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Health Assessment > Chapter 16 > Flashcards

Chapter 16 Flashcards

1
Q

Part of the respiratory tract that warms, moisturizes, transports air
-filters particles

A

upper

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2
Q

What are the 2 Portions of the respiratory system

A
  1. Upper
  2. Lower
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3
Q

lower

A

Part of the respiratory tract where oxygenation, ventilation occurs
-takes air from one area to another

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3
Q

base

A

bottom of lung

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3
Q

Thorax

A

One of the body’s most dynamic regions
Constantly in motion
-Bony thoracic cage (12 pairs of ribs)
-Thoracic cavity: three main compartments
- Thoracic nerves: T1-T12; dermatomes (Phrenic nerve: goes through the diaphragm,
- Intercostal nerves: goes through the intercostal muscles)
-Thoracic muscles
-Arterial blood supply
-Numerous veins
-Lungs: pulmonary arteries (2), pulmonary veins (2)
-Landmarks (used to document accurately):
Vertical: ribs
- Horizontal: Series of lines provide horizontal reference marks

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3
Q

Anterior thoracic landmarks

A

-Ribs: associated interspaces
-Suprasternal (jugular) notch
-Sternal angle (angle of Louis)
Site of the apex of the heart
Bifurcation of right, left mainstream bronchi
Easier to locate in thinner people
-Intercostal space (ICS) (2-6 are easier to feel)
-Costal angle

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4
Q

12th rib

A

must go posterior or lateral to feel this rib

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4
Q

apex

A

top of lung

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5
Q

Posterior thoracic landmarks

A

Ribs + vertebral spinal processes

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6
Q

Midsternal

A

Anterior reference line
-medial sternum

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7
Q

Vertical reference lines

A

Anterior (parallel to sternum)
-Midsternal: medial sternum
-Midclavicular: bilateral, medial clavicles
-Anterior axillary lines: bilateral, axillary folds
Posterior (parallel to vertebral line)
-Vertebral line: medial vertebral spinal processes
-Midscapular line: medial of scapulae
-Posterior axillary line: superior axilla to inferior thoracic
-Midaxillary line: medial axilla

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8
Q

Anterior Axillary lines

A

Anterior Reference line
-bilateral, axillary folds

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8
Q

Midclavicular

A

Anterior reference line
-bilateral, medial clavicles

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9
Q

Midscapular

A

Posterior reference line
-medial of scapulae

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9
Q

vertebral line

A

Posterior reference line
-medial vertebral spinal processes

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10
Q

right lung

A

3 lobes
-upper, middle, lower
-minor fissure divides right upper lobe horizontally

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10
Q

Posterior axially line

A

Posterior reference line
-superior axilla to interior thoracic
-middle of back

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11
Q

Midaxillary line

A

Posterior reference line
-medial axilla

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11
Q

Left lung

A

2 lobes
-upper and lower

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12
Q

Oblique fissure

A

each lung is divided by

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12
Q

Right middle Lobe

A

auscultated anteriorly, under right breast
-some can be done posteriorly

13
Q

auscultation of lungs

A

-done top to bottom in an H-like pattern
-listen for 1 full breath cycle
-done anteriorly and posteriorly

14
Q

lower respiratory tract

A

Trachea bifurcates
-Right main bronchus: shorter, wider, more vertical
- Branches: bronchi; bronchioles; alveoli (gas exchange)
-Larger airway sounds > smaller airway sounds
- Pleurae: continuous membranes within thorax (this space can collect fluid; if too much=respiratory distress; movement helps with this)
-Visceral: lines outer lung surface
-Parietal: lines thoracic wall, mediastinum; diaphragm
Pleural space

15
Q

Right main Bronchus

A

Side of trachea that is shorter, wider, more vertical

16
Q

Branches

A

bronchi; bronchioles; alveoli (gas exchange)
-Larger airway sounds > smaller airway sounds

17
Q

pleurae

A
  • continuous membranes within thorax (this space can collect fluid; if too much=respiratory distress; movement helps with this)
    -Visceral: lines outer lung surface
    -Parietal: lines thoracic wall, mediastinum; diaphragm
    Pleural space
18
Q

visceral

A

lines outer lung surface

19
Q

parietal

A

lines thoracic wall, mediastinum, diaphragm

20
Q

Mechanics of Respiration

A

Primarily: automatic process
-Main trigger for breathing: increased blood CO2
-Alteration causes
Medications (e.g., opiates, sedatives, overdose): hypoventilation
Anxiety, brain injury: hyperventilation
Inhalation
-Diaphragm: contracts, flattens and pulling lungs down
-Thorax, lungs: elongate, increases vertical diameter
-External intercostals: open ribs, increases diameter
-Increased thoracic diameter thorax pressure < atmospheric pressure
-Approximately 500 to 800 mL of air enters lungs.
Expiration: passive process:
-Diaphragm, internal intercostal, abdominals relax
-Lung pressure > atmospheric pressure
-Air pushed from lungs: chest, abdomen relax
Conditions= altered respirations

21
Q

inhalation

A

during inhalation it contracts, flattens which pulls that lungs down

21
Q

Thorax, Lungs

A

these elongate and increase vertical diameter during inhalation

22
Q

External intercostals

A

during inhalation ribs open and increase diameter
-this causes thorax pressure to be less that atmospheric pressure

23
Q

During inhalation: the thoracic diameter increases
this causes thorax pressure to be __________________ atmospheric pressure

A

less than

24
Q

approximately how much air enters the lungs during inhalation

A

500-800 mL

25
Q

during exhalation lung pressure is ________ atmospheric pressure

A

greater than

25
Q

expiration

A

-diaphragm, internal intercostal, abdominal relax during
-chest and abdomen relax

26
Q

Lifespan considerations: older adults

A

Effects of aging on respiration
-Respiratory strength declines
-Lungs lose elasticity (ability to open and close)
-Decreased flexibility in rib cartilage (can’t breath as deep, decreases chest volume)
-Bone density decreases (increased risk of fractures)
-Decreased AP ratio (more barreled appearance to chest)
Cultural considerations
-Disease prevalence (TB?, shot records, VCG vaccine-fade positive; Prisoners have increased risk for TB)
-Ethnic variability (african-americans have larger chest; asians have a decreased volume capacity)
-Genetic patterns
pectus excavatum: interior part of chest sinks in
- pectus carinatum: chest bulges out (pigeon chest)
Disease processes: CF, Emphysema may be hereditary
- Environmental: around smoking, vaping (increased risk for cauliflower lung); around bad equipment- protection appropriate?

27
Q

pectus excavatum

A

interior part of chest sinks in

28
Q

pectus carinatum

A

chest bulges out (pigeon chest)

29
Q

Subjective Data Collection

A

-Past medical history
-Lifestyle and personal habits (around smoke)
-Occupational history (exposure to chemicals)
-Environmental exposures (seasonal allergies)
-Medications (opioids slow rate)
-Family history

29
Q

Urgent assessment

A

Acute shortness of breath: emergent
Immediate assessments
-Respiratory, pulse rates; BP; O2 saturation (effort)
-Lung auscultation; O2, inhaler administration
-may need arterial blood gas test
Elevate head of bed. (have them breath slower)
- Continually assess patient anxiety level (may need to cluster their care)
-Encourage relaxation techniques.
Patients are stable: Fatigue limits assessment data.
-Prioritize subjective data collected.
-Cluster care

30
Q

risk reduction and health promotion

A

-Past history
-Health goals (does the pt have a health goal)
-Lifestyle and personal habits
Smoking cessation (ask at every visit if ready to quit)
-Occupational health
-Environmental exposure
Prevention of asthma (know a person’s triggers)
-Medications
Immunizations (pneumaccocal pneumonia; prevnar: decreased child death rate; annual flu shot;)

31
Q

Common Symptoms

A

Common respiratory symptoms
-Chest pain (location, when it started; aggregating and alleviating factors)
-Dyspnea (pain with breathing, find source)
-Orthopnea (difficulty laying down); paroxysmal nocturnal dyspnea (pooling liquid in lungs)
-Cough; sputum (wet, dry, color, continuous)
-Wheezing (inspiration/expiration; 1 side or both; inhaler)
-Functional abilities (interfering with ADL and ALDLs
-Lifespan considerations: older adults (increases SOB, need help?)
-Cultural considerations
traveled outside the country and what country did they come from; flu most vulnerable: young, pregnant and immunocompromised

32
Q

Objective Data Collection

A

Common and specialty or advanced techniques
-Initial survey: equipment; preparation
Comprehensive physical assessment: general
-Posterior chest: inspection; palpation (vibrations, crepitus “99”); percussion; auscultation
-Breath sounds: characteristics
Vesicular; bronchovesicular; bronchial
Altered: coarse; diminished/decreased; absent; stridor
-Adventitious breath sounds: crackles (normal); wheezes (high pitched narrow airway); rhonchi (rumbling; low tone; heard in inspiration and expiration)
-Comprehensive physical assessment: general—(cont.)
Anterior chest: inspection; palpation; percussion (easier on upper part of anterior chest); auscultation
-Lifespan considerations: older adults
-Cultural considerations (smoking)
Make sure rise and fall is easy, smooth and regular in pattern

33
Q

diaphragmatic excursion

A

distance that the diaphragm moves with inhalation

34
Q

chest expansion

A
  • Posterior
  • Place hands with thumbs pinching a skin fold at the level of T9 or T10
  • Ask client to take a deep breath in
  • Observe the movement of your thumbs (how far they spread apart)
  • Your thumbs should move 5-10 cm apart symmetrically
  • It is normal to have a decreased chest expansion in the elderly due to calcification of the costal cartilages and loss of accessory musculature
  • Anterior
    Place hands along the costal margins with thumbs pointing towards the xiphoid process
35
Q

inspection

A

need gown for pt, warm environment, stethoscope and alcohol swabs for

36
Q

2 signs of consolidation in the lungs

A
  1. Bronchophony
  2. Egophony
37
Q

bronchophony

A

99 should be muffled in this test

38
Q

egophony

A

“E” should sound like an “A”

39
Q

Critical Thinking

A

Laboratory and diagnostic testing
-Lab data; radiography; pulmonary function tests (tells how well air is moving)
-Collaboration (lets physician know lab values)
Diagnostic reasoning
-Nursing diagnoses; outcomes; interventions
-Outcomes (partial list) (short term or long term)
Maintain clear lung fields.
Demonstrate effective coughing (prevents pneumonia)
Demonstrate improved ventilation and adequate oxygenation.
-Interventions (partial list)
Auscultate breath sounds every 2 hours.
Position patient to optimize respiration.
Teach and encourage incentive spirometry use every 2 hours
What you can do

Health Assessment (7 decks)

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