measures O2 saturation of hemoglobin

• Reflects light off the hemoglobin
molecules
• Measures the absorption of light by
hemoglobin
• Normal range is from 95% to 100%

Factors Interfering with
Pulse Oximetry
• Nail polish
• Automated BP cuffs, hemodialysis fistulas,
or arterial lines interfere with blood flow
• Shock and hypovolemia
• Patient movement, ambient light, and
venous pulsations may also cause
inaccurate readings

Peak Flow Meters
• Track trends in a patient’s condition,
evaluate air movement to determine
severity of asthma exacerbation
• Measure the peak expiratory flow rate
• Normal values based on age and body
size
• Severity scale: Utilizes red, yellow, and
green zones to determine the severity of
decrease in peak flow
Arterial Blood Gas Studies (ABG)
• Provide information on arterial oxygen and

carbon dioxide levels
• Oxygen saturation, bicarbonate, and blood
pH are also calculated
• CO2 is major determinant of respiratory
alkalosis/acidosis
• Bicarbonate level is determinant of
metabolic acidosis/alkalosis
Capnography
• Measurement of exhaled CO2

• Some utilize paper treated to detect the
presence of acid such as CO2
• Others use spectrography, generate
waveform readings

Capnography
• Useful in determining ventilatory status,

readiness for extubation
• Also used to determine pulmonary vessel
perfusion in patients with pulmonary
embolus

Capnography Monitor

Medical Surgical Nursing
Preparation for Practice
CHAPTER 34
Caring for the Patient
with Upper Airway Disorders

Facial Bones
• Mandible
• Maxilla
• Zygoma
• Temporal bones
• Frontal bone

Mandible
• U-shaped bone
• Together with the maxilla, largest and
strongest bone of the face
• Forms lower jaw, holds the lower teeth in
place
• Articulates with temporal bones at the
temporomandibular joint
• Only mobile bone of the facial skeleton;
motion is essential for mastication
Nursing Management for
Mandibular Fractures
• Determine patient’s nutritional requirements and
knowledge deficits
• Oral nutrition with high-protein liquid diet and calories
is essential
• Avoid weight loss if possible to ensure nutritional
adequacy for healing
• Nasogastric or oral gastric tube supports nutrition if
patient has extensive facial swelling
• Observe for nausea and vomiting, intervene to
prevent aspiration
Maxilla
• Largest component of the middle third of

the facial skeleton
• Attaches laterally to the zygomatic bones
• Key bone in the midface, provides
structural support
• Fractures less frequently than mandible or
nose due to strong structural support

Classification System of
Maxillary Fractures
• Le Fort I Fracture (horizontal)
• Le Fort II Fracture (pyramidal)
• Le Fort III Fracture (transverse)

Zygoma
• A paired bone, commonly called the

cheekbone
• Articulates with maxilla, temporal,
sphenoid, and frontal bones
• Forms prominence of the cheek
• The masseter muscle is suspended from
the zygomatic arch

Temporal Bone
• Situated at the sides and base of the skull

• Houses cochlear and vestibular end
organs, facial nerve, carotid artery, jugular
vein

Nursing Management for
Temporal Bone Fractures
• Care is conservative
• Assess for nerve damage and hearing loss
• Test for otorrhea; may indicate a CSF leak
• Monitor lumbar drain if inserted
• If facial nerve injury is present, provide eye
care
• Institute CSF leak precautions – HOB 30o , no
straining, bending or lifting
Frontal Bone
• Makes up the forehead, upper edge and

roof of the orbit
• Forms the anterior portion of the cranium
• Frontal sinus – air-filled cavity between
lamina of the frontal bone
• Serves as a mechanical barrier to protect
the brain


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Complete Assessment

Copyright ©2010 by Pearson Education, Inc.

• Components of Physical Exam

Copyright ©2010 by Pearson Education, Inc.

• Patients’ lifestyles and habits and

Copyright ©2010 by Pearson Education, Inc.

• aging decreases respiratory function

Copyright ©2010 by Pearson Education, Inc.

• Cystic fibrosis (CF): genetic disorder,

Copyright ©2010 by Pearson Education, Inc.

• Initial assessment activity

• Color and appearance of skin

Copyright ©2010 by Pearson Education, Inc.

• Inspection of the neck

Copyright ©2010 by Pearson Education, Inc.

• Palpation of skin and extremities

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

• Patient should be upright

Bell - is best for detecting

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Figure 33.2 Lobes of the lung—anterior.

Figure 33.3 Lobes of the lung—posterior

• Auscultated over the trachea

Copyright ©2010 by Pearson Education, Inc.

• Anterior: heard on either side of sternum,

Copyright ©2010 by Pearson Education, Inc.

• Pause between inspiration and expiration;

Copyright ©2010 by Pearson Education, Inc.

• Heard over most of the thorax

Copyright ©2010 by Pearson Education, Inc.

• Decreased or no sounds where normal

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

• An important aspect of the history in

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

• Pain during respiration may decrease tidal

Copyright ©2010 by Pearson Education, Inc.

• For patients with cardiac and respiratory

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

• Measures O2 saturation of hemoglobin

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

• Provide information on arterial oxygen and

• Measurement of exhaled CO2

Copyright ©2010 by Pearson Education, Inc.

• Useful in determining ventilatory status,

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

• Largest component of the middle third of

Copyright ©2010 by Pearson Education, Inc.

Copyright ©2010 by Pearson Education, Inc.

• A paired bone, commonly called the