The Valsalva maneuver is a breathing technique that can be used to help diagnose a problem with the autonomic nervous system (ANS). It can also be used to help restore a normal heart rate if your heart starts beating too fast. Show
Named after 17th century Italian physician Antonio Maria Valsalva, the technique requires you to try exhaling when your airways are blocked. A version of the Valsalva maneuver can also be used to help balance the air pressure in your ears. In addition to closing your mouth and pinching your nose, you bear down as if having a bowel movement. The maneuver causes several rapid changes in your heart rate and blood pressure. You should first try this technique under a doctor’s supervision to make sure you’re doing it correctly, and for a safe, but effective amount of time. To perform the Valsalva maneuver, follow these steps in order:
The Valsalva maneuver can be done sitting or lying down. Ask your doctor which approach is right for you. The Valsalva maneuver can be divided into four phases. Phase oneBlowing air against closed airways as you bear down causes the pressure in your chest to increase. That’s because the pressure in your aorta inside your chest briefly increases, and blood is forced out of your heart to your limbs and the rest of your body. This first phase causes a temporary spike in your blood pressure. Phase twoThe second phase causes a steady drop in blood pressure as a limited amount of blood in the veins returns to the heart. This lower amount of blood returning to the heart results in less blood pumped from the heart and a fall in blood pressure. Your ANS senses this pressure drop and responds by increasing your heart rate and output, and contracting your arteries. All of this leads to the return of blood pressure to a normal range if your ANS is healthy. Phase threeAt the end of the maneuver, you relax and your blood pressure falls for a few moments. This is the third phase. Phase fourSoon, blood starts rushing back to the heart. After a few heartbeats, blood flow should be back to normal and your blood pressure will rise because your blood vessels are still constricted. The blood pressure increase ideally causes the heart rate to come back to normal. That’s phase four. This simple procedure is used for a number of different reasons. Two important purposes are related to how the Valsalva maneuver affects your blood pressure and heart rate. Restoring heart rhythmThe shifts in blood pressure and heart rate as you move through the four phases of the maneuver can often restore a normal heart rhythm when your heart is experiencing tachycardia. Tachycardia is an abnormally fast heart rate. If one Valsalva maneuver doesn’t do the trick, your doctor may recommend you try it a second time. Diagnosing an ANS disorderIn addition to treating an abnormal heart rate, the Valsalva maneuver can also be used to help diagnose an ANS disorder. The pattern of your heart rate and blood pressure changes through the various phases of the Valsalva maneuver can help your doctor identify problems with your sympathetic and parasympathetic nerve functions. If you have a condition called postural orthostatic tachycardia syndrome (POTS), you’ll experience significant increases in your blood pressure during phases two and four. POTS is a condition in which your heart rate rapidly increases when you stand up after you’ve been sitting or lying down. It can be a very serious health problem, leading to fainting, falls, and other complications. Treating clogged earsThe Valsalva maneuver can also help with relatively harmless problems, such as air temporarily blocking the Eustachian tube in your inner ear. You may have experienced this feeling during takeoff or landing on an airplane. The Valsalva maneuver can often be used to help your ears “pop” open by forcing air through your sinuses and Eustachian tube. The Valsalva maneuver shouldn’t be used to treat all types of cardiovascular problems. Don’t try this technique if you have high blood pressure and are at high risk for a stroke or heart attack. Talk to your doctor before trying this technique if you have a heart rhythm problem, also known as an arrhythmia. If you try the maneuver several times to slow a racing heart, but get no relief from your tachycardia, go to an emergency room. You should also go to an emergency room if you have an unusually rapid heartbeat and you have chest pain, shortness of breath, or you feel faint. Trying the Valsalva maneuver to clear your ears should also be done with caution. If you try exhaling too hard, you could rupture an eardrum. The Valsalva maneuver can be a helpful treatment and diagnostic tool, but it should always be done first with instructions from a doctor. If you’re able to do it safely, it can be a quick and easy way to get your heart beating at a safe and normal rate. If your doctor has never suggested it, go ahead and ask. It may turn out to be a great help to your heart and your quality of life.
A nursing health assessment of the respiratory system involves the examination of the thorax and the lungs. A respiratory assessment is performed as part of a routine head-to-toe assessment. At times a more focused assessment of the respiratory system is necessary. And, as with any other system, knowing possible symptoms and how to focus the interview and physical assessment are important skills for nursing students to have. As with any study of systems, a good foundation of anatomy and physiology is important. Also, it is important to understand some basic principles of the respiratory system. Remember to review your anatomy and physiology before you practice your assessment. The article 9 Facts About the Respiratory System Every Nursing Student Should Know will be helpful in understanding some foundational respiratory concepts. During a respiratory assessment, a nursing student will use skills of inspection, palpation, percussion, and auscultation. This article with 9 Helpful Tips for Performing a Nursing Health Assessment of the Respiratory System will help you in your practice. Tip #1 – Gather Information on Past Medical HistoryPatients who have a respiratory complaint may have a history of respiratory conditions. Therefore, gathering information about previous illnesses will help you perform a more accurate respiratory assessment. Ask the following questions to gather more information about the past medical history.
Tip #2 – Gather Information on Chief Complaints or Symptoms.Gathering health information about the patient’s chief complaints and symptoms will help narrow the diagnosis of the respiratory condition. Below are some areas of assessment that focus on symptoms. Respiratory RateRespiration is the delivery of oxygen to the body and the elimination of carbon dioxide from the body. Below are some terms to remember about respiration. Eupnea is normal respirations. Ask the patient questions about any abnormal respiratory rates. Below are some questions to begin the conversation to get information. If a patient is experiencing or has experienced abnormal respiration, ask the following questions.
Shortness of BreathThe term for shortness of breath is dyspnea. It is non-painful but the patient feels the level of exertion for breathing is not normal. This symptom needs further investigation because it can be a serious complaint. If a patient is experiencing or has experienced shortness of breath, ask the following questions.
CoughA cough is a respiratory symptom that can be serious or not serious. Usually, a cough is preceded by a deep breath. A cough is a response to some type of irritant along the respiratory tract. The irritants can include mucus, foreign bodies, infectious agents, blood, pus or dust. A cardiovascular problem can also cause a cough. If a patient is experiencing or has experienced a cough, ask the following questions.
Sputum ProductionSputum production is associated with a cough. If a patient produces sputum frequently in large amounts, it usually suggests a problem. If a patient is experiencing or has experienced a cough with sputum production, ask the following questions.
HemoptysisHemoptysis is the coughing up of blood from the lungs. The blood can be frank blood or streaks of blood in the sputum. If a patient is experiencing or has experienced hemoptysis, attempt to assess the volume of blood. Try to find out if the blood may be originating from a source other than the lung. Chest PainA patient may experience chest pain with breathing. Also, systems other than the respiratory system can cause chest pain. Cardiovascular problems can be a cause of the chest pain. If a patient is experiencing or has experienced chest pain, ask the following questions.
Tip #3 – Know the Landmarks of the Thorax Anteriorly, and PosteriorlyTo perform a good respiratory assessment, the nursing student must be able to have a mental picture of the thorax. Visualize the lungs, ribcage, the spine, and other landmarks. Assess the anterior and the posterior thorax separately. Bony LandmarksThe landmarks of the anterior thorax include the clavicle, sternum (suprasternal notch, manubrium, sternal angle, the body of the sternum, and the xiphoid process) and anterior ribs. The landmarks of the posterior thorax include the spinal process (spine), scapula and posterior ribs. The images above show the anterior and posterior landmarks of the thorax. The bony projection that is usually visible at the base of the neck is C7 (cervical vertebrae 7) and T1 (thoracic vertebrae 1). Imaginary lines of the thoraxThere are also some imaginary lines that are helpful with the assessment of the thorax anteriorly and posteriorly. Anteriorly you have the midsternal line, midclavicular line, and the anterior axillary line. The midsternal line begins at the sternal notch extending down the middle of the sternum or the middle of a person’s chest. The midsternal line divides the sternum into a right half and a left half. The midclavicular line begins at the middle of the clavicle and extends down to around the 12th rib. This line should divide the right or left thorax in half. The anterior axillary line begins at the anterior axillary fold extending downward and ending around the 12th rib. Posterior imaginary lines include the vertebral line, the scapular line, and the posterior axillary line. The vertebral line falls down the spinous process of the vertebrae. This line divides the back of the thorax into the right and left sides. The scapular line begins at the inferior edge of the scapula extending downward ending around the 12th rib. The scapular line divides the right or left side of the back in half. The posterior axillary line begins at the posterior axillary fold moving downward ending at the 12th rib. Muscles of the Respiratory SystemThe muscles of the respiratory system include the diaphragm, the intercostal muscles, the sternocleidomastoid muscle, the scalene muscle, the pectoralis major muscle, the pectoralis minor muscle, and the rectus adominis muscle. The diaphragm is the major muscle of respiration. The additional muscles expand the neck and lift the ribcage during respiration. Read more about the muscles of respiration here! Lobes of the LungsThe lungs are cone-shaped organs. They are made of spongy, elastic tissue. The lungs are divided into sections called lobes. The right lung has three lobes. These are the upper, middle and lower lobe. The left lung has two lobes. These are the upper and lower lobe. The left lung is slightly smaller than the right lung because of the position of the heart. The lobes of the lung are somewhat independent of each other because they each receive air via their own bronchus. Fissures divide the lobes of the lungs. These fissures extend through the lungs. A pleural membrane lines the fissures. The apices of the lungs extend above the clavicle anteriorly and above the scapular posteriorly. Because the lung is cone-shaped, it ends between the 6th and 8th rib anteriorly and the 10 rib posteriorly. Tip #4 – Inspection of the Anterior and Posterior ThoraxInspection of the thorax is the same anteriorly and posteriorly.
Tip #5 – Palpation of the Anterior and Posterior ThoraxLightly palpate the thoracic area anteriorly and posteriorly. During palpation, you are looking for pain, tenderness, abnormalities, pulsations, lesions, masses or abnormal movement. Note the expansion of the chest. You may use palpation to check for chest expansion when it is difficult to observe the expansion or when you suspect asymmetry. To palpate for chest expansion posteriorly
To palpate for chest expansion anteriorly
Next, palpate for tactile fremitus. Fremitus is the vibration transmitted through the chest wall when a patient speaks. Tactile is the sense of touch. So tactile fremitus is check for fremitus using touch. The assessment of tactile fremitus is not an assessment tool often used by nurses. You normally will see it used by physicians or advanced practice nurses. However, you still need to know what it is. It could be an NCLEX question. Tactile fremitus can be checked anteriorly and posteriorly but is usually checked posteriorly. To check tactile fremitus
Tip # 6 – Percuss the Anterior and Posterior ThoraxPercussion is used to assess the density of the lungs. It is also used to assess the air in the lungs. Percussion of the thorax is another one of those assessment tools you will probably only see in the lab. To be really good at percussion you have to see it demonstrated. You also have to practice the skill. You can read how to do it over and over and you may get it, but seeing an instructor demonstrate this procedure is the key. That being said, this article will just provide some notes of percussion you should be familiar with. Those percussion notes include flatness, dullness, resonance, hyperresonance, and tympany. FlatnessFlat percussion sounds are a high-pitched sound with a soft quality. This sound is heard over dense tissue where there is no air. DullnessDullness usually has a medium pitch. You will hear the dullness when there is a combination of a solid and a fluid-filled area. ResonanceResonance sounds are heard over normal lungs. These sounds usually have a low pitch. HyperresonanceHyperresonance sounds are also low-pitched. However, these sounds are lower than resonance sounds. You will hear hyperresonance sounds over hyper-inflated lungs. TympanyTympany sounds are drum-like sounds. A gas-filled area can cause tympanic breath sounds. Also, a pneumothorax can cause tympanic breath sounds. Tips #7 – Auscultation of the Anterior and Posterior ThoraxThe auscultation of the anterior and posterior thorax is one of the most important assessment techniques you can learn. To become good at auscultation of the thorax, learn a pattern of auscultation that covers all the lobes of the right and left lung. Also, you must know the difference between normal breath sounds and adventitious breath sounds.
To auscultate breath sounds
Tip #8 – Auscultation of Breath SoundsBreath sounds are created when air moves in and out the respiratory tract. When you assess breath sounds you are assessing the pitch, intensity, quality and duration of the inspiration and expiration. The classification of normal breath sounds includes vesicular, bronchovesicular, bronchial, and tracheal. VesicularVesicular breath sounds usually are a low-pitched sound and have a soft quality. You will hear vesicular breath sounds from the beginning of inspiration to almost the end of expiration. Therefore, there is not usually a pause in this breath sound. You can hear vesicular breath sounds throughout the lungs. BronchovesicularBronchovesicular breath sounds are the inspiration and expiration sounds heard. These breath sounds will have a pause between inspiration and expiration. They have a moderate pitch. You can usually hear this breath sound over the upper portion of the lungs around the 1st and 2nd intercostal spaces. BronchialBronchial breath sounds are a high-pitched sound. The expiration period is longer than the inspiration period. You will hear these sounds best next to the trachea. TrachealBreath sounds heard over the trachea are tracheal breath sounds. The tracheal breath sounds are high-pitched and are loud. The sounds are heard equally during inspiration and expiration. Tip #9 – Auscultation of Adventitious Breath SoundsAbnormal breath sounds are called “extra” or “adventitious” breath sounds. Adventitious breath sounds include crackles (formerly known as rales), wheezes, rhonchi and friction rubs. Air flowing by liquid cause crackles (rales).
Air flowing through constricted airways cause wheezes.
Air flowing over thick secretions cause rhonchi.
Inflammation of the pleural space cause friction rubs.
In conclusion, the tips above will help you with a nursing health assessment of the respiratory system. These skills will also help you with a head-to-toe assessment. Begin by practicing your auscultation skills. Listen to as many different breath sounds as possible. This includes well people also. Once you have learned to recognize normal breath sounds, you will be able to recognize adventitious breath sounds when you hear them. The 9 tips above will give you a foundation as you increase your skills of performing not only a respiratory assessment but also a head-to-toe nursing health assessment. Reference Bickley LS., Szilagyi PG., (2017). Bates Guide to Physical Examination and History Taking. 12th ed. Philadelphia, PA. Wolters Kluwer/Lippincott Williams & Wilkins. Jarvis C., (2017). Physical Examination & Health Assessment. St Louis, MO. Elsevier Inc. Mosby’s Medical Dictionary (2017). 10th ed. St Louis, MO. Elsevier Inc. Disclaimer: The information contained on this site is not intended or implied to be a substitution for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained is provided for educational purposes only. You assume full responsibility for how you chose to use this information. Follow Nursecepts |