General respiratory and terms to know Flashcards
Which of the following are expected findings of a lung assessment?
A. Relaxed, silent, regular, automatic
B. Regular, grade 2+, manual
C. Relaxed, easily heard, regular, automatic
A. Relaxed, silent, regular, automatic
A nurse preforms percussion on a patient with emphysema. What is an expected finding?
A. Resonance
B. Hyporesonance
C. Hyperresonance
C. Hyperresonance
How many breaths per minute is expected?
A. 11-21 breaths
B. 5-10 breths
C. 10-20 breaths
C. 10-20 breaths
What is the expected range for oxygen saturation?
A. 95-100%
B. 99-100%
C. 85-100%
A. 95-100%
Where is the apex of the lung located?
Highest point of lung tissue located above the clavicle
How many lobes are in the right side of the lung?
3 lobes
How many lobes are in the left side of the lung?
2 lobes
What is the innermost layer of the lungs?
Visceral membrane
What are the two stages of respiration?
Inspiration and expiration
How is breathing controlled?
Where does the body regulate and control breathing?
Breathing is involuntary and controlled by the respiration center in brain stem (pons and medulla).
What does ventilation mean?
Ventilation is the action of inspiration and expiration (full cycle)
What is Perfusion?
Perfusion is the ability of the cardiovascular system to pump oxygenated blood to the tissues.
Diffusion is responsible for moving the respiratory gases from one area to another by concentraion gradents.
- exchange of gases between air in the alveoli and blood in the capillaries
Google: Blood flowing through the pulmonary capillaries in the lungs
- The amount of blood reaching the alevoli where gas exchange occurs
What are some factors of oxygenation?
psychological
decreased oxygen-carring capacity
hypovolemia
decreased inspired oxygen concentration
increased metabolic rate
conditions affecting chest wall movment
developmental
lifestyle
environment
Hypovolemia: a decreased volume of circulating blood in the body
What subjective data is related to pulmonary disease?
Persistant cough
Sputum streaked with blood
Voice change
Chest pain (pulmonary embolism can mimic heart attack pain)
SOB
Orthopnea
Dyspnea
Activity intolerance
Recurring pneumonia or bronchitis (3 episodes, longer than 3 months)
What subjective data is related to tuberculosis?
Persistent cough
Hemoptysis
Unexplained weight loss
Night sweats
Fever
Define orthopnea
Shortness of breath when lying down
Define Dyspnea
Shortness of breath
Define hemoptysis
Bloody sputum
Define tachypnea
RR greater than 24 and shallow
Define Hyperventilation
Respiratory rate greater than 24 and deep
Define bradypnea
Respiratory rate less than 10
Define hypoventilation
Respiratory rate less than 10. Irregular and shallow
Define Cheyne-stokes respiration
Wax and wean with apnea (regular)
Define biot respiration
wax and wean with apnea (irregular)
Describe COPD respiration
Prolonged expiration with dyspneic episodes
pursed lip breathing
Define tactile freitus
Palpable vibrations
Felt when client says “99” Consolidation, mass or fluid
What subjective data could be found when assessing risk for lung disease
smoking/ second hand smoke
environmental- pollutants, radiation
family history of cancer, allergies, COPD, TB
Immunocompromised (fungal pneumonia)
Lack of immunization (prone to airborne illnesses)
What subjective data could be found when assessing for risk of TB
HIV
Substance abuse
Low income
Nursing or group home
Homeless
Prison
Family with TB (community)
Immigrant from a country where TB is prevalent
General inspection during respiratory assessment
Facial
Facial expression and level of conciousness
- hypoxia
- air hunger
General inspection of respiratory
Thorax
Shape and configuration of thorax
- Costal angle 90 degrees
- skeltal deformaties
General inspection of respiratory
Postion
Position
- relaxed able to support own weight without leans on arms
This is called tripod positioning
General inspection of respiration
Skin and nail
Consistent with genetic background and sun exposure
- note abnormal changes of skin, lips, and nails (cyanosis, pallor), lesions or deformaties
- the person has to hypoxic to present with cyanosis
Where is central cyanosis
Seen on legs first and usually creeps up
Appears with honeycomb pattern and blue color
What is the rule of thumb when assessing COPD and barrel chest?
Not all patients with COPD have a barrel chest, but all patients with a barrel chest have COPD
How do tracheal sounds present?
High pitched, loud
These are normal bronchial sounds
Where do intercostal reatractions occur?
Above clavicle and sternum
Could suggest atelectasis or forced inspiration with COPD
