Module 2-a

Question 1

Fetal circulation

Answer 1

Umbilical cord- 1 vein , 2 arteries. O2 bld –placenta–umbilical vein. Splits in 2 at the base of the liver.

Question 2

Foramen Ovale

Answer 2

Opening between the right/left atria. Bypasses pulmonary circulation. Most oxygenated bld passes through here.

Question 3

Infant Resp

Answer 3

30-60 per min. Abdominal breathing. Crackles sometimes present at the end of deep resp.

Question 4

Early childhood resp (1-5 yrs)

Answer 4

20-40, irregular pattern. Expiration longer then inspiration.

Question 5

Late childhood resp (6-12 yrs)

Answer 5

15-25 resp. Thoracic breathers. Inspiration longer then expiration.

Question 6

Aged adult resp. (65 +)

Answer 6

12-20. Thoracic.

Question 7

Factors that affect Respiratory Function

Answer 7

Age, gender, exercise, acid-base balance, brain lesions (hemorrhage/tumor), high altitude, resp disease (COPD), anemia, anxiety, meds (narcotics, amphetamines), acute pain.

Question 8

Nursing assessment and Resp. function

Answer 8

patterns, recent changes, cough, sputum, CP, dyspnea, fever, fatigue.

Question 9

Techniques for assessment (resp) Inspection

Answer 9

Inspection- always least invasive to most invasive. Contour (convex), Movement (symmetrical), Color (warm/dry- check for scars) Rate/Rhythm (assess for 1 min./ nasal flaring)

Question 10

Techniques for assessment (resp) Palpation

Answer 10

Palpation- Excursion or movement- (trach centered b/t clavicles). Vocal Fremitus (capacity to feel sound in the chest, non-bony area/ Pneumonia), Temp- (check in certain areas) Crepitus - air pockets (rice krispies).

Question 11

Techniques for assessment (resp) Percussion

Answer 11

Percussion- Resonance (loud, hollow, high pitched over normal lungs. Hyperresonance (emphysema/ loud boom), Flat tone (bone, heavy muscle), Tympany (high pitched, drum like sound heard in the stomach). Dullness (medium pitch, intensity / liver)

Question 12

Techniques for assessment (resp) Auscultation

Answer 12

Auscultation- apex to the base, Vesicular, low pitch (base on inspiration) Bronchial, high pitch (along the trachea, expiration longer then inspiration), Brochovesicular, medium pitch (blowing sound during expiration, equal I and E.

Question 13

Adventitious Sounds (Resp function) Crackles

Answer 13

Crackles/Rales- discontinuous (intermittent, low, high pitched sound on inspiration. Never cleared by a cough.)

Question 14

Adventitious Sounds (Resp function) Wheezes

Answer 14

Wheezes- continuous ( high pithced on I and E)

Question 15

Adventitious Sounds (Resp function) Gurgles

Answer 15

Gurgles/Rhonchi- continuous (loud, low, course. Snoring, can clear with a cough. Large airway obstruction)

Question 16

Adventitious Sounds (Resp function) Pleural Friction Rub

Answer 16

Pleural Friction Rub ( dry, grading sound. Inflammation of pleural space. “screeching”)

Question 17

Adventitious Sounds (Resp function) Stridor

Answer 17

Stridor- (mostly w/ infants. Upper airway inflammation, gasping of air)

Question 18

Diagnostic Tests for Resp. Function

Answer 18

CBC, PFT, ABG, SPO2, Cytologic, Bronchoscopy, Skin, CXR/CT, Thoracentesis (pleural effusion)

Question 19

Nursing DX: Altered Respiratory Function

Answer 19

Ineffective airway clearance, R/T thick secretion, fever, fatigue, dehydration, poor nutrition as manifested by: restlessness, inability to walk w/o coughing.

Question 20

Manifestations of the for O2 (subjective)

Answer 20

verbalize- diff. breathing, pain, anxiety, fear, fatigue, dizziness, drowsiness, lightheadedness, numbness in extremities.

Question 21

Manifestations of the for O2 (objective)

Answer 21

observes-use of accessory muscles, flared nostrils, abnormal breath sounds, cyanosis, coughing, tachy, sputum, distended neck veins, restlessness, and skin changes

Question 22

Nursing interventions (promote effective cough)

Answer 22

sit upright-flat footed, reminder to cough, specific coughing schedule, coughing exercises (productive/nonproductive)

Question 23

Nursing interventions (pollution free environment)

Answer 23

job change, protevtive equipment, enforce laws, dust/vacuum, wear a mask when needed, restrict exposure, pat attention to pollution alerts, avoid smoking.

Question 24

Measures that promote comfort

Answer 24

Positioning (high Fowlers) b/c of orthopnea (inability to breath lying flat), adequate fluid intake, humidified air (cool mist), percussion (cupping), vibrating, postural drainage, good nutrition, meds