Discussion: SOAP Notes

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CHAPTER

The Respiratory System— Pulmonology

After studying this chapter, you will be able to:

10.1 Identify the roots/word parts associated with the respiratory system.

10.2 Translate the Subjective terms associated with the respiratory system.

10.3 Translate the Objective terms associated with the respiratory system.

10-2

Learning Outcomes

Talking Points:

Discuss the objectives for this chapter. Relate the objectives to the SOAP note plan.

Learning Outcomes

10.4 Translate the Assessment terms associated with the respiratory system.

10.5 Translate the Plan terms associated with the respiratory system.

10.6 Distinguish terms associated with the respiratory system in the context of electronic health records.

10-3

Talking Points:

Discuss the objectives for this chapter. Relate the objectives to the SOAP note plan.

Introduction and Overview of the Respiratory System

Main function of the respiratory system is to bring oxygen into the body and carbon dioxide out of the body

10-4

Talking Points:

Word parts associated the anatomy of the upper respiratory tract

adenoid/o

adenoidectomy

adenoiditis

tonsill/o

tonsillectomy

tonsillits

nas/o, rhin/o

nasogastric tube

nasendoscope

rhinorrhea

10-5

10.1 Word Parts of the Respiratory System

Talking Points:

Word parts associated the anatomy of the upper respiratory tract:

adenoid/o means adenoid (lymphatic tissue in the nasopharynx).

adenoidectomy – removal of adenoids

adenoiditis – inflammation of adenoids

tonsill/o means tonsil (lymphatic tissue in the oropharynx).

tonsillectomy – removal of tonsils

tonsillits – inflammation of tonsils

nas/o, rhin/o mean nose.

nasogastric tube – tube that is placed in the nose to the stomach

nasendoscope – device to view the inside of the nose

rhinorrhea – discharge from the nose

10.1 Word Parts of the Respiratory System

or/o

orofacial

oronasal

laryng/o

laryngospasm

laryngitis

10-6

Talking Points:

or/o means mouth.

orofacial – pertaining to the mouth and face

oronasal – pertaining to the mouth and nose

laryng/o means larynx (voice box).

laryngospasm – sudden closure of the larynx

laryngitis – inflammation of the larynx

10.1 Word Parts of the Respiratory System

The upper respiratory tract is made up of the nose, pharynx, and larynx

Nose

nares

septum

turbinates

vascular

mucus

Function is to heat, humidify, and filter incoming air

10-7

Talking Points:

The anatomic features of the nose:

Nares – two of them, right and left; the entry way into the nose

Septum – cartilage and bone that separates the nose into right and left sides

Turbinates – cartilages that swirl the air; done so it will increase contact with the inside of the nose to heat, humidify, and filter it

Vascular – nose has a large amount of blood vessels in order to heat the incoming air

Mucus – helps to humidify and trap dirt, debris, and pathogens from the air

10.1 Word Parts of the Respiratory System

From the nose or mouth, air passes through the pharynx

nasopharynx

oropharynx

laryngopharynx

It then enters the larynx

Produces voice

Then enters the trachea

10-8

Talking Points:

The pharynx is the throat. It is divided into three regional areas.

The larynx is also known as the voice box, and its main function is to produce sounds by rubbing together the vocal cords.

From the larynx, air enters the trachea, which has a bumpy outer surface.

10.1 Word Parts of the Respiratory System

sept/o

septectomy

septoplasty

sin/o, sinus/o

sinusitis

sinusotomy

10-9

Talking Points:

sept/o means septum.

septectomy – removal of the septum

septoplasty – surgical repair of the septum

sin/o, sinus/o mean sinus (a hollow space).

sinusitis – inflammation of a sinus (cavity)

sinusotomy – incision into a sinus

10.1 Word Parts of the Respiratory System

Lower respiratory tract

trachea

bronchi

lobar bronchi

segmental bronchi

bronchioles

alveoli

10-10

Talking Points:

The lower respiratory tract starts at the trachea and ends at the alveoli.

The trachea divides into right and left bronchi, which enter the right and left lungs. From the bronchi, the airways divide and become progressively smaller. There is a bronchi for each lobe and segment of the lungs. From the segmental bronchi, the airways become very small (bronchioles) and end in microscopic air sacs called alveoli (singular is alveolus).

Gas exchange occurs at the level of the alveoli.

10.1 Word Parts of the Respiratory System

pneum/o, pneumat/o, pneumon/o

pneumatology

pneumonia

pulmon/o

pulmonologist

pulmonary

10-11

Talking Points:

pneum/o, pneumat/o, pneumon/o mean lung or air (based on context of use).

pneumatology – study of the lungs

pneumonia – lung infection

pulmon/o means lungs.

pulmonologist – lung specialist

pulmonary – pertaining to the lung

10.1 Word Parts of the Respiratory System

lob/o

lobectomy

lobotomy

bronch/o, bronchi/o

bronchoscope

bronchiostenosis

bronchiol/o

bronchiolitis

bronchiolectasis

alveol/o

alveolitis

alveolar

10-12

Talking Points:

lob/o means lobe.

lobectomy – removal of a lobe

lobotomy – incision into a lobe

bronch/o, bronchi/o mean bronchus.

bronchoscope – instrument to view the inside of a bronchus

bronchiostenosis – narrowing of a bronchus

bronchiol/o means bronchiole (little bronchi).

bronchiolitis – inflammation of a bronchiole

bronchiolectasis – widening of a bronchiole

alveol/o means alveoli (air sac).

alveolitis – inflammation of an alveolus

alveolar – pertaining to an alveolus

10.1 Word Parts of the Respiratory System

thorac/o, pector/o (pectus), steth/o

thoracic

pectoralgia

pectus excavatum

stethoscope

10-13

Talking Points:

thorac/o, pector/o (pectus), steth/o mean chest.

thoracic – pertaining to the chest

pectoralgia – chest pain

pectus excavatum – chest (sternum) that goes inward

stethoscope – device to listen to chest sounds

10.1 Word Parts of the Respiratory System

pleur/o

pleuritis

pleurectomy

phren/o

phrenospasm

10-14

Talking Points:

pleur/o means pleura (membrane that surrounds the lung and chest wall).

pleuritis – inflammation of the pleura

pleurectomy – removal of the pleura

phren/o means diaphragm.

phrenospasm – sudden contraction of the diaphragm

10.1 Word Parts of the Respiratory System

Process of respiration

Inspiration

Diaphragm and intercostal muscles contract

Pressure in the chest decreases

Air is “sucked” into the lungs

Expiration

Passive, does not require muscle contraction

10-15

Talking Points:

Respiration is a complete cycle of inspiration and expiration.

10.1 Word Parts of the Respiratory System

ox/o

hypoxia

hypoxemia

spir/o, -pnea

spirometry

sleep apnea

capn/o, carb/o

hypercapnia

hypocarbia

10-16

Talking Points:

ox/o means oxygen.

hypoxia – condition of low oxygen

hypoxemia – condition of low oxygen in the blood

spir/o, -pnea mean breathing.

spirometry – device that measures breathing

sleep apnea – lack of breathing while sleeping

capn/o, carb/o mean carbon dioxide.

hypercapnia – elevated levels of carbon dioxide

hypocarbia – low levels of carbon dioxide

The most common complaint is coughing

Productive or nonproductive

Other symptoms

Respiratory rate

Respiratory depth

Chest pain

10-17

10.2 Patient History, Problems, Complaints

Talking Points:

The most common complaint is coughing. A cough can be described as productive or nonproductive. A productive cough from the chest produces sputum. A nonproductive cough does not produce any material.

Other symptoms include:

Respiratory rate – tachypnea (too fast); bradypnea (too slow)

Respiratory depth – hyperventilation (very deep); hypoventilation (shallow)

Chest pain – when related to the pleura (pleuritic chest pain); this pain occurs with inspiration or with a cough

10.2 Patient History, Problems, Complaints

Breathing rate

eupnea

apnea

tachypnea

bradypnea

Breathing depth

hypopnea

hyperpnea

Breathing abnormalities

dyspnea

hyperventilation

hypoventilation

10-18

Talking Points:

Breathing rate:

eupnea – normal breathing

apnea – absence of breathing

tachypnea – rapid breathing

bradypnea – slow breathing

Breathing depth:

hypopnea – shallow breathing

hyperpnea – deep breathing

Breathing abnormalities:

dyspnea – difficulty breathing

hyperventilation – breathing deep and fast; leads to hypocapnia (low levels of carbon dioxide)

hypoventilation – breathing shallow and slow; leader to hypercapnia (high level of carbon dioxide)

Upper respiratory tract complaints

epistaxis

rhinorrhea

Lower respiratory tract complaints

thoracalgia

pleuralgia, pleurodynia

phrenospasm

10-19

10.2 Patient History, Problems, Complaints

Talking Points:

Upper respiratory tract complaints:

epistaxis – nose bleed

rhinorrhea – runny nose

Lower respiratory tract complaints:

thoracalgia – chest pain

pleuralgia, pleurodynia – pleural pain

phrenospasm – involuntary contraction of the diaphragm (hiccups)

Lower respiratory tract complaints – discharges and secretions

expectoration

sputum

hemoptysis

10-20

10.2 Patient History, Problems, Complaints

Talking Points:

Lower respiratory tract complaints – discharges and secretions:

expectoration – coughing and spitting up material from the lungs

sputum – mucus coughed from the lungs

hemoptysis – coughing up blood

10.3 Observation and Discovery

Methods to observe signs of respiratory problems

Physical findings

Lab tests

Specialized tests

Imaging

10-21

Talking Points:

Methods to observe signs of respiratory problems:

Physical findings can be found by touching the patient (palpation) or watching the patient (breathing pattern, skin color)

Lab tests – measure the level of carbon dioxide (capnography) and oxygen (oximetry)

Specialized tests – spirometry is a test to measure how well the lungs are functioning

Imaging – a ventilation/perfusion scan is a method to compare the amount of air being brought in (ventilation) to the amount of blood and the areas where blood is brought into the lung (perfusion); it is also possible to view the inside of the bronchi with a tiny camera (bronchoscope)

10.3 Observation and Discovery

Listening to lung sounds (auscultation)

pectoriloquy

Observing skin

cyanosis

10-22

Talking Points:

Listening to lung sounds (auscultation):

pectoriloquy – patient speaks while the health professional listens to areas with a stethoscope

Observing skin:

cyanosis – bluish color of skin

10.3 Observation and Discovery

Conditions of the tissue and airways

atelectasis

bronchiectasis

pulmonary edema

10-23

Talking Points:

Conditions of the lung tissue and airways:

atelectasis – incomplete expansion of lung tissue

bronchiectasis – abnormal expansion of the bronchi

pulmonary edema – swelling of lungs (lung tissue becomes wet)

10.3 Observation and Discovery

Conditions of the pleura

pleural effusion

hemothorax

pneumohemothorax

pneumothorax

10-24

Talking Points:

Conditions of the pleura:

pleural effusion – large amount of fluid in the pleural space

hemothorax – blood in the pleural space

pneumohemothorax – air and blood in the pleural space

pneumothorax – air in the pleural space

10.3 Observation and Discovery

Lab data that reflects carbon dioxide levels

hypercapnia, hypercarbia

hypocapnia, hypocarbia

Lab data that reflects oxygen levels

hypoxia

hypoxemia

10-25

Talking Points:

Lab data that reflects carbon dioxide levels:

hypercapnia, hypercarbia – high carbon dioxide

hypocapnia, hypocarbia – low carbon dioxide

Lab data that reflects oxygen levels:

hypoxia – low oxygen level

hypoxemia – low oxygen level in the blood

10.3 Observation and Discovery

Evaluation of carbon dioxide

capnography

capnometer

Evaluation of oxygen

oximetry

10-26

Talking Points:

Evaluation of carbon dioxide:

capnography – procedure to measure carbon dioxide levels

capnometer – device to measure carbon dioxide levels

Evaluation of oxygen:

oximetry – procedure to measure oxygen levels

Imaging procedures

computed tomography

pulmonary angiography

ventilation-perfusion scan

Evaluation of sleep

polysomnography

Evaluation of lung function

pulmonary function testing

spirometry

10-27

10.3 Observation and Discovery

Talking Points:

Imaging procedures:

computed tomography – imaging procedure using a computer to make images that are “slices” of the body

pulmonary angiography – imaging of the pulmonary vessels

ventilation-perfusion scan – scan that tests whether a problem in the lungs is due to airflow (ventilation) or blood flow (perfusion)

Evaluation of sleep:

polysomnography – process of measuring sleep activity

Evaluation of lung function:

pulmonary function testing – group of tests to evaluate condition and operation of lungs

spirometry – procedure to measure breathing

10.3 Observation and Discovery

Evaluation of the inside of the respiratory system

bronchoscopy

10-28

Talking Points:

Evaluation of the inside of the respiratory system:

bronchoscopy – process of viewing the inside of the bronchi

10.4 Diagnosis and Pathology

Most common cause of respiratory problems is infection

Other causes are diseases

acute

chronic

10-29

Talking Points:

The most common cause of respiratory complaints is infection. This is because the respiratory tract is open to the outside environment.

Other causes are diseases that are acute, such as asthma attacks, or chronic, such as chronic obstructive pulmonary disease.

10.4 Diagnosis and Pathology

Upper respiratory tract infections

rhinitis

sinusitis

pansinusitis

laryngitis

laryngotracheobronchitis

10-30

Talking Points:

Upper respiratory tract infections:

rhinitis – inflammation of the nose

sinusitis – inflammation of the sinus

pansinusitis – inflammation of all the sinuses

laryngitis – inflammation of the larynx

laryngotracheobronchitis – inflammation of the larynx, trachea, and bronchi

10.4 Diagnosis and Pathology

Disease of the upper respiratory tract

sleep apnea

10-31

Talking Points:

Disease of the upper respiratory tract :

sleep apnea – ceasing to breathe while sleeping

Lower respiratory tract infections

bronchitis

bronchiolitis

pleuritis, pleurisy

pneumonia

10-32

10.4 Diagnosis and Pathology

Talking Points:

Lower respiratory tract infections:

bronchitis – inflammation of the bronchi

bronchiolitis – inflammation of the bronchiole

pleuritis, pleurisy – inflammation of the pleura

pneumonia – infection of the lung

Diseases of the lower respiratory tract

chronic obstructive pulmonary disease (COPD)

emphysema

asthma

10-33

10.4 Diagnosis and Pathology

Talking Points:

Diseases of the lower respiratory tract:

chronic obstructive pulmonary disease (COPD) – group of pulmonary diseases characterized by continual blocking of lung passages (emphysema, chronic bronchitis, and bronchiectasis)

emphysema – loss of elasticity of the alveoli; difficulty exhaling air

Asthma is the lungs’ version of an allergic reaction. The body’s response to the allergen (trigger) is to narrow the airways by constriction of muscles surrounding the airway and swelling of tissue on the inside of the airway. There may also be increased sputum production.

Conditions of the lower respiratory tract

bronchiogenic cancer

pneumoconiosis

pulmonary embolism

10-34

10.4 Diagnosis and Pathology

Talking Points:

Conditions of the lower respiratory tract:

bronchiogenic cancer – cancer that originated in the bronchi

pneumoconiosis – lung disease caused by inhaling dust

pulmonary embolism – matter in the pulmonary vasculature that blocks pulmonary blood supply

10.5 Treatments and Therapies

Medications that treat respiratory conditions address

bronchospasm

cough

Surgical procedures for respiratory conditions

Remove diseased tissues

Place breathing tubes in the trachea

10-35

Talking Points:

Medications that treat respiratory conditions address:

Bronchospasm (narrowing of the airway) – treated with bronchodilators

Cough – treated with antitussives

Surgical procedures for respiratory conditions:

Remove diseased tissues – removal of lobe of lung (lobectomy)

Place breathing tubes in the trachea – endotracheal intubation or tracheostomy

10.5 Treatments and Therapies

Surgical heart procedure to treat upper respiratory tract conditions

Surgery to remove tissues

laryngectomy

10-36

Talking Points:

Surgical heart procedure to treat upper respiratory tract conditions:

Surgery to remove tissues:

laryngectomy – surgical removal of the larynx

10.5 Treatments and Therapies

Surgical procedures to treat breathing conditions

tracheotomy

tracheostomy

endotracheal intubation

10-37

Talking Points:

Surgical procedures to treat breathing conditions:

tracheotomy – incision into the trachea (this must be done first, then a tracheostomy is performed)

tracheostomy – creation of an opening in the trachea

endotracheal intubation – insertion of a tube into the trachea (to assist with breathing)

10.5 Treatments and Therapies

Surgical procedure to treat lower respiratory tract conditions

Surgery to remove tissue

lobectomy

pneumonectomy

10-38

Talking Points:

Surgical procedure to treat lower respiratory tract conditions:

Surgery to remove tissue:

lobectomy – removal of a lobe of lung

pneumonectomy – removal of an entire lung

10.5 Treatments and Therapies

Surgical procedures applied to the pleura

pleuropexy

thoracocentesis, thoracentesis

thoracotomy

thoracostomy

10-39

Talking Points:

Surgical procedures applied to the pleura:

pleuropexy – reattachment of the pleura

thoracocentesis, thoracentesis – puncture of the thorax (into the pleural space)

thoracotomy – incision into the thorax

thoracostomy – creation of a hole into the thorax (usually to place a tube into the pleural space)

10.5 Treatments and Therapies

Procedure to breathe for the patient

cardiopulmonary resuscitation (CPR)

10-40

Talking Points:

Cardiopulmonary resuscitation is the process of applying pressure to the chest wall to circulate blood and to breathe for the patient.

10.5 Treatments and Therapies

Device to delivery respiratory medications

nebulizer

Medications to treat mucus

expectorant

mucolytic

Medication to treat cough

antitussive

Medication to treat bronchospasm

bronchodilator

10-41

Talking Points:

Device to deliver respiratory medications:

nebulizer – machine turns medication into an aerosol that is breathed in

Medications to treat mucus:

expectorant – encourages expulsion of material from the lungs

mucolytic – breaks down mucus (makes it thinner so it is easier to cough up)

Medication to treat cough:

antitussive – prevents cough

Medication to treat bronchospasm:

bronchodilator – expands the walls of the bronchi (by relaxing muscles that surround the airways)

10.6 Electronic Health Records

10-42

Talking Points:

Discuss consult note. The consult note helps the learner see the use of the terms presented thus far in context.

After studying this chapter, you should be able to:

10.1 Identify the roots/word parts associated with the respiratory system.

10.2 Translate the Subjective terms associated with the respiratory system.

10.3 Translate the Objective terms associated with the respiratory system.

10-43

Learning Outcomes

Talking Points:

Summarize the objectives for this chapter. Relate the objectives to the SOAP note plan.

Learning Outcomes

10-44

10.4 Translate the Assessment terms associated with the respiratory system.

10.5 Translate the Plan terms associated with the respiratory system.

10.6 Distinguish terms associated with the respiratory system in the context of electronic health records.

Talking Points:

Summarize the objectives for this chapter. Relate the objectives to the SOAP note plan.