Lung Assessment Flashcards
Name the anterior reference lines
Midclavicular and medial line
Pt is dehydrated. What sound might you hear when auscultating lungs?
Pleural rub (when you step on snow)
Pt has pneumonia. Pt complains of pain when breathing.
Pleuritis
When I lay down, I feel like I cannot breathe. I can place pillows behind me and that helps.
Orthopnea
What is orthopnea?
Difficulty breathing when laying down
What is parozysmal nocturnal dyspnea?
In the middle of night, the pt has trouble sleeping. And they wake up in the middle of the night. Feeling like they were not breathing.
I am having trouble breathing. This is known as…
Dyspnea
I snore and sometimes I feel like I have to gasp for a breath
Sleep apnea
You have a pt who has no history of respiratory issues and is basically healthy. The nurses is auscultating and hearing adventitious lung sounds. What do you ask the pt to do?
Ask patient to cough
Order of the lung assessment?
Inspection, Palpation, Percussion, Auscultation
Patient has a barrel chest, what assessment phase is this?
Inspection
Patient is cyanotic, what assessment phase is this?
Inspection
The patient’s chest rises and falls evenly, what assessment phase is this?
Inspection
You are observing your pt during respirations and you notice their chest appears to sink in just below the neck, under the breastbone, rib cage, and intercostal spaces. Why is this happening?
The patient is compensating by attempting to bring in more air into the lungs
Kyphosis
Hunchback. May be related to osteoporosis in the elderly.
When we palpate, what are we looking for?
To check for crepitus pain, tenderness, edema, proper motions
When palpating, you feel a crackling sensation. What could this be?
Crepitus
What is tactile fremitus?
Vibrations
You assess for tactile fremitus. You place your hands on their back ad ask them to say “99.” Why do you do this?
You want it to feel the same on both sides
What does it mean if there is unequal vibrations when palpating for tactile fremitus?
Consolidation on one side of the lung.
What sounds could we hear when we percuss?
Tone (hollow sounds on both sides),
Hyperresonance (air trapped in the lungs),
Dullness (i.e., over a solid or liquid tumor)
Resonance (low pitch sound over healthy tissue)
Diaphragmatic excursion (measuring the movement of the diaphragm)
What is emphysema?
Loss of elasticity in alveioli, therefore, air gets trapped
What sound do you hear when the pt has emphysema
Resonance
Usually we are listening to…
vesicular sounds
Bronchial sounds are heard during
expiration
Vesicular sounds are heard during
inspiration
Bronchovesicular sounds are heard during
both
You ask your pt to repeat “99” while you auscultate their chest. What is this called?
Bronchophony
During auscultation, you notice it is easy to under the “99” sound. Should you concerned?
Yes. May indicate a tumor or pneumonia
You ask your pt to repeat “E” while you auscultate their chest. What is this called?
Egophany
You ask your pt to repeat “E” while you auscultate their chest. The E sounds like A. Is this concerning?
Yes. Possible fluid in the lungs.
You ask your pt to whisper “123” while you auscultate their chest. What is this called?
Whisper pectoriloquy
During your respiratory assessment, you auscultate a high pitched sound during inspiration. What do you document this as?
Stridor
Pt is admitted to Ed with exacerbation of asthma. What is the most prominent adventitious sound you are likely to hear and what causes it?
Wheezing.
Inflammation and bronchospasm.
Pt has been admitted into the ICU with a TBI (traumatic brain injury). Their respirations are sometimes deep, sometimes shallow, and occasional apnea. How will you document this?
Biot
Pt who is in hospice is now deep and rapid breathing, followed by periods of apnea. How will you document this?
Cheyne Stokes
A pt is brought into the ED in diabetic ketoacidosis (DKA) They appear to be hyperventilating. How will you document this?
Kussmauls
Common variations in older adults
Increased chest diameter
Kyphosis
Decreased thoracic expansion
Use of accessory muscles to exhale
At risk for fractures (osteoporosis)
Experiencing dyspnea with aging lungs
Decreased ability to cough
Difference between kyphosis and scoliosis?
Kyphosis is the rounding of the thoracic spine
Scoliosis is a lateral deviation of the spine
If someone has long term clubbing, can it be indicative of pulmonary difficulties?
Yes, chronic
What are symptoms of pulmonary edema?
dyspnea, restlessness, cyanosis, pink frothy sputum
It is difficult to palpate as it lies behind the clavicle
First rib
A loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields.
Resonance
Very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema.
Hyper-resonance
Loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach
Tympany
Medium-pitched, thud-like sound that is percussed over solid tissue such as the liver.
Dullness
During palpation of a client’s organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing what kind of palpation
Deep palpation
