now let's review inspection so when looking at your client the position of the person is critical to observe so someone who's breathing easily obviously looks relaxed and upright facial expressions also look relaxed now if someone can't breathe obviously they're going to be panicked they're going to be anxious they will often change positions almost like running a Sprint right they may have hands on the hips they might have hands on the head trying to open up that rib cage or they often show this tripod position where they're leaning over hands on the knees or even elbows on the knees there and they're really just trying to get this back around it to expand the lungs now in terms of loc the level of Consciousness the big question you have to ask is really are they alert because remember oxygen feeds the brain so really the first sign of deoxygenation is some type of altered level of Consciousness so if someone has good oxygen they're going to have a good level of Consciousness so for example AO times three or AO times four fancy words for alert and oriented times three or four now if you take someone's ability to breathe away they're no longer going to be alert because their brain's not going to have that oxygen so they may appear confused like mentioned before and this is what's called altered level of Consciousness they may not know who they are where they are or even answer simple questions like their date of birth and even the president so as you know decreased amount of oxygen is going to the brain and eventually the client is going to be passed out or basically unconscious okay now moving on to skin color so obviously someone who is being perfused with good oxygen is going to have those pink undertones and it really doesn't matter their pigmentation the key term there is pink undertones now someone's struggling to breathe will have first or basically early deoxygenation they're going to have pallor or pallor and late is that cyanosis that blue skin tones nursing school is hard work simple nursing.com makes it simple we take your classroom lectures and notes to create a handcrafted study plan with specialized videos and visual study guides that highlight only the top tested need to know key points coupled with thousands of practice questions to test your knowledge all neatly organized in our new app try it for free today visit simple nursing com now what do we know about the conditions of the nails here with the condition of the nails like we spoke about before we're looking at that profile sign or that profile angle okay so normal would be that 160 degrees but if it's 180 degrees or more our club 180 then that would be clubbing which would indicate poor oxygenation or that long-term chronic hypoxia long-term chronic hypoxia those are the key terms for your exams now in terms of the respiratory rate and Rhythm remember normal breathing has a regular rate and Rhythm normal inhalation and exhalation or inhale and exhale and it is in a range for normal respiratory rate which is 12 to 20. now if they can't breathe early on the respiratory will go up this is what's known as tachypneia so just let the name help you attacking means fast penia is for the lungs now late they're going to have that labored breathing that they can't maintain for a long time so that's obviously going to decrease and lead into braid opinion so Brady meaning slow and pedia referring to the lungs now in terms of the work of breathing there's a specific key term known as exertion this is basically how much effort is the client exerting to breathe so how do we really kind of assess this so work of breathing think how difficult does it look like they're breathing usually okay like right now I'm looking at my patient and it doesn't look like he's putting in any work at all normally so sometimes we call that unlabored breathing okay so unlabored or so we don't see any accessory muscle use they're not having a difficult time breathing we don't see nostril flaring those would be all signs that they are having hard time breathing or their increased work of breathing and sometimes you'll see that abbreviated as wob which just stands for work of breathing so usually if someone isn't having a hard time doing that exertion it just looks like they're doing no work at all now two big key points to know is when someone is having difficulty breathing or basically too much exertion they're typically going to look like this as mentioned before this tripod position we're trying to round the back and have that lung open up and also this purse lip breathing where you can kind of think of like a purse or basically having breathing through a straw your lips kind of go like this kind of like closing a purse or a coin bag or simply breathing through a straw that's going to help expand the lungs correct and it yes it can kind of prevent air trapping so sometimes we even coach our patients with COPD to do some purslip breathing because it can keep that airway open for a little bit longer if they breathe through those pursed lips okay so now let's talk a little further about accessory muscle use okay so if you think about accessories to like an outfit that's that little something extra that adds to your overall outfit you know like maybe you're going to add a scarf a watch a bracelet okay so that little something that helps the big picture so the accessory muscles are going to be little muscles that help the rest of that lung and rib cage expansion so that's going to be these muscles here also it's going to be the muscles in between the ribs so those intercostal muscles and usually when your patient is breathing and they're not having a hard time breathing you don't actively see those working even though they are but if this patient was having a hard time breathing you would actively see these little muscles between the rib pulling in and trying to help with that expansion you might even see their shoulders moving up and down with every breath makes sense and that would show that they're having that extra work of breathing because they're using those little muscles in an active way that we can visually see that makes sense because you know the diaphragm is right there as a big muscle and we're trying to use all these other muscles to help us breathe absolute ABS the chest wall okay and so we're going to look at what is the anterior to posterior diameter which is the front to back compared to the transverse side to side and we compare that in a ratio we want this to be one to two or sometimes we say that in reverse a two to one ratio where the transverse diameter is two times wider than the front to back the anterior posterior so what happens when we have an increased front to back barrel chest right yes so that's when we lose that two to one ratio because that increased front to back so in those patients with that increased front to back that barrel chest lots of times we don't see as much in and out they have more shallow respirations right because since their chest wall is already out it doesn't go up and down as well we have a lot of that air trapping now this is commonly seen in patients with COPD absolutely or basically patients with emphysema who've smoked a lot and they've basically broken off those alveoli in the chest and now air just gets trapped in there expanding that chest wall so they have a lot of air trapping and so that's where we have that Barrel around chest and so along with that shape and configuration of the chest wall we have the costal angle so costal basically needs ribs okay so the costal angle is going to be this angle right here on the front of the rib cage so we want that costal angle to be about 90 degrees so this angle in the front of the ribs be about 90 degrees and that's what you see in someone with that normal chest wall configuration of the two to one ratio thing okay so if you have a patient with barrel chest with that increased front to back what happens is that costal angle actually increases is going to become bigger than 90 degrees so to almost look obtuse or basically flat absolutely now for a practice question which of the following assessment findings is associated with a costal angle increased in emphysema and even pregnancy so guys many students get this incorrect remember emphysema we have air trapping and think about pregnancy we have a big huge belly here with a little baby fetus growing inside the belly so both will increase that costal angular