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Year 2: Nursing Adults with Acute conditions > Assessing and Managing Acute Respiratory Patient > Flashcards

Assessing and Managing Acute Respiratory Patient Flashcards

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1
Q

Which part of the ABCDE assessment come under respiratory assessment?

A

A and B - Airway and Breathing

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2
Q

A structured assessment of a respiratory patient includes what aspects? (7)

A

HIPPALO

  • History taking
  • Inspection
  • Auscultation
  • Percussion
  • Palpation
  • Look, Listen and Feel approach
  • Other Clinical observations
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3
Q

When inspecting a patient’s chest, what features should you look out for?

A

• General appearance - colour
cyanosis?

  • Symmetry?
  • Obvious dyspnoea
  • Ability to speak

• Use of accessory muscles,
shoulder hauling

• Air hunger

• Evidence of noisy
breathing/cough

  • Position of trachea
  • Movement of chest wall

• Chest wall/spinal deformities,
scars

• Finger clubbing/Nicotin

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4
Q

What is cyanosis and what is it an indication of?

A

It is a bluish/purpleish tinge to the skin which indicates hypoxemia

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5
Q

What is hypoxemia?

A

an abnomally low level of O2 in arterial blood.

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6
Q

What does it mean to “inspect” the the chest?

A

To look at the chest

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7
Q

What does it mean to “aucultate” the the chest?

A

To listen

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8
Q

Where are breath sound produced during chest auculation?

A

The large airways

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9
Q

What alters the sound of the chest when breathing?

A

obstructions to the flow

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10
Q

Obstructions to the flow can do what to chest aucultation?

A

alter the sound

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11
Q

The large airways are responsible for what during chest auculattion?

A

Breath sounds

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12
Q

Which parts of the lung should be auscultated?

A

Side to side

top to bottom

over anterior & posterior lung fields

bilaterally (both lungs)

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13
Q

Which part of the stethoscope is used for chest auscultation?

A

The diaphragm

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14
Q

What are the 3 normal lung sound?

A

Bronchial

Brochovesicular

vesicular

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15
Q

Where can bronchial sounds be heard?

A

on the anterior chest over trachea area

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16
Q

What do bronchial sounds sound like?

A

High pitched and loud

Inspiration slightly shorter than expiration

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17
Q

If patient has normal breath sounds which are:

High pitched and loud

Inspiration slightly shorter than expiration

what type do they have?

A

Bronchial chest sounds

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18
Q

What type of breath sounds can be heard on the anterior chest over trachea area?

A

Bronchial chest sounds

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19
Q

Where can broncho-vesicular sounds be heard?

A

anteriorly and posteriorly over the bronchi

anteriorly: 1st & 2nd Intercostal space

Posteriorly: between the scapulae

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20
Q

What do bronchial sounds sound like?

A

medium pitch

inspiration &expiration is equal

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21
Q

List examples of abnomal breath sound/

A

wheeze

Crackles

ronchi

Stridor

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22
Q

What does it mean to palpate the chest?

A

to physically feel the chest

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23
Q

What do clinicians look for when palpating the chest?

A
  • Chest wall tenderness
  • Chest wall movement
  • Evidence of surgical emphysema
  • Coarse/popping/grating-pleural friction rub
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24
Q

What can clinicians tell from percussing the chest

A

underlying lung structure

presence of
air, liquid or solid material

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25
Q

Prior to doing a respiratory assessment, what is the most important factor of the airway should be considered?

A

is it patent?

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26
Q

What indicates that a patient’s airway is patent?

A

If the patients is talking to you

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27
Q

When taking a history during a respiratory assessment, what question’s might you ask the patient?

A

Allergies?

Smoking?

Medication: Inhalers, Nebulisers, Home oxygen?

Travel history? (?TB)

Breathing symptoms? cough?
How long? sputum? colour of sputum?

Long-term condition? I.e Asthma, COPD?

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28
Q

What muscles a normally utilised during respiration?

A

diaphram

Intercostal muscles

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29
Q

Muscles other than the diaphram and intercostal muscles which are used during respiration are known as what?

A

Accessory muscles (i.e pectoral muscle)

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30
Q

What do quiet percussion sunds on a patient’s lung tell you about the structure?

A

medium is more dense

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31
Q

How do percussion sounds change thoughout the lung

A

sounds of air - loud

sounds over fluid - less loud

sounds over solid areas soft.

32
Q

What can hyper-resonance indicate?

A

pneomothorax or over inflated lung (COPD)

33
Q

How might pneumothorax or over-inflated lung be identified from percussion?

A

Hyper-resonant areas.

34
Q

Why is it important to calculate RR consitently and accurately?

A

RR is the most sensitive clinical sign of changing condition

35
Q

What is the normal range for RR in a healthy adult?

A

12-18bpm

36
Q

How should normal l breathing be?

A

quiet, unlaboured and even

37
Q

What is pulse oximetry and what is it used for?

A

Non-invassive assessment of oxygen satuartion

gives indication of oxygen delivery to tissues.

38
Q

When might pulse oximetry be unreliable?

A

if a person has poor peripheral perfusion, dark skin, extreme light.

39
Q

What is the difference between oxygenation and ventilation?

A

oxygenation is addition of oxygen to the body

ventilation is the inhilation of room air into the lungs.

40
Q

What are the 2 static lung volumes you need to know for the exam?

A

Functional residual capacity

residual volume

41
Q

What is functional residual capacity?

A

volume of air which remains in the lungs after normal expiration.

42
Q

What is residual volume?

A

Volume which remains in lungs after maximum expiration

43
Q

What happens to FRC and RV in people who have COPD an Emphysema?

A

increases

44
Q

What term is given to the volume of air which remains in the lungs after normal expiration?

A

functional residual capacity

45
Q

What term is given to the Volume which remains in lungs after maximum expiration?

A

Residual volume

46
Q

What do Peak flow meters measure?

A

How fast a patient can breathe out

47
Q

Which vessels are ABGs usually taken from?

A

radial, brachial or femoral arteries

48
Q

What can Abg values tell you?

A

Respiratory disturbance

metabolic disturbance

or combination of the two

compensation

49
Q

What are the 2 types of respiratory disturbance?

A

respiratory acidosis

respiratory alkalosis.

50
Q

A patient with resp acidosis may present with what type of valus on ABG reading?

A

low pH

High PaCO2

51
Q

A patient with resp alkalosis may present with what type of valus on ABG reading?

A

high pH

Low PaCO2

52
Q

If a patient has ABG readings which are of:

low pH

High PaCO2

what may be wrong with the patient?

A

Patient is in respiratory acidosis.

?retaining CO2

53
Q

If a patient has ABG readings which are of:

Hight pH

Low PaCO2

what may be wrong with the patient?

A

respiratory akalosis

?patient hyperventilating

54
Q

What does can PaO2 on an ABG strip say about a patient’s condition?

A

do they have normal arterial oxygen concentration?

are thy hypoxaemic?

55
Q

What does low PaO2 indicate?

A

Hypoxaemia

56
Q

How is Hypoxaemia indicated on an ABG strip?

A

Low PaO2 and/or low SO2

57
Q

Which type of respiratory failure is hypoxaemia likely to occur in?

A

Type 1. Can happen in Type 2 however this does not necessarily happen

58
Q

is hypoxaemia likely to be present in respiratory acidosis or alkalosis?

A

acidosis

59
Q

Which values from an ABG strip are used to determine metablic disturbances?

A

pH

HCO3 and Base Excess levels

60
Q

If a patient has ABG readings which are of:

low pH

Low HCO3

Low BE (-tive)

what may be wrong with the patient?

A

metabolic acidosis

61
Q

If a patient has ABG readings which are of:

high pH

high HCO3

high BE (+tive)

what may be wrong with the patient?

A

metabolic alkalosis

62
Q

How does the body compensate acidosis in the bood?

A

breath out more CO2, if this is not enough, more buffer is used to soak up the excess.

63
Q

How is compensation demonstrated in an ABG strip?

A

pH restoring to normal value.

64
Q

list some normal changes to the respiratory system as a result of age.

A

Chest wall compliance

elasticity of lung tissue

number of alveoli

strength of expiratory muscles

65
Q

What are the types of respiratory failiure?

A

Type 1 and type 2

66
Q

How is Type 1 respiratory failure classified?

A

hypoxaemia but no hypercania

low SpO2 or PaO2

PaCo2 normal or low

67
Q

How is Type 2 respiratory failure classified?

A

Hypercapnia is always evident (but pH may be compensated)

High PaCO2

Hypoxaemia is also possible

68
Q

List some of the causes for type 1 respiratory failiure

A

Chest infection

pneumonia

asthma

pulmonary embolism

69
Q

List some of the causes for type2 respiratory failure

A

COPD

extreme obesity

70
Q

List examples of acute respiratory disorders you might come across in the hospital?

A 
Chest infection
• Pneumonia
• Asthma, COPD, Emphysema
• Atelectasis
• Pneumothorax
71
Q

Whereabouts is in the respiratory tract does a chest infection occur?

A

in the upper respiratory tract

72
Q

What are the main symptoms of a chest infection?

A

Productive cough

fever

73
Q

What is atelectasis?

A

it is when aleveli structures in the lung collapse and close shut.

74
Q

What can cause atelectasis?

A

General Anaesthesia, secretions blocking an airway, plural effusion

75
Q

What does ARDS stand for?

A

Acute respiratory Distress Syndrome

Year 2: Nursing Adults with Acute conditions (12 decks)

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