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NURS3313 Adult Health > Chapter 17 Assessment of Respiratory Function > Flashcards

Chapter 17 Assessment of Respiratory Function Flashcards

1
Q

Functions of the Respiratory System

A

O2 transport, gas exchange, respiration, & ventilation

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2
Q

Ventilation

A

Movement of air in & out of the airways

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3
Q

Upper Respiratory Tract Function

A

Warms & filters air

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4
Q

Lower Respiratory Tract Function

A

Gas exchange (diffusion)

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5
Q

What occurs during gas exchange?

A

Delivering O2 to the tissues via bloodstream

Expel waste gases (CO2)

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6
Q

Upper Airway Structures

A

Nose, paranasal sinuses, pharynx, tonsils, adenoids, larynx, & trachea

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7
Q

Nose Function

A

Serves as a passageway for air to pass to & from the lungs

Filters impurities & humidifies & warms air as it is inhaled

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8
Q

Cilia

A

Short, fine hairs that provide a constant whipping motion that serves to propel mucus & foreign substances away from the lungs & toward the larynx

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9
Q

Paranasal Sinuses Function

A

Serves as a resonating chamber in speech

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10
Q

Tonsil & Adenoid Function

A

Guard the body from organisms invading the nose & throat

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11
Q

What is another name that the larynx is referred to?

A

“Voice box”

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12
Q

Epiglottis

A

A valve flap of cartilage that covers the opening to the larynx during swallowing

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13
Q

Glottis

A

Opening between the vocal folds in the larynx

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14
Q

Thyroid cartilage

A

Largest of cartilage structures that forms a part of the Adam’s apple

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15
Q

Cricoid cartilage

A

Only complete cartilaginous ring in the larynx

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16
Q

Arytenoid cartilage

A

Used in vocal movement w/the thyroid cartilage

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17
Q

Vocal Cords

A

Ligaments controlled by muscular movements that produce sound

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18
Q

Trachea

A

The “windpipe”

Composed of smooth muscle w/ C-shaped cartilaginous rings at regular intervals

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19
Q

Why are the cartilaginous rings in the trachea incomplete?

A

The cartilaginous rings in the trachea are incomplete on the posterior surface to give firmness to the wall of the trachea to prevent collapse

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20
Q

Which organs compose the lower respiratory tract?

A

The lungs w/alveolar & bronchial structures

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21
Q

How many lobes does the RT lung have versus the LT lung?

A

The RT lung has 3 lobes & the LT lung has 2

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22
Q

Pleura

A

Serous membrane that serves as the inner lining of the lungs

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23
Q

What area does the visceral pleura cover?

A

The lungs

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24
Q

What area does the parietal pleura cover?

A

Lines the thoracic cavity, lateral wall of the mediastinum, diaphragm, & inner aspects of the ribs

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25
Q

What is the purpose of lobar & segmental bronchi?

A

They facilitate effective postural drainage

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26
Q

Do bronchioles have cartilage in their walls?

A

No, their patency depends on the recoil of the surrounding smooth muscle & on alveolar pressure

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27
Q

Physiologic Dead Space

A

Portion of the tracheobronchial tree that does not participate in gas exchange

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28
Q

Respiration

A

Gas exchange between the atmospheric air & the blood & the cells of the body

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29
Q

Apnea

A

Temporary cessation of breathing

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30
Q

Obstructive Sleep Apnea

A

Temporary absence of breathing during sleep secondary to transient upper airway obstruction

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31
Q

Which areas need to move in order for ventilation to occur?

A

Ventilation req movement of the walls of the thoracic cage & of its floor, the diaphragm

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32
Q

Inspiration

A

When the capacity of the chest is increased, air enters through the trachea

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33
Q

Expiration

A

Chest wall & diaphragm move back into the original position
-Lungs recoil & force air out via trachea & bronchi

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34
Q

Compliance

A

Elasticity & expandability of the lungs & thoracic structures

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35
Q

Pulmonary diffusion

A

Process by which O2 & CO2 are exchanged from areas of high concentration to areas of low concentration

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36
Q

Pulmonary perfusion

A

Actual blood flow through the pulmonary vasculature

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37
Q

Tidal Volume

A

Volume of air inhaled & exhaled w/each breath

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38
Q

Inspiratory Reserve Volume

A

Maximum volume of air that can be inhaled after normal inhalation

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39
Q

Expiratory Reserve Volume

A

Max volume of air that can be exhaled forcibly after normal exhalation

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40
Q

Residual Volume

A

Volume of air that remains in the lungs after max exhalation

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41
Q

Dyspnea

A

Subjective feeling of discomfort while breathing

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42
Q

Tachypnea

A

Abnormally rapid respirations

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43
Q

Hypoxemia

A

Low blood O2 level

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44
Q

Orthopnea

A

Shortness of breath when lying flat, relieved by sitting or standing

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45
Q

Stridor

A

Continuous, high-pitched musical sound due to airway narrowing (usually heard on inspiration)

MEDICAL EMERGENCY!!

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46
Q

Where can stridor be auscultated?

A

It can be auscultated over the neck

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47
Q

Egophony

A

Abnormal change in tone of voice that is heard when auscultating the lungs

48
Q

Cough

A

Reflex that protects the lungs from the accumulation of secretions/ inhalation of foreign bodies

49
Q

Cough reflex may be impaired by…

A

Weakness/ paralysis of resp muscles
Prolonged inactivity
Presence of NG tube
Anesthesia
Brain disorders

50
Q

Sputum Production

A

Reaction of the lungs to any constantly recurring irritant & often results from persistent coughing

51
Q

Nursing Assessment: Sputum Production

A

Is there sputum production?

Nature:
-Color: Thick & yellow, green, rust-color, or change in color is indicative of bacterial infection
-Consistency
-Odor

52
Q

For respiratory disorders, where is the chest pain usually located?

A

Pain is present usually on the side where the pathological process is located

53
Q

True or False (T or F):Patients w/chest pain from a pulmonary cause may get relief from laying on the affected side

A

True

54
Q

Wheezing

A

Continuous, high-pitched musical sound (can be heard in either inspiration or expiration)

55
Q

Wheezing on Inspiration

A

Bronchitis

56
Q

Wheezing on Expiration

A

Asthma

57
Q

Hemoptysis

A

Expectoration of blood from the respiratory tract

58
Q

Hemoptysis from the Lungs

A

Frothy, bright-red & mixed w/sputum

59
Q

Hemoptysis from the Stomach

A

Blood is a darker red color, not frothy

60
Q

Smoking is the single most important contributor to respiratory illnesses (T or F)

A

True

61
Q

Pack Years

A

The number of cigarettes smoked per day X the number of years the patient has smoked

62
Q

Risk Factors for Developing Respiratory Disease

A

Abnormal immune response (asthma)
Exposure to indoor & outdoor pollutants
Genetic makeup
Infection
Obesity
Personal/family history of lung disease
Smoking

63
Q

Nail Clubbing

A

Nail bed appears to be spongy and nail angle is distorted

64
Q

Cyanosis

A

Bluish coloring of the skin (late indicator of hypoxia)

65
Q

True or False (T or F): Central cyanosis is an early sign of hypoxia

A

False; Confusion, decreasing O2 sats, labored breathing, & nasal flaring are early signs
-Cyanosis is a late indicator

66
Q

Which accessory muscles are used during inspiration?

A

Sternocleidomastoid, scalene, and trapezius muscles

67
Q

Which accessory muscles are used during expiration?

A

Abdominal and internal intercostal muscles

68
Q

Crackles

A

Non-musical discontinuous popping sounds during inspiration caused by delayed reopening of the airways heard on chest auscultation

69
Q

What respiratory conditions are crackles associated with?

A

Associated w/ HF, pulmonary fibrosis, obstructive pulmonary disease

70
Q

Friction Rubs

A

Discontinuous, low-pitched, rubbing sound (can be heard during both inspiration & expiration)

71
Q

What respiratory conditions are friction rubs associated with?

A

Inflammation & loss of lubricating fluid

72
Q

Diagnostic Test: Pulmonary Function Tests (PFTs)

A

Used for diagnosis w/chronic respiratory disorders via spirometry measurements, lung volumes, arterial blood gas (ABG)

73
Q

What do PFTs evaluate?

A

Lung mechanics, gas exchange, and acid-base disturbance

74
Q

Nursing Interventions for PFTs

A

Determine whether analgesics are needed

Consult w/physician regarding holding bronchodilators

Instruct client to void prior to exam
-Once test starts, it cannot stop

Remove dentures

Reframe from smoking or eating a heavy meal 4-6 hours before the test

75
Q

Diagnostic Test: Arterial Blood Gases (ABG)

A

Provides info on O2 status & and acid-base balance

76
Q

What does an ABG (arterial blood gas) assess?

A

The lung’s ability to provide adeq tissue perfusion, removal of CO2, ability to maintain normal pH

77
Q

Normal pH Ranges

A

7.35-7.45

78
Q

Normal CO2 Range

A

35- 45 mmHg

79
Q

Normal PO2 Range

A

> 80 mmHg

80
Q

Normal HCO3 Range

A

22-26 mEq/L

81
Q

Metabolic Acidosis

A

pH is low & Bicarb is low

82
Q

Metabolic Alkalosis

A

pH is high & Bicarb is high

83
Q

Respiratory Acidosis

A

pH is low & CO2 is high

84
Q

Respiratory Alkalosis

A

pH is high & CO2 is low

85
Q

ROME Acronym

A

Respiratory
Opposite
Metabolic
Equal

86
Q

Diagnostic Tests: Pulse Oximetry (SpO2)

A

Normal values 95% - 100%
* Values < 90% need evaluation

Unreliable when there is low
perfusion
* Shock, cardiac arrest, sepsis,
hypothermia
* Nail polish can affect SpO2

87
Q

When should cultures be obtained?

A

They should be obtained prior to starting antibiotic therapy

88
Q

Imaging Studies: Chest X-Ray

A

Patient is not required to be NPO

Patient need to be able to take a
deep breath and hold it without
discomfort

89
Q

Imaging Studies: CT scan

A

NPO for 4 hours beforehand if contrast dye used
* Allergy to iodine or shellfish
* Contrast contraindication

90
Q

MRI Nursing Interventions

A

All metal must be removed (includes nicotine patches that have foil comp)

Assess for implanted devices: Aneurysm clips, pacemaker/defibrillator

Assess px’s ability to lie flat 30-90mins

Px will hear loud/thumping noise

Px will be able to comm w/staff via microphone

If px is claustrophobic may need anti-anxiety meds

If confused, may need to be sedated

91
Q

MRI Contraindications

A

Severe obesity

Confusion & agitation

Claustrophobia

Implanted metal

92
Q

Bronchoscopy

A

Scope inserted via throat to inspect inner respiratory structures

93
Q

Complications of Bronchoscopy

A

Infection

Aspiration

Hypoxemia

Pneumothorax

Bleeding

Perforation

94
Q

Nursing Interventions for Bronchoscopy

A

Informed consent

NPO for 4-8hrs (prev aspiration)

Dentures must be removed

Pt is sedated

Topical anesthetic used to suppress cough reflex

Small amount of blood-tinged sputum & fever may be expected w/in the first 24hrs

95
Q

Post-Procedure Monitoring for Biopsies

A

NPO until gag reflex returns
Vital signs per orders
Dyspnea
Bleeding
Pneumothorax
Uneven/absent breath sounds Right vs. Left
Uneven chest movement
Infection at the site

96
Q

Thoracentesis

A

Aspiration of fluid and air from the pleural space

97
Q

Pre-Procedure Nursing Interventions for Thoracentesis

A

Informed consent

Monitor vital signs

Check labs (coagulation)

Help to position the client over the bedside table

Instruct client to breathe deeply & not cough

98
Q

Post-Procedure Nursing Interventions for Thoracentesis

A

Monitor vital signs

Apply pressure dressing (monitor for bleeding & crepitus)

Monitor for pneumothorax, air embolism, & pulmonary edema

99
Q

Crepitus

A

Crackling/grating sound caused by subcutaneous air

100
Q

Atelectasis

A

Collapse of alveoli & often is described in relation to chest x-ray findings & clinical signs & symptoms

101
Q

Signs & Symptoms of Atelectasis

A

Dyspnea

Cough

Sputum prod

102
Q

Common Causes of Acute Atelectasis

A

People who are immobilized and have a shallow, monotonous breathing pattern due to thoracic/abdominal surgery

103
Q

Signs & Symptoms of Acute Atelectasis

A

Lobar atelectasis (large amount of lung tissue)

Dyspnea

Cough

Sputum prod

Tachycardia

Tachypnea

Pleural

Central cyanosis

104
Q

How does non-obstructive atelectasis occur?

A

Occurs as a result of reduced ventilation

105
Q

How does obstructive atelectasis occur?

A

Occurs due to a reabsorption of gas (trapped alveolar air is absorbed into the bloodstream)-> no additional air can come in-> collapse

106
Q

Nursing Measures to Prevent Atelectasis

A

Frequent turning

Early mobilization

Strategies to expand the lungs and to manage secretions

107
Q

Pleural Effusion

A

Fluid accumulating in the pleural space

108
Q

Pneumothorax

A

Air in the pleural cavity caused by a puncture of the lung/chest wall

109
Q

Hemothorax

A

Blood in the pleural space

110
Q

A nurse is caring for a client following a thoracentesis. Which manifestations are recognized as a risk for complication?
A) Dyspnea
B) Fever
C) Localized bloody drainage on the dressing
D) Hypotension

A

A) Dyspnea

111
Q

A client’s partner states the client woke up this morning, did not recognize her, & report chills. Which action should the nurse take FIRST? (Priority)

A) Obtain vital signs
B) Obtain a complete history from the client
C) Obtain sputum culture
D) Provide a pneumococcal vaccine

A

A) Obtain vital signs

112
Q

Which client diagnosed w/pneumonia, is MOST likely to have community-acquired pneumonia?

A) A client newly admitted to a long-term care facility
B) A client who recently traveled on a cruise ship
C) A client who has had multiple family visitors
D) A client whose spouse recently died

A

A) A client newly admitted to a long-term care facility

113
Q

A nurse is assessing a client following a bronchoscopy. What findings should the nurse report to the provider?
A) Blood-tinged sputum
B) Sore throat
C) Dry, nonproductive cough
D) Bronchospasm

A

D) Bronchospasm

114
Q

The nurse is interviewing a client who reports a dry, nonproductive cough. Which medication does the nurse question?
A) Aspirin
B) Angiotensin-converting enzyme (ACE) inhibitors
C) Cardiac glycosides
D) Bronchodilators

A

B) Angiotensin-converting enzyme (ACE) Inhibitors

115
Q

Which assessment finding indicates that the client has chronic hypoxia?
A) Crackles
B) Peripheral edema
C) Clubbing of the fingers
D) Cyanosis

A

C) Clubbing of the fingers

116
Q

The nurse is caring for a client w/ a pulmonary disorder. Which finding is indicative of a LATE symptom of hypoxia?
A) Cyanosis
B) Dyspnea
C) Restlessness
D) Confusion

A

A) Cyanosis

NURS3313 Adult Health (27 decks)

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