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NURS 522: Health Assessments > Chapter 19: Thorax & Lungs > Flashcards

Chapter 19: Thorax & Lungs Flashcards

1
Q

What should the costal angle be?

A

90 degrees

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2
Q

What are the anterior reference lines?

A

Anterior axillary line, midclavicular line, midsternal line

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3
Q

What are the posterior reference lines?

A

Scapular line, vertebral line

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4
Q

What are the lateral reference lines?

A

Anterior axillary line, midaxillary line, posterior axillary line

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5
Q

Where should you assess if you suspect consolidation of gunk in the lungs?

A

Posterior

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6
Q

Developmental Competence for Infants

A

Newborns have a high RR baseline; obligate nose breathers

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7
Q

Developmental Competence for Pregnant Women

A

Pregnant women may have shortness of breath as a result of impact of enlarging uterus (physiologic dyspnea…not abnormal)

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8
Q

Developmental Competence for the Aging Adult

A

Decreased vital capacity and increased residual volume (can’t breathe in as much and can’t breathe out as much)…higher risk for lung disease or affects of

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9
Q

What is the most common chronic disease in childhood?

A

Asthma; consider triggers and SDOH

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10
Q

Subjective Data

A

Cough
Shortness of breath
Chest pain
History or smoking or respiratory infection
Environmental exposure (eg. work)
Patient-centered care (TB test, chest XR, vaccinations)

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11
Q

Sputum

A

White/clear = colds, bronchitis, viral infection
Yellow/green = bacterial infection
Rust colored = TB, pneumococcal pneumonia
Frothy pink = pulmonary edema

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12
Q

Dyspnea

A

Difficulty breathing

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13
Q

Orthopnea

A

Difficulty breathing when lying down (heart failure)

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14
Q

Paroxysmal Nocturnal Dyspnea (PND)

A

When you wake up feeling short of breath…startles you up and induces quick breathing to catch up

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15
Q

Hemoptysis

A

Bloody sputum

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16
Q

Inspection

A

Facial expression
LOC
Posterior/anterior cage
Quality of respirations
Finger clubbing

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17
Q

Facial Expression

A

Pursed breathing, nasal flaring

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18
Q

Posterior/Anterior Cage

A

Shape and configuration: AP < transverse diameter (0.7-0.75)
Positioning: tripoding, compensation
Skin color and condition: cyanosis, pallor

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19
Q

Quality of Respirations

A

Labored vs. unlabored
Use of accessory muscles: sternocleidomastoid, trapezius (watch neck)

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20
Q

Clubbing

A

180 degree angle; result of chronic O2 deficiency (smokers, COPD, lung disease, heart disease)

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21
Q

Crepitus

A

Coarse, crackling sensation caused by free air trapped in subcutaneous tissue

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22
Q

Palpation

A

Symmetrical chest expansion
Tacile fremitus

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23
Q

Symmetrical Chest Expansion

A

Place hands at T9-T10 level and feel expansion for full respiration (check anterior and posterior)…should be symmetrical

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24
Q

Tactile Fremitus

A

Checks for palpable vibrations…decreased vibrations could indicate consolidation in the lungs
Have the patient say resonant words/phrases (“99” or “blue moon”) at each spot while you feel with the palmar assessment
5 posterior spots, 4 anterior spots
Move in pattern across and down the thorax
Avoid boney prominences

25
Q

Decreased Fremitus

A

Obstructed bronchus, pleural effusion, pneumothorax, emphysema

26
Q

Increased Fremitus

A

Compression or consolidation (pneumonia)

27
Q

Percussion

A

The prominent note over the lungs is RESONANCE
9 posterior spots, 5 anterior spots

28
Q

Hyper-resonance

A

LOWER pitched, booming sound
Emphysema or pneumothorax

29
Q

Dull

A

Soft, muffled thud
Pneumonia, pleural effusion, atelectasis, tumor

30
Q

Auscultation

A

Assessing the passage of air through tracheobronchial tree, which creates a characteristic set of noises
Have patient breathe in and out at each spot
9 posterior spots, 5 anterior spots

31
Q

“Normal” Breath Sounds

A

Bronchial
Bronchovesicular
Vesicular

32
Q

Bronchial Sounds

A

Loud, high-pitched, coarse quality
Heard over the larynx and trachea
Inspiration < expiration

33
Q

Bronchovesicular Sounds

A

Intermediate sound quality
Heard over the major bronchi
Inspiration = expiration

34
Q

Vesicular Sounds

A

Soft, low-pitched, whispering quality
Heard over fine airways near site of air exchange
Inspiration > expiration

35
Q

Decreased (absent) Breath Sounds

A

Bronchial tree is obstructed
Emphysema
Anything obstructing sound transmission
TOP PRIORITY FINDING

36
Q

Increased Breath Sounds

A

Sounds are louder than expected
High-pitched, tubular
Sound very close to your stethoscope
Consolidation or compression causes a dense lung area

37
Q

Adventitious (abnormal) Sounds

A

Crackles
Wheeze
Ronchi
Stridor
Pleural friction rub

38
Q

Crackles

A

Fine = high-pitched, soft, brief sound
Coarse = low-pitched, moist, bubbling sound

Pneumonia, emphysema, heart failure

39
Q

Wheeze

A

High-pitched, musical sounds
Asthma

40
Q

Ronchi

A

Low-pitched, snoring sound
May clear with a cough
Bronchitis, fluid in the lungs

41
Q

Stridor

A

Loud, high-pitched, crowing or honking in upper airway
Airway obstruction
EMERGENCY

42
Q

Pleural Friction Rub

A

Loud, low-pitched, grating or squeaky sounds
Decrease in pleural fluid

43
Q

Tachypnea

A

Fast breathing (20+)

44
Q

Hyperventilation

A

Fast breathing that is too deep

45
Q

Bradypnea

A

Slow breathing (under 12)

46
Q

Hypoventilation

A

Slow and too shallow breathing

47
Q

Cheyne-Stokes Respirations

A

Eb and flow between apnea and tachypnea
Meningitis, heart failure

48
Q

Atelectasis

A

Collapsed shrunken section of alveoli or an entire lung
Causes = airway obstruction, compression of the lung, lack of surfactant
Expected observations = uneven chest expansion

49
Q

Objective Assessment for Atelectasis

A

Inspection: cough, increased respiratory rate and pulse, cyanosis
Palpation: chest expansion and tactile fremitus decreased on the affected side, tracheal shift with large collapse
Percussion: dull
Auscultation: decreased or absent vesicular sounds over affected area

50
Q

Pneumonia

A

Infection in the lung parenchyma leaves alveolar membrane edematous and porous…alveoli fill up with bacteria, cellular debris, fluid, etc…little to no room for air/gas exchange
Symptoms: fever, cough with pleuritic chest pain, blood-tinged sputum, chills, fatigue

51
Q

Objective Assessment for Pneumonia

A

Inspection: tachypnea, guarding and lag on affected side, nasal flaring and accessory muscle use for children
Palpation: pulse > 100 bpm, decreased chest expansion on affected side, increased tactile fremitus if bronchus open, decreased tactile fremitus if bronchus obstructed
Percussion: dull
Auscultation: adventitious sounds…crackles in adults, diminished breath sounds in children

52
Q

Emphysema

A

Destruction of pulmonary connective tissue, permanent enlargement of air sacs
Produces hyper inflated lung and increase in lung volume

53
Q

Objective Assessment for Emphysema

A

Inspection: increased AP diameter (barrel chest), use of accessory muscles, tripoding, tachypnea
Palpation: decreased tactile fremitus and chest expansion
Percussion: hyper-resonant
Auscultation: decreased breath sounds

54
Q

Asthma

A

Hypersensitivity reaction to certain allergens, irritants, microbes, etc.
Creates complex bronchospasm and inflammation, edema in bronchiole walls, and mucous secretion
Greatly increase airway resistance

55
Q

Objective Assessment for Asthma

A

Inspection: tachypnea with audible wheeze, use of accessory muscles, cyanosis, barrel chest if chronic
Palpation: tactile fremitus decreased, tachycardia
Percussion: resonant
Auscultation: diminished air movement, decreased breath sounds with prolonged expiration; adventitious sounds…wheezing on expiration

56
Q

Pleural Effusion

A

Collection of excess fluid in intrapleural space with compression of overlying lung tissue
Fluid subdues lung sounds

57
Q

Objective Assessment for Pleural Effusion

A

Inspection: increased respirations, dyspnea, dry cough, tachycardia, cyanosis, asymmetrical expansion, abdominal distention
Palpation: decreased or absent tactile fremitus, decreased chest expansion on the affected side
Percussion: dull
Auscultation: Decreased or absent breath sounds; adventitious sounds…crackles

58
Q

Pneumothorax

A

Free air in the pleural space
Partial or complete collapse of the lung

59
Q

Objective Assessment for Pneumothorax

A

Inspection: unequal chest expansion
Palpation: decreased or absent tactile fremitus, tracheal shift to (unaffected side), decreased chest expansion on affected side
Percussion: hyper-resonant
Auscultation: decreased or absent breath sounds; adventitious sounds…none

NURS 522: Health Assessments (12 decks)

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