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N321: Nursing Assessment of Clients > Module 6 > Flashcards

Module 6 Flashcards

1
Q

Mammary glands lie over the …

A

muscles of the anterior chest wall

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2
Q

Where do the breast lie?

A

Horizontally over the sternum to the mid axillary line, and vertically from the 2nd to 6th Intercostal Spaces

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3
Q

What determines the difference in breasts between the genders?

A

Estrogen and Progesterone

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4
Q

The breasts are a _____ reproductive muscle

A

accessory reproductive muscle

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5
Q

Functions of the Breast

A

Milk
Sexual Stimulation

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6
Q

Types of Breast Tissue

A

Glandular
Fibrous
Adipose

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7
Q

Glandular Breast Tissue

A
  • Functional tissue
    -Makes milk
  • arranged into 15-20 lobes in a circular orientation with 50-75 lobules and 10-100 acini cells producing milk
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8
Q

Acini Cells

A

Cells producing milk

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9
Q

Fibrous Breast Tissue

A

The cooper’s suspensory ligaments

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10
Q

Cooper’s Ligaments

A

ligaments that support the shape of the breast by connecting skin and muscle throughout

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11
Q

Adipose Breast Tissue

A

Subcutaneous and Retromammary Fat of the breast

Makes up the majority of the breast, determines shape and size, but does not have a functional capacity

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12
Q

How are the mammary ducts constructed to bring milk to the nipples?

A

lobules, ductules, and lobes converge into a single milk duct that transports the milk

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13
Q

What else is looked at during a breast exam?

A

The axilla and the lymphatics

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14
Q

What are the sets of lymph nodes examined alongside the breast?

A

Axillary Lymph Nodes
Clavicular Lymph Nodes

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15
Q

Important Axillary Lymph Nodes to examine in a breast exam?

A
  1. Lateral - drains the arm - brachial
  2. Central - on midaxillary line
  3. Pectoral - anterior axillary - drains most of the breast
  4. Subscapular - posterior axillary
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16
Q

The Central Axillary Node…

A

gets drainage from the other nodes, and a small amount flows into the Clavicular nodes

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17
Q

2 Clavicular Lymph Nodes to Exam

A

Supraclavicular and Infraclavicular

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18
Q

Concerning Findings in Lymph Node Examination?

A

Enlargement
Tender or Painful Nodes
Nonpainful Enlargement
Larger than 1 cm enlargement
Nonmoving Lymph Node Mass

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19
Q

Non Modifiable Associations for the Health History Breast Exam

A
  • Things that cannot be changed -

Gender
Age at Menarche
Age at Menopause
Genetics (thought as highly important to risk)
Race/Ethnicity
Family History
Personal History
Previous Chest Radiation
Diethylstilbestrol Exposure
Age During Pregnancies (May be modifiable)

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20
Q

Menstruation and Menopause at what ages cause a higher risk for breast cancer?

A

Menstruation pre age 12 and Menopause post age 55

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21
Q

DES

A

Diethylstilbestrol

Now banned medicine for miscarriage in the 1940/50s that has been shown to cause a severely high rate of breast cancer in the daughters of the medication’s user

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22
Q

Modifiable Associations for the Health History Breast Exam

A

Children
Oral contraceptives
Hormones
Medications
Breast Feeding
Alcohol
Excessive Weight Gain
Physical Activity
Night Light

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23
Q

Children prior to age ____ is thought to be more protective against breast cancer

A

30

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24
Q

Use of hormone therapy for estrogen and progesterone ____ risk of breast cancer, but cessation of use ____ risk after 2-3 years

A

increases; decreases

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25
Q

Medications for ____ ____ and ____ can increase breast cancer risk

A

Breast enlargement and Transgender (breast enlargement)

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26
Q

Breast feeding is ____ against breast cancer

A

protective

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27
Q

Excessive Weight and Obesity increases estrogen thus leading to …

A

a higher risk of breast cancer

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28
Q

Physical activity can decrease breast cancer risk by ___%

A

10

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29
Q

Unclear Associations for the Health History Breast Exam

A

Night Work
Secondhand Smoke
Dieting and Vitamins
Medications
Environmental

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30
Q

How might night work increase breast cancer rate?

A

it is unclear and undergoing further study right now, but decreased melatonin levels may be linked to a higher risk of cancer

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31
Q

At the start of the Physical Exam of the Breast it is important to do/keep in mind what things?

A
  1. Always provide privacy as it may be embarrassing
  2. you want to teach the patient on breast awareness and to reassure them (decreases anxiety or embarrassment)
  3. May need a chaperone (especially if you are a male nurse)
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32
Q

Physical Assessment of the Breast includes what techniques?

A

Inspection
Palpation

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33
Q

Inspection of the breast should be done in what position(s)?

A

while sitting and while supine

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34
Q

Palpation of the breast includes what parts and intensity?

A

Light, Mid, and Deep Palpation

Breast, Axillae (tail of spence and lymph nodes), and Clavicular lymph nodes

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35
Q

Tail of Spence

A

the prolongation of the upper and outer breast quadrant into the axillary direction (“Axillary Tail”)

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36
Q

Why do we inspect breast in a supine position too?

A

So the tissue spreads out to see something you may not while sitting

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37
Q

Inspection of the breast occurs in what areas?

A

Between the 2nd and 6th ribs

Between the sternal edge and the midaxillary line

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38
Q

Inspection of the Breast in a Sitting Position involves the patient doing what things?

A

Sitting with arms at side

Sitting with arms pressed into waist

Sitting with arms above head

Sitting while leaning forward

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39
Q

Inspection of the Breast in a Lying Down position involves the patient doing what?

A

Having their arm up next to the ear with a pillow under one side, this allows the breast tissue to spread over the chest wall

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40
Q

What should be observed for during breast inspection?

A

Size
Shape
Surface Characteristics
Edema
Dimpling
Retractions
Venous Patterns
Areolar and Nipple Characteristics

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41
Q

Tanner Scale

A

Scale that assesses breast development during puberty and starts usually around ages 8-13 in women

11 years is the average starting age of breast development

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42
Q

If nipples are seen inverted …

A

ask whether they normally are inverted, if they are then it is not concerning

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43
Q

Montgomery Tubules

A

lubricate the nipple/areolar region

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44
Q

Peau D Orange

A

Dimpling of the breast caused by a blocked duct which causes congestion leading to the pitting orange like look of the breast

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45
Q

Pendulous Breasts

A

occurs due to gravity pulling on the cooper ligaments with age, so you have the patient lean forward to check the ligaments

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46
Q

What sort of things inspected may be concerning?

A

Thick Area Felt
Dimpling
Nipple Crust
Red or Hot
New Fluid
Skin Sores
Bumps
Growing Venous Patterns
New Sunken Nipple
New Size/Shape
Peel like Skin
Hard Lump

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47
Q

Breast Retractions

A

When the nipple caves inwards

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48
Q

Venous Patterns in the Breast

A

each side should generally look the same, but different congestion/venous patterns should be noted as it may indicate malignancy

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49
Q

Concerning Nipple Characteristics

A

Color not being dark pink to dark brown
Dry Patchiness/Eczema
New Discharge other than when breastfeeding
Green/White or Bloody/Clear Discharge
Unilateral differences rather than Bilateral
Persistent or Spontaneous differences

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50
Q

Paget’s Disease

A

Aggressive Cancer that can be detected in the areolar and nipple region (but it may be hidden by use of creams)

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51
Q

Green and White Discharge from the Nipple May Indicate…

A

a cyst

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52
Q

Bloody or Clear Discharge from the Nipple may indicate…

A

metastasis (cancer)

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53
Q

Reasons for Nipple Discharge

A

Drugs like oral contraceptives, antihypertensive, and tranquilizers

Hypothyroidism

Pituitary Adenoma

Overstimulation

Benign Cancers (Intraductal papilloma, papillomatosis, duct ectasia)

Malignant Cancer

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54
Q

Supernumerary Breast or Nipple

A

a non concerning “extra” nipple that may have formed along the milk line

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55
Q

Gynecomastia

A
  • more mamillary density in meds

can be from drugs, hormones, thyroid toxosis, or weight gain

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56
Q

Breast health is for …

A

EVERY patient, not just female

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57
Q

When palpating the breast…

A

it is best if they enter the supine position now

use a systematic method

use light and then deep palpation

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58
Q

Most Registered nurses do not…

A

give breast exams - but it is technically within the scope of practice

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59
Q

Areas to Make Sure you Palpate on a Breast Exam

A

Tail of Spence
Glandular Area
Areola Area
Nipple Compression (check for discharge, may be advised against at times)

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60
Q

Systemic Methods of Palpating Breasts

A

Concentric Circles
Spokes of Wheel
Grid Top to Bottom
Compass inward and outward

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61
Q

When discussing a finding on the breast, refer to it in terms of…

A

a clock face

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62
Q

Abnormal Breast Palpation Findings

A

Mastitis
Benign and Malignant Masses (Fibroids, Growths, Etc)

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63
Q

Mastitis

A

Milk duct infection

caused usually by a blocked duct (due to blockage or cancer)

important to know if they are lactating currently, because if not it can indicate cancer

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64
Q

Why should mastitis be treated quickly?

A

because it can lead to systemic problems

Teach the new mom if they have flu like symptoms like malaise or that they are not lactating to immediately see a provider

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65
Q

Fibrocystic Breasts

A

Catch all term for many benign breast growth conditions

Swollen, painful, tender, “lumpy bumpy”

often due to hormones or a high caffeine and fat diet

if these are painful, tender, or lumpy they should still be checked for a rare inflammatory breast cancer just in case

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66
Q

Fibroadenomas

A

Benign Solid Breast Tumors

Oval Shape
rubbery
Mobile
5 mm to 5 cm (huge spectrum)
Rare post-menopause
can grow “overnight”/quickly
large and uncomfortable for the patient
can occur even in younger people

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67
Q

Malignant Mass in Breasts

A

Hard

Sharp Edges / Irregular Shape

Non-Mobile

Non-Tender (Could be tender sometimes though, see Fibrocystic final point)

Nipple Erosion, Retraction, or Blood Discharge may occur

Enlarged, shrunken, or dimpled breasts may occur with no pain present

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68
Q

51% of Breast Cancers occur in what region?

A

the upper outer breast region (near the axillary area)

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69
Q

Cancer in the breasts are …

A

very widespread (many different areas can occur)

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70
Q

Invasive (Infiltrating) Ductile Carcinoma

A

most common breast cancer

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71
Q

When documenting breast exam findings what things should be included?

A

Location (in terms of clock face and how far from nipple)

Size (terms of actual measurements)

Shape

Consistency

Mobility of Mass

Tenderness

Erythema

Dimpling over the mass

Depth of the Mass

Ex: 1 cm hard, circular, non-moveable, painless mas noted at 2 O clock, 2 cm from areola in right breast, no erythema or edema noted

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72
Q

Diagnostic Breast Tests

A

Mammograms
Ultrasounds
Needle Aspirations
Surgical Biopsy

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73
Q

Usually diagnostic breast tests occur between…

A

patient and provider

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74
Q

Recommended Mammogram Age?

A

baseline at 35/36 with yearly ones starting at 40, or 10 years prior to a family members diagnosis of breast cancer

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75
Q

Ultrasound

A

often used in addition to the mammogram to help visualize dense breasts

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76
Q

Needle Aspiration and breast cancer diagnosis

A

Determines fluid contents of the mass

used depending on lesion type seen and potential risks of this test

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77
Q

Surgical Biopsy and breast cancer diagnosis

A

Determines whether a mass is malignant

used depending on lesion type seen and potential risks of this test

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78
Q

Breast Awareness should be taught in the patient’s…

A

early 20s

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79
Q

Most important thing nurses do in regard to breast health?

A

Patient Teaching of Awareness and Examinations

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80
Q

When should self breast exams be done?

A

If they no longer menstruate.. choose a day of the month for the exam

If they still menstruate… do shortly after the time of menstruations for a better baseline and less pain

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81
Q

How should the self breast exam be done?

A

Move in a grid like manner into the axilla

Do it lying down or in the mirror

They may do it themselves or need help from a provider

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82
Q

The overall newer consensus on self breast exams are…

A

they may not be all that useful, and awareness may be better to teachq

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83
Q

Example Nursing Diagnoses from the Breast Examination

A

Anxiety
Breast Feeding (effective, ineffective, interrupted)
Body image disturbance
Fear
Health Seeking Behaviors
Knowledge Deficit
Pain (acute, chronic)
Risk for infection

84
Q

Purpose of the Respiratory system

A

the lungs, in conjunction with the circulatory system, deliver oxygen to and expel carbon dioxide from the cells of the body

To maintain adequate O2 levels in the blood to maintain cellular life

85
Q

Purpose of the upper respiratory system

A

warms, humidify, filter inhaled air

make sound

send air to lower airways

86
Q

The lungs/lower respiratory system…

A

accomplishes gas exchange

87
Q

What does the respiratory system include?

A

Airways
lungs
bony thorax
respiratory muscles
central nervous system
upper and lower respiratory systems

88
Q

Structures of the Upper Respiratory Tract

A

Nose
Sinuses and Nasal Passages
Pharynx (naso, oro, largynogo)
Tonsils and Adenoids
Larynx: Epiglottis, Glottis, Vocal Cords, Cartilages

89
Q

Thorax

A

base of the neck to the area superior of the diaphragm

90
Q

Epiglottis

A

flap of tissue that covers the top of the larynx when the patient swallows.

Protects the person from aspirating food or fluid into the lower airways

91
Q

The larynx is on top of …

A

the trachea, and houses the trachea

92
Q

Structures of the Lower Respiratory System

A

Trachea
Lungs
Pleura
Mediastinum
Lobes of the Lungs
Bronchi and Bronchioles
Alveoli

93
Q

Carina

A

area where the trachea divides into two bronchi

94
Q

Amount of Lobes per Lung

A

Right - 3 - upper middle lower

Left - 2 - upper lower

95
Q

Apex of the Lungs

A

Located at the top’

sit slightly above the clavicle

96
Q

Base of the Lungs

A

located at the bottom

sit slightly superior to the diaphragm

97
Q

Visceral Pleura

A

pleura wrapping each lung

98
Q

Parietal Pleura

A

lines the chest/thoracic cage wall

has nerve endings

99
Q

Between the Visceral and Parietal pleura, there is …

A

pleural fluid

100
Q

____ is where gas exchange occurs

A

Alveoli

101
Q

How many alveoli are in the adult lung?

A

300 million

102
Q

2 Important Structures of the Respiratory System

A

Thorax / Thoracic Cage

Respiratory Muscles

103
Q

Thoracic Cage

A

Everything under the thorax:

Clavicles
Sternum
Scapulae
12 Sets of ribs
12 Thoracic Vertebrae

104
Q

Respiratory Muscles

A

Diaphragm
External Intercostal Muscles
Accessory inspiratory muscles (Trapezius, Sternocleidomastoid, Scalenes)

105
Q

Respiration

A

the process of gas exchange between atmospheric air and the blood at the alveoli and between the blood and the cells of the body

106
Q

exchange of gases occurs because…

A

of differences in partial pressures

107
Q

Pulmonary Ventilation

A

Inspiration + Expiration

it is the movement of air in and out of the airways

108
Q

Inspiration

A

active phase of ventilation

involves the movement of muscles and thorax to bring air into the lungs

109
Q

Expiration

A

the passive phase of ventilation (normally)

movement of air out of the lungs

110
Q

What occurs in the thoracic cavity during Inspiration?

A

contraction of the diaphragm (downwards/flattening) and contraction of the external intercostal muscles increases thoracic space

The lowered pressure causes air to enter through the airways to inflate lungs

111
Q

The thoracic cavity is a ___ chamber

A

airtight

112
Q

The floor of the thoracic cavity is the …

A

diaphragm muscle

113
Q

What occurs in the thoracic cavity during expiration?

A

The diaphragm relaxes (bowl shape upward) and intrathoracic pressure increases

Increased pressure means air is pushed out of the lungs as the lungs deflate

Expiration as a passive process requires the elastic recoil of the lungs to occur

114
Q

Inspiration is normally X/3rd of the Respiratory Cycle, and Expiration is X/3rds

A

Inspiration is 1/3
Expiration is 2/3

115
Q

Pressure in the thoracic cavity on inspiration

A

lowered

116
Q

Pressure in the thoracic cavity on expiration

A

increased

117
Q

Ventilation Perfusion (V/Q Ratio)

A

Ventilation is the movement of air in and out of the lungs, while perfusion is the blood that reaches the alveoli

So an adequate V/Q ratio determines adequate gas exchange as air must reach the alveoli to be available for gas exchange

118
Q

___ occurs when there is an imbalance of ventilation and perfusion which results in ____

A

Shunting; Hypoxia

119
Q

Tidal Volume (TV)

A

air volume of each breathe

measure several breaths since it can vary form breath the breath

120
Q

Inspiratory Reserve Volume (IRV)

A

maximum amount that can be inhaled AFTER a normal inhalation

121
Q

Expiratory Reserve Volume (ERV)

A

maximum volume that can be exhaled AFTER a normal exhalation

122
Q

Vital Capacity (VC)

A

the maximum volume of air exhaled from a maximal inspiration

VC = TV + IRV + ERV

123
Q

Forced Expiratory Volume (FEV)

A

volume exhaled forcefully over time in seconds. Time is indicated as a subscript, usually 1 second

124
Q

Who usually does measurement of volume and inspiratory forces?

A

a respiratory therapist (but we need to be able to teach use, like how we teach COPD patients the spirometer for use at home)

125
Q

Spirometer

A

measures volumes of air exhaled and is used to assess lung capacities

126
Q

Pulmonary Function Tests

A

assess respiratory function and determine the extent of dysfunction

127
Q

Peak Flow Rate

A

reflects maximal expiratory flow and is frequently done by patients using a home spirometer

128
Q

Diagnostic Procedures and Tests for the Respiratory System

A

ABGs
Sputum collection and Analysis
CXR, CT, MRI
PFT - measure inspiration and expiration rates and ratios
O2 Sat

129
Q

Sputum is best collected…

A

in the morning while noting color and density

130
Q

White Sputum indicates…

A

normal function or a viral/cold infection

131
Q

Green Sputum indicates …

A

bacteria

132
Q

Rust color Sputum may indicate …

A

Pneumonia or Tuberculosis

133
Q

Pink Frothy Sputum may indicate..

A

pulmonary edem

134
Q

Bright Red Sputum indicates

A

blood

135
Q

Brown/Black Sputum indicates

A

blood or hemoptysis

136
Q

Arterial Blood Gases (ABGs)

A

measurement of arterial oxygenation and CO2 levels

Used to assess adequacy of alveolar ventilation, ability of the lungs to provide O2 and remove CO2, and acid base level

137
Q

Pulse Oximetry

A

Non invasive method of monitoring oxygen saturation of the blood

DOES NOT REPLACE ABGs

may be unreliable if they smoke, have nail poliush, etc

138
Q

Normal Pulse OX level is…

A

95-100%

139
Q

What information to glean from the Subjective health history portion of the respiratory exam?

A

-present symptoms
-past and family history
-onset of symptoms (COLDSPA)
-Precipitating Factors (QRST/COLDSPA)
-aggravating and alleviating factors
-treatments and self care interventions
-immunizations - pneumovax, influenza annually, etc

140
Q

Listen and Learn what things during the health history respiratory assessment?

A

SOB
Cough - productive, chronic, etc
Sputum Production
Wheezing
Chest Pain
History of Smoking
What is their normal posture or breathing style
Recent Chest Trauma
General health
Work
Asthma

141
Q

Make sure to get specific information on attempts to quit smoking because…

A

they could say they quit but only started a day ago

make sure to be non judgmental and not preachy

142
Q

5 As to advising smokers

A

Ask, Advice, Assess, Assist, Arrange

143
Q

____ patients who move toward quitting smoking

A

praise

144
Q

Important Landmarks for the Physical Respiratory Assessment

A

Anterior: Midsternal, Midclavicular, Anterior Axillary Lines

Posterior Chest: C7, T1, T4, T7, T10, Vertebral Line, Scapular Line, Posterior Axillary line

Lateral Chest: Midaxillary line, T9, T5

145
Q

Suprasternal Notch

A

Notch in anterior neck above the manubrium and angle of louis - great starting point

146
Q

Angle of Louis

A

Notch distal to the suprasternal notch indicating the 2nd Intercostal

147
Q

Positioning of client for Physical Respiratory Assessment

A

Sitting for Posterior and Lateral and Anterior, or Supine for Anterior Assessment

148
Q

You can hear lung sounds from what side?

A

The posterior sides

149
Q

Techniques and order used for Physical Respiratory Assessment

A

Inspection –> Palpation –> Percussion –> Auscultation

150
Q

It is important to look at ____ for comparison in the physical respiratory assessment

A

symmetry

151
Q

Inspection during the Physical Respiratory Assessment

A

-Hallway Assessment
-Introduction
-Use good lighting
-check LOC
-measure and assess respiration pattern and retractions
-assess skin, color, condition, lesions, cyanosis potential (nail beds and lips), signs of respiratory distress
-thoracic configuration, symmetry, AP diameter
-abnormalities like barrel chest, kyphosis, scoliosis, funnel and pigeon chest
-assess neck muscles
-assess bilateral symmetric chest expansion (Thoracic Expanse)

152
Q

Signs of Respiratory Distress

A

SOB
Diaphoresis
Grunting
Nasal Flaring
Audible Wheezing
Intercostal Retractions

153
Q

LOC

A

level of consciousness

hypoxic patients may be disoriented or confused or agitated so be aware and do not assume that it is their typical personality

154
Q

Respiratory rate in adults should not go above..

A

24 maximum (typically 12-20)

155
Q

Infant Respiration Rate

A

20-40

156
Q

AP Diameter

A

Ratio of lateral and anterior/posterior thorax - should be a 2:1 ratio normally

157
Q

Kyphosis

A

curvature in the spine/back

158
Q

Barrel Chest

A

AP diameter of 1:1 - seen often chronic bronchitis/ COPD patients (due to trouble expiring)

159
Q

It is very to important to do what during palpation, percussion, and auscultation of the chest?

A

Do a bilateral comparison !!!

160
Q

Pattern of Anterior Chest Physical Examination (Palp/Perc/Ausc)

A
  1. Anterior neck
  2. Bilateral ICS 2 (angle of louis)
  3. Bilateral ICS 4
  4. Bilateral ICS 6
  5. Bilateral Lateral ICS 6
161
Q

Pattern of Posterior Chest Physical Examination (Palp/Perc/Ausc)

A
  1. Anterior neck
    2.Bilateral T1
  2. Bilateral T4
  3. Bilateral T7
    5 Bilateral T10
  4. Bilateral Lateral 9
  5. Bilateral lateral 5
162
Q

When Palpating the Chest what should you keep in mind?

A
  1. perform with one hand or two
  2. feel thoracic muscles and skeleton for pulsations, tenderness, depressions, masses, unsual movement or positions
  3. Crepitus
  4. Location of trachea
  5. Thoracic Expansion
  6. Vocal or Tactile Fremitus
163
Q

Crepitus

A

snap crackle pop sound/feeling during palpation indicating an air pocket

164
Q

Fremitus

A

vibrations recognized in the upper lungs and decreasing in intensity as you move away from the vocal cords while the patient says “99”

absence is concerning

165
Q

Palms of the hand can indicate patient ___

A

pain (palms used in resp exam)

166
Q

Percussion used in a respiratory assessment?

A

Indirect (tap on your own fingers)

compare bilaterally for sounds

167
Q

Lots of air does what to fremitus

A

less fremitus occurs

168
Q

Lots of fluid accumulation does what to fremitus

A

more fremitus occurs

169
Q

Resonant Percussion (loud, low, long, hollow) indicates what?

A

Normal Lung Tissue

Bronchitis

170
Q

Flat Percussion (soft, high, short, very dull) indicates what?

A

Consolidations

Bones

171
Q

Dull Percussion (medium, med to high duration, medium dull thud) indicates what?

A

A solid area like in pneumonia

The heart

172
Q

Tympanic Percussion (loud, high, medium, drum like) indicates what?

A

Air collection
Emphysema
Pneumothorax

(not as common as Hyperresonant)

173
Q

Hyperresonant Percussion (very loud, very low, longer, booming, abnormal air trapped sounds) indicates what?

A

Large Pneumothorax

174
Q

What lung sounds are heard through auscultation?

A

Bronchial/tubular, Bronchovesicular, Vesicular

175
Q

Breath smells can be indicative of …

A

illness

176
Q

Bronchial / Tubular Sounds

A

Blowing, hollow sounds

over the trachea, above the clavicles on each side of the sternum

loud, high pitched

Inspiration < Expiration

177
Q

Bronchovesicular Sounds

A

Medium pitched

found in 2nd intercostal space and T4 (posterior)

Next to the sternum between the scapulae

Inspiration = Expiration

178
Q

Vesicular Sounds

A

soft low pitched

over the lung periphery

Inspiration > Expiration

179
Q

Abnormal Breath Sounds in Auscultation?

A

Crackles
Rhonchi
Wheezing
Pleural Friction rub
Silence

180
Q

Crackles

A

FINE high pitched, discrete (crackling on inspiration)

heard at the end of inspiration

medium lower more moist sounding in the mid stage of inspiration with coarse loud bubbly sounds heard in inspiration

All are not cleared by coughing

mostly found in the base of the lungs usually

181
Q

Rhonchi

A

Sonorous Wheeze (low snore like during inhale and exhale)

low, low course sound, snore like

continuous during inspiration or expiration

may clear with cough accompanied by mucus accumulated in the trachea or large bronchi

182
Q

Wheeze

A

Sibilant Wheeze (musical during inhale and exhale)

musical sound squeak

louder on expiration

183
Q

Pleural Friction Rub

A

dry rubbing grating inflammation of the pleural surfaces (rubbing heard on inhale and exhale)

loudest at the anterior lateral surface

184
Q

Silence (During Auscultation)

A

Diminished sound indicative of things like emphysema, atelectasis, and bronchospasm

185
Q

Atelectasis

A

complete or partial collapse of the entire long or an area (lobe) because alveoli deflated or filled with fluid

common complication following surgery

“Collapse in Alveoli”

186
Q

Crackles late on inspiration may indicate …

A

Pneumonia, Congestive Heart Failure, or Edema

187
Q

During Auscultation the patient should…

A

breathe deeply through the mouth

188
Q

Physiological Changes of the Respiratory System With Age?

A

Decrease in:
-Stretching and compliance of chest wall
-rib motility and tone
-strength and function of respiratory muscles
-depth and oxygenation
-ability to cough and expectorate

Increase in:
-risk for accumulation of secretions leading to pneumonia
-potential increase in respiration rate

189
Q

Interventions to improve the airway?

A
  1. Administer Oxygen when ordered
  2. Sit them at the head of the bed upright (high fowlers 90deg)
  3. Encourage coughing and deep breathing (10 times at least every hour)
  4. Lots of fluid intakes, but restrictions (dont want to overhydrate and cause edema)
190
Q

Hyperventilation

A

an increase in rate and depth of rbeathing

191
Q

Kussmaul

A

rapid deep labored breathing often seen during diabetic ketoacidosis

192
Q

Tachypnea

A

respiration greater than 24 per minute

193
Q

Bradypnea

A

respiration lower than 10 per minute

194
Q

Hypoventilation

A

decreased depth and rate of breathing, and an abnormal pattern

195
Q

Chain Stokes

A

alternating periods of rapid breathing along with periods of apnea

196
Q

Ataxic

A

significant disorganization of varying irregular and regular types of respirations (disorganized respiration)

197
Q

Air Trapping

A

in COPD / obstructive respiratory disorders

increased difficulty getting air out

198
Q

normal adult chest sounds should be ..

A

resonant

199
Q

When auscultating the chest make sure to be touching?

A

the patients skin directly with the diaphragm

200
Q

Right way to use an Incentive Spirometer

A

Set goal with yellow marker –> Sit up and exhale completely –> seal mouth around device –> inhale slowly to keep side indicator within normal range –> keep inhaling until impossible then hold breath for 6 seconds –> exhale slowly allowing the piston to fall completely –> do 10 times every hour or two while patient is awake

201
Q

Atmospheric Oxygen is ___%

A

21

202
Q

Flow Meter

A

device that goes into the wall to regulate oxygen output in L/Min

203
Q

Nasal Canular

A

delivers lower flow rate of oxygen to a higher rate (1-6 L) and are often called nasal prongs

may need to get humidified at higher rates

204
Q

Simple Face Mask

A

Step up in flow rate from nasal canula

205
Q

Rebreather

A

step up in flow rate from simple face mask

206
Q

Non-rebreather/Modified Rebreather

A

step up in flow rate from rebreather (largest flow rate)

207
Q

Oxy Mask

A

Good for claustrophobia due to more holes

can deliver flow rate of any other device (1-15 L with 24-90% FiO2)

N321: Nursing Assessment of Clients (18 decks)

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