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Angel Elliott

on 14 June 2013

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Physical Assessment

Angel Lee Elliott, Jessica Dahlstrom,
Erin Harty, & Christiana Igbo

Non invasive
Endoscopic exams

Three types:
bronchoscopy- bronchi
laryngoscopy- larynx
mediastinoscopy- sternum
Rationale & Results: Preformed to view, and/or biopsy and culture of the local structure.
Pre: Procedure/expected outcomes/risk/benefits explained and consent obtained.
Check allergies
Check labs (CBC, platelet count, PT, electrolytes, and chest x-ray)
NPO 4-8 hours
Benzodiazepines (sedation/amnesia)
Anesthetic to oropharynx
(Caution: methemoglobinemia)
Procedure: Bronchoscopy suite or bedside. Inserted in nairs or oropharynx.
Monitor HR, BP, RR, 02 sat
Apply supplemental O2
Monitor; effects, gag reflex, VS/O2 Sat lung sounds Q 15 mins X2 hours.
Assess for complications: bleeding, infection, or hypoxemia.

Introduction: Aspiration of pleural fluid or air.
Rationale & Results: For diagnosis, to relieve lung compression, and/or medication installation.
Pre: Assess allergies, verify consent, and prepare the site.
Teach pt what to expect (stinging, pressure, importance of remaining still).
Position patient.
Procedure: Bedside/MD or NP with ultrasound and CT. Local anesthetic.
Keep the patient informed throughout the procedure.
Observe for for shock, pain, nausea, pallor, diaphoresis, cyanosis, tachypnea, and dyspnea.
No more than 1000 ml at a time.
Pigtail drain may be placed.
Post: Chest X-ray to r/o pneumothorax and mediastinal shift.
Monitor VS, lung sounds, and puncture site.
Encourage DB.
Document procedure, pt response, drainage, specimens, location, and resp assessments.
Teach s/sx for pneumothorax (can occur within 24 hours).


Introduction: Obtain histologic analysis, culture, or cytologic.
Transbronchial biopsy (TBB)
Transbronchial needle aspiration (TBNA)
Transthoracic needle aspiration
Rationale & Results: Definite diagnosis of cancer, infection, inflammation, or lung disease.
Pre: Prepare for local anesthetic or general anesthesia.
Anxiety reduction
Explain procedure
Teach what to expect.
Verify consent obtained.
Two types:
Percutaneous- performed in radiology
Open biopsy done in OR.
Requires thoracotomy. Two specimens (usually upper & lower).
Chest tube will be placed to remove air & fluid and promote lung inflation.
Position based on location of lesions.
Post (Percutaneous):
Apply dressing.
Chest X-ray.
Monitor VS/breath sounds Q 4 hours for 24 hours, assess for resp distress.
Report absent breath sounds STAT (Pneumothorax).
Assess for frank bleeding from lung trauma (hemoptysis).

Post (General):
Chest tube care: Keep below chest, maintain water seal, measure drainage Q hour X24 hours

Lung Biopsy

Determines predicted normal values
Women= higher bronchial response & larger airways
Dark skin= 3-5% lower pulse ox reading

Residential or occupational
Dust, chemical, irritants
Teach use of mask and good ventilation

Cigarettes & pipe tobacco/controlled substances
PPD x # of yrs= pack years

Rx: side effects that lead respiratory changes
OTC: s/s pt that is self-treating
Illicit: inhaled drugs effect on lung function

Foods, dust, molds, pollen, stings, plants, animals
Allergic reactions (wheezing, sneezing, rhinitis, urticaria, anaphylaxis)
Treatment type and response

Disease exposure (e.g Hantavirus)

Cancer, cystic fibrosis, emphysema

History of Asthma, Pneumonia, TB, Influenza...

OLDCART in chronological order
Cough- sign of lung disease
Assess duration, onset, & if r/t physical activity
Characteristic (e.g productive, dry, hacking, tickling)
Sputum production
Color- clear, white, tan, grey, yellow, green, rust, pink
Consistency- thin, thick,watery, frothy, mucoid
Odor- if present
Quantity- tsp, Tbsp, cups. normal= up to 90mL/day

Chest pain- description to determine cause (pleural, MS, cardiac, GI)
Assess if pain is worse with cough, DB, swallowing?
Cardiac= crushing
Pulmonary= rubbing @ end of inhale/exhale
not made worse by pressing over are
Dyspnea- difficulty breathing
Subjective assessment
Onset (slow/abrupt); duration, relieving factors (position changes); adventitious sounds
Quantify by severity of interference with ADLs
S/S PND and orthopnea

Nose- assess for deformities, symmetry, color, swelling, drainage, bleeding
Mouth- assess for color, symmetry, drainage, edema, ulceration, enlarged tonsils
Neck - assess lymph nodes and trachea for: position, mobility, tenderness, masses

Lesions, masses, symmetry, curvatures
Rate, rhythm, depth of inspirations
Anteroposterior diameter ratio normal= 1:1.5
Rib slope and spacing

Movement symmetry- chest expansion
Abnormalities- masses, lesions, bruise, swelling, crepitus, tenderness
Tactile fremitus- air, fluid, or obstruction in airways
Increased density= increased transmission of vibrations

Percussion notes (table 29-3 pg 553)
Resonance- low, hollow, normal lung tissue
Hyperresonance- high, booming, trapped air
Flatness- high, short, solid (bone or effusion)
Dullness- medium, medium, organ or consolidated lung
Tympany- high, short, filled with air (pneumothorax)

Adventitious breath sounds
Crackles- popping
Fine or coarse
r/t deflated airway or fluid
Wheeze- squeeky & cont.
r/t narrowed airways
Rhonchus- snoring
r/t secretions or obstruction
Pleural friction rub- rough grating/scratching sound
Inflamed pleura rubbing together (TB, pneumonia)

Normal breath sounds:
Bronchial- trachea & larynx
Inspiration < expiration
High pitch
Bronchovesicular- major bronchi
Inspiration = expiration
Moderate pitch
Vesicular-peripheral lung fields
Inpiration > expiration
Low pitch

Skin and mucous membrane
Pallor or cyanosis, nail beds, clubbing, oral membranes
General appearance
Weight and muscle loss, hypertrophied accessory muscles
SOB on exertion or speaking
r/t anxiety, fear, stress
Encourage pt to express feelings and concerns
Teach coping methods & help identify support systems

Possible NDx:
Ineffective airway clearance
Risk for aspiration
Ineffective breathing pattern
Impaired gas exchange
Risk for infection
Impaired spontaneous ventilation
Dysfunctional ventilatory weaning response


Age, Gender, Race
Environmental Hazards
Smoking History
Drug Use
Adult & Childhood Illnesses
Current S/Sx
Head & Neck
Other Indicators
Which nursing intervention is the priority in preparing the client for pulmonary function testing (PFT)?
A. Administer bronchodilator medication on call.
B. Encourage clear fluid intake 12 hours before the procedure.
C. Ensure no smoking 6 hours before the test.
D. Provide supplemental oxygen as testing begins.
Ans C

Question 4

Which of these assessment findings will be of greatest concern when the nurse is assessing a client with emphysema?
A. Barrel-shaped chest
B. Bronchial breath sounds heard at the bases
C. Hyperresonance to percussion of the chest
D. Ribs lying horizontal
Ans B

Question 3

The RN has received report about all of these clients. Which client needs the most immediate assessment?
A. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
B. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes
C. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago
D. Client with pleural effusion who has decreased breath sounds at the right base
Ans A

Question 2

Your client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which of these nursing tasks is best for the charge nurse to delegate to the experienced nursing assistant working in PACU?
A. Assess breath sounds.
B. Check gag reflex.
C. Determine level of consciousness.
D. Monitor blood pressure and pulse.
Ans D

Question 1
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