1|Unit 1: Concepts in the care of at Risk and Sick Adult Clients with
A l t e r a ti o n s / P r o b l e m s i n O x y g e n a ti o n
ASSESSMENT thick and purulent], bronchiectasis (abnormally
widened airway) [a little bit greenish], bronchitis [a little
A. HEALTH HISTORY bit greenish], fungal infection (thick, white), bacteria, or
1. COMMON SYMPTOMS viral bronchitis (thin mucoid, laway), Lung tumor
a. DYSPNEA – a subjective feeling of (pinkish tinge), hemoptysis (blood tinge), pulmonary
difficult or labored breathing edema (fragrant pinkish, nagbubula-bula parang yung
b. COUGH – a reflex that protects the nagpapalubo ng balloon nung mga bata), lung abscess
lungs from the accumulation of lalo na sa pneumothorax and hemothorax (foul
secretions or inhalation of foreign body; smelling), etc.
Results from irritation / inflammation of Since the child could not expectorate the thin mucoid
the mucous membrane sputum, pumped is done because it is very thin.
Subjective because there are other diseases that mimics II. WHEEZING
dyspnea e.g. COPD, Fatigue, Anxiety, Obese, Heart - A high -pitched musical sound heard on expiration
problems, allergic, anemic. (asthma) or inspiration (bronchitis) findings w/
bronchoconstriction or airway narrowing
First and foremost, reaction is to sneeze because of - RHONCHI – a low pitched continuous heard over the
irritation from a foreign body or from inflammation. lungs in partial airway obstruction
Recurrent irritated lung results in persistent coughing,
watery discharge. Rales. Small clicking, bubbling, or rattling sounds in the
lungs. They are heard when a person breathes in
First and foremost, to be presented to the doctor is (inhales). ...
labored breathing or difficulty of breathing. Beware of
Rhonchi. Sounds that resemble snoring. ...
hypoxic patients, interventions should be done
immediately ASAP. Put on oxygen inhalation (3-5 LPM Stridor. Wheeze-like sound heard when a person
via nasal cannula for at risk patients). 1-2 LPM is the breathes. ...
safest for asthmatic patients, but do not use face mask
Wheezing. High-pitched sounds produced by narrowed
for CO2 will not be retained, use nasal cannula instead. airways.
Hyperventilating patients should be given a brown
paper bag to facilitate proper breathing. III. CHEST PAIN
- Associated w/ pulmonary pain is sharp, stabbing,
Hyperventilation causes the body to expel too much and intermittent or dull, aching, and persistent
carbon dioxide, and “rebreathing” exhaled air helps - In carcinomas, pain is dull (2-3 from 0-10 scale)
restore that lost gas. - Assess the quality, intensity & radiation of pain
(right or left, nape, shoulder, etc.) & explore the
I. SPUTUM PRODUCTION precipitating factors
- The reaction of the lungs to a recurring irritant &
results from persistent coughing w/ nasal discharge Associated with heart disease. Dull and aching could be
- Purulent sputum [contains pus, composed of white tolerated. Persistent need immediate medical attention
blood cells, cellular debris, dead tissue, serous fluid, (e.g. from anginal pain could be MI). Sharp, stabbing,
and viscous liquid] (thick & yellow, green, or rust and persistent = high pain scale = medical attention as
colored) bacterial infection soon as possible (could be MI).
- Thick mucoid suggest lung tumor
IV. HEMOPTYSIS (blood from the lungs)
- Profuse (abundant), frothy (bubbly) pink material
- Expectoration (coughing out) of blood from the
indicates pulmonary edema
respiratory tract
- Foul smelling sputum or bad teeth with lung abscess
- Causes can be: pulmonary infection, cancer of the
(appearance of pus-filled cavity inside the lung)
lungs, abnormalities of the heart, or blood vessels,
Sputum is very important, through C&S or other exams, pulmonary artery or vein abnormality, pulmonary
since it could detect any lung diseases such as embolus & infarction
pneumonia (rusty), COX’s disease (??) [abscess, white,
2|Unit 1: Concepts in the care of at Risk and Sick Adult Clients with
A l t e r a ti o n s / P r o b l e m s i n O x y g e n a ti o n
- BLOODY SPUTUM: from the nose (EPITAXIS) o Peripheral cyanosis results from decreased
preceded by sniffing blood flow to the body’s periphery (fingers,
- BLOOD FROM LUNG: bright red frothy & mixed w/ toes & earlobes)
sputum; w/ tickling sensation of the chest, salty
taste, burning or bubbling sensation, has an alkaline II. UPPER RESPIRATORY STRUCTURES
pH greater than 7 a. Nose & Sinuses
- BLOOD FROM STOMACH (HEMATEMESIS): is Palpate the paranasal sinuses
vomited, much darker or coffee – ground emesis b. Mouth & Pharynx
has an acid pH of blood less than 7 Teet
c. Trachea
PAST, HEALTH, SOCIAL, & FAMILY HISTORY
Palpation external nudge, tongue
- Childhood illnesses, immunization including the depressor
recent influenza & pneumonia vaccination, medical
conditions, injuries, hospitalization, surgeries, III. LOWER RESPIRATORY STRUCTURES & BREATHING
allergies, current medications - Assessment of this structure includes inspection,
- Personal & social history addresses issues such as palpation, percussion, & auscultation (IPPA) of the
diet, exercise, sleep, recreational habits & religion thorax
- Psychological factors that may affect the patient are - Client should be positioned as necessary before
also explored assessment
- Assess for risk / genetic factors that may contribute a. POSITIONING
to the patient’s lung condition o To assess the posterior thorax & lungs,
client should be in a sitting position, arms
RESPIRATORY DISEASE RISK FACTORS crossed on the chest & hands placed on the
- SMOKING opposite shoulders thus separating widely
- Exposure to secondhand smoke the scapulae & exposes more lung area for
- Familial history of lung disease assessment
- Genetic make-up (cystic fibrosis, asthma) b. THORACIC INSPECTION
- Exposure to allergies (allergic rhinitis) & Chest Configuration
environmental pollutants (overcrowded, pollution) Barrel Chest
- Exposure to certain recreational / occupational Funnel Chest (pectus
hazards (factory workers, lead poisoning) excavatum)
- Vitamin D deficiency (best source is from the sun) Pigeon Chest
PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM
I. GENERAL APPEARANCE
- Clubbing of the Finger
o A change in the normal nail bed
o Could be found in chronic hypoxia, chronic
lung infection, & malignancy of lungs
Very significant for asthmatic patients. Clubbing results
from the recurrent hypoxia.
- Cyanosis
o Bluish discoloration of the skin & a late sign
of hypoxia
o Not reliable sign of hypoxia
o Central cyanosis is observed by the color of
the tongue & lips
