Lower resp

• Resp inspection: resp rate, rhythm, depth, thorax shape, expectorations and audible sounds, position, spo2, use of accessory muscle, lesions, nail clubbing, color, LOC
• Retractions when using accessory muscles are above the clavicles and the sternum
• resp palpation: chest expansion, capillary refill, tenderness, mass and bulges, tactile fremitus
• Tactile fremitus: tell the patient to say 99, should feel a symmetrical vibration with the side of your hands
• A decreased vibration when doing tactile fremitus is a sign of obstruction (pleural effusion or emphysema) and an increased vibration to one side is a sign of pneumonia
• Resp auscultation: adequate air entry, symmetry, adventitious sounds
• Four adventitious sounds: stridor, rhonchi, wheezing, crackles
• Stridor

  • inspiratory musical wheeze
  • loudest over trachea
  • suggests obstructed trachea or larynx
  • associated condition could be inhaled foreign body, upper airway inflammation or spasm
• Rhonchi

  • loud low pitched rumbling coarse sounds (sounds like snoring)
  • heard during inspiration or expiration
  • primarily heard over trachea and bronchi but if loud enough, could be heard over most lung fields
  • associated conditions are acute bronchitis and COPD
• Wheezing

  • continuous high pitched musical sound, longer than crackles
  • hissing quality is heard over expiration but can be heard on inspiration audibly
  • produced when air flows through narrowed airways
  • associated conditions are COPD and asthma
• Crackles

  • discontinuous, intermittent, nonmusical, brief sounds
  • heard more commonly with inspiration
  • caused by air moved through secretion and collapsed alveoli
  • associated conditions: atelectasis, pneumonia, pulmonary edema from heart failure
• Diagnostic testing can be: health assessment and physical examination, sputum culture and sensitivity, CBC and blood cultures, Covid swab, chest radiography
• Pneumonia is an acute inflammation of the lung parenchyma (tissue) caused by a microbial agent such as a virus or bacteria
• Causes of pneumonia are defense mechanisms that fail to protect the airway which is normally sterile distal to the larynx
• risk factors of pneumonia are aging, altered consciousness, aspiration, prolonged immobility, chronic diseases, immunosuppressive meds, smoking, URTIs
• There are four types of pneumonia: community acquired, hospital acquired, aspiration, opportunistic
• Community acquired pneumonia has an onset in community or during the first two days of hospitalization. It has the highest incidence in the winter and in smokers
• hospital acquired pneumonia occurs after 48 hours of hospitalization. Risk factors are immunosuppression and endotracheal intubation
• Aspiration pneumonia is more likely in patients with loss of consciousness, decreased gag and cough reflex, tube feedings and dysphagia
• opportunistic pneumonia is for already weak patients, eg: taking immunosuppressive drugs, cancer treatments, long terms corticosteroids, AIDS, severe malnutrition
• Clinical manifestations of pneumonia are fever and chills, cough with purulent sputum, pleuritic chest pain, increased fremitus, crackles
• Usually pneumonia has no complications but some could be pleurisy (inflammation of the pleura), atelectasis, pleural effusion (fluid in pleural space), bacteremia
• Presence of secretions in alveoli (pneumonia) is a diffusion problem since it affects gas exchange
• Presence of secretions in the bronchi (bronchitis) is a ventilation problem since it compromises the airways
• Acute bronchitis is the inflammation of the bronchi in the lower respiratory tract, usually caused by an infection
• Causes of acute bronchitis is an acute exacerbation of chronic bronchitis (AECB), a virus such as rhinovirus or influenza and bacteria
• Clinical manifestations of acute bronchitis are a persistent cough, low grade fever, malaise and headache, productive cough, tachycardia, tachypnea, wheezing
• Treatment for acute bronchitis is supportive therapy such as fluids, rest and anti-inflammatories, cough suppressants or bronchodilators, antibiotics for AECB
• Respiratory distress is characterized by dyspnea, tachypnea, use of accessory muscles, diaphoresis, stridor or audible wheezing, monosyllabic speech, tripod position, cyanosis, altered level of consciousness or agitation
• Respiratory distress requires immediate medical assitance
• Nursing interventions are administration of antibiotic or oxygen therapy, analgesics for chest pain, anitipyretic (reduce fever), IV fluids, encourage fluid intake, encourage small frequent meals to meet caloric intake
• Prevention treatment is pneumococcal and influenza vaccines, proper positioning during meals, hand hygiene, repositioning patients every 2 hours, avoid exposure to sick individual, avoid or quit smoking
• Lower respiratory conditions are acute bronchitis and pneumonia
• Lower resp tract consists of the trachea, bronchus, bronchioles, lung and diaphragm