Common Respiratory Conditions

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Chapter 18 | Respiratory
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1

Normal Lung

Inspection: AP < transverse diameter, relaxed posture, normal musculature, rate 10-18 breaths/min, regular; no cyanosis or pallor

Palpation: symmetric chest expansion, tactile fremitus present and equal bilateral, diminishing towards periphery, no lumps, masses, or tenderness

Percussion: resonant

Auscultation: vesicular over peripheral fields, bromchovesicular anterior, and between scapulae posterior

Adventitious sounds: none

2

Atelectasis (Collapse)

Condition: collapsed shrunken section of alveoli or an entire lung as a result of 1. airway obstruction 2. compression on the lung, and 3. lack of surfactant

Inspection: cough, lag on expansion on affected side; increased repertory rate and pulse, possible cyanosis

Palpation: chest expansion decreased on affected side, tactile fremitus decrease/absent over area, with large collapse, tracheal shift towards affected side

Percussion: dull over area

Auscultation: breath sounds decreased vesicular or absent over area, voice sounds variable, usually decreased or absent over affected area

Adventitious sounds: none if bronchus is obstructed, occasional fine crackles if bronchus is patent

3

Lobar Pneumonia

Condition: infection in lung parenchyma leaves alveolar membrane edematous and porous; thus RBCs and WBCs pass fro the blood to alveoli; alveoli progressive fill up with bacteria solid cellular debris, fluid, and blood cells; decreases surface area, causing hypoxemia

History: fever, cough with pleuritic chest pain, blood-tinged sputum, chills, SOB, fatigue

Inspection: increased respirations >24/min

Palpation: chest expansion deceased on affected side; tactile fremitus increased if bronchus patent, decreased if bronchus is obstructed

Percussion: dull over lobar pneumonia

Auscultation: tachycardia; loud bronchial breathing; voice sounds increased clarity

Adventitious sounds: crackles, fine to medium

4

Acute Bronchitis

Condition: an acute infection of the trachea and larger bronchi characterized by cough, lasting up to 3 weeks; most cases are viral; epithelium of bronchi are inflamed and damaged, increased mucus production; most cases occur with smokers, aging adults, children, and in winter months

Inspection: cough is productive/nonproductive, sore throat, low-grade fever, postnasal drip, fatigue, substernal aching

Palpation: no pain, no increased fremitus

Percussion: resonance predominates

Auscultation: may be clear and equal bilaterally; no egophony

Adventitious sounds: no crackles

5

Chronic Bronchitis

Condition: proliferation of mucus glands resulting in excessive mucus secretions; usually caused by cigarette smoking

Inspection: hacking, rasping cough productive of thick mucoid sputum; chronic - dyspnea, fatigue, cyanosis, possible clubbing of fingers

Palpation: tactile fremitus normal

Percussion: resonant

Auscultation: normal vesicular, voice sounds normal

Adventitious sounds: crackles over deflated area, may have wheeze

6

Emphysema

Condition: caused by destruction of pulmonary connective tissue (elastin, collagen), permanent enlargement of air sacs; increases airway resistance, especially on expiration, hyper inflated lung; cigarette smoking accounts for 80-90% of cases

Inspection: increased AP diameter, barrel chested, accessory muscles used to aid respiration, tripod position, SOB, tachypnea

Palpation: decreased tactile fremitus and chest expansion

Percussion: hyper resonant

Auscultation: decreased breath sounds, muffled heart sounds resulting in over distention of lungs

Adventitious sounds: usually none; occasionally wheeze

7

Asthma (Reactive Airway Disease)

Condition: allergic hypersensitivity to certain inhaled allergens, irritants, microbes, stress or exercise; complex response - bronchospasm and inflammation, edema in walls, secretion of highly visors mucus into airways

Inspection: during severe attack - increased RR, SOB with audible wheeze, use of accessory neck muscles, cyanosis

Palpation: tactile fremitus decreased, tachycardia

Percussion: resonant

Auscultation: diminished air movement; breath sounds decreased, with prolonged expiration; voice sounds decreased

Adventitious sounds: bilateral wheezing on expiration, sometimes inspiratory and expiratory wheezing

8

Pleural Effusion (Fluid) or Thickening

Condition: collection of excess fluid in the intrapleural space, with compression of overlying lung tissue; watery capillary fluid (transudative), protein (exudative), purulent matter (empyema), blood (hemothorax), or milky lymphatic fluid (chylothorax)

Inspection: increased respirations, dyspnea, dry cough, tachycardia, cyanosis, asymmetric expansion, abdominal distention

Palpation: tactile fremitus decreased or absent; tracheal shift way from affected side; decreased chest expansion on affected side

Percussion: dull

Auscultation: breath sounds decreased or absent; voice sounds decreased or absent

Adventitious sounds: crackles, pleural rub

9

Heart Failure

Condition: pump failure with increasing pressure of cardiac overload causes pulmonary congestion or an increased amount of blood present in pulmonary capillaries; pulmonary capillaries engorged; bronchial mucosa swollen

Inspection: increased RR, SOB on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, pallor

Palpation: skin moist, clammy; tactile fremitus normal

Percussion: resonant

Auscultation: normal vesicular; heart sounds include S3 gallop

Adventitious sounds: crackles at lung bases

10

Pneumothorax

Condition: free air in pleural spaces causes partial or complete lung collapse; can be spontaneous or traumatic or tension

Inspection: unequal chest expansion

Palpation: tactile fremitus decreased or absent; tracheal shift to unaffected side; chest expansion decreased on affected side; tachycardia, decreased BP

Percussion: hyper resonant

Auscultation: breath sounds decreased or absent; boise sounds decreased or absent

Adventitious sounds: none

11

Pneumocystis jirovefi (P.carinii) Pneumonia

Condition: virulent form of pneumonia is a protozoal infection associated with AIDS; cysts containing the organism and macrophages from alveolar spaces, alveolar walls thicken, and the disease spreads to bilateral interstitial infiltrates of foamy, protein rich fluids

Inspection: anxiety, SOB, dyspnea on exertion, malaise, tachypnea, dry, nonproductive cough

Palpation: deceased chest expansion

Percussion: dull over areas of diffuse infiltrate

Auscultation: breath sounds may be diminished

Adventitious sounds: crackles may be present but often are absent

12

Tuberculosis

Condition: initial complex (acute inflammatory response); scar tissue forms, lesion calcifies and shows on x-ray; reactivation of previously healed lesion; dormant bacilli now multiply, producing necrosis, captivation, and caseous lung tissue

Subjective: initially asymptomatic, showing as potivie skin test on x-ray; progressive TB involves weight loss, anorexia, easy fatiguability, low-grade afternoon fevers, night sweats

Inspection: cough initially nonproductive; later productive of purulent, yellow-preen sputum, may be blood tinged; dyspnea, orthopnea, fatigue, weakness

Palpation: skin moist at night from night sweats

Percussion: resonant initially; dull over any effusion

Auscultation: normal or decreased vesicular breath sounds

Adventitious sounds: crackles over with upper lobes common, persist full expiration and cough

13

Pulmonary Embolism

Condition: undissolved material originating in less or pelvis detach and travel through venous system, returning blood to right heart, and lodge to occlude pulmonary vessels; arise from DVT; results in ischemia, increased pulmonary artery pressure, decreased CO, and hypoxia

Subjective: chest pain, worse on deep inspiration, dyspnea

Inspection: apprehensive, restless, anxiety, mental status changes, cyanosis, tachypnea, cough, Pao2 <80% on pulse ox; arterial blood gasses show respiratory alkalosis

Palpation: diaphoresis, hypotension

Auscultation: tachycardia, accentuated pulmonic component of S2 heart sound

Adventitious sounds: crackles, wheezes

14

Acute Respiratory Distress Syndrome (ARDS)

Condition: acute pulmonary insult (trauma, gastric acid aspiration, shock sepsis) damages alveolar capitulary membrane; increased permeability of pulmonary capillaries and alveolar epithelium and to pulmonary edema

Subjective: acute onset of dyspnea, apprehension

Inspection: restlessness, disorientation, rapid, shallow breathing, productive cough, thin, frothy sputum; retractions; decreased PaO2 blood gases show respiratory alkalosis, late sign is cyanosis

Palpation: hypotension

Auscultation: tachycardia

Adventitious sounds: crackles, rhonchi

15

Lung Cancer

Condition: most fatal of malignancies; 4 types: squamous cell; adenocarcinoma; large cell, small cell

Subjective: fatigue, nausea and vomiting, change in taste perception, anorexia; persistent cough may also bed productive; dyspnea; dull poor localized chest pain; 10-25% are asymptomatic

Inspection: weight loss, clogging, hoarseness, anemia, hemoptysis

Auscultation: may have wheezing, atelectasis, pleural effusion, pneumonia distal to obstruction