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Health Assessment > Nose Sinuses, Thorax And Lungs > Flashcards

Nose Sinuses, Thorax And Lungs Flashcards

1
Q

Bronchophony

A

Auscultate posterior chest. 99 should be soft and muffled, if loud and clear, consider lung consolidation.

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2
Q

Egophony

A

Evaluates intensity of spoken voice. Have pt. say eee, should hear soft, muffled eee, if aaa heard, consider lung consolidation

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3
Q

Whispered Pectoriloquy

A

Performed when a +) bronchophony is auscultated. Have pt. whisper 1,2,3. Sound should be faint and muffled. Clear with lung consolidation.

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4
Q

Normal breathing

A

The respiratory rate is about 14-20 per min in normal adults and up to 44 per min in infants.

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5
Q

Slow Breathing (Bradypnea)

A

Slow breathing may be secondary to diabetic coma, drop-induced respiratory depression, and increased intracranial pressure.

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6
Q

Sighing Respiration

A

Breathing punctuated by frequent sighs should alert you to the possibility of hyperventilation syndrome-a common cause of dysprea and dizziness. Occasional sighs are normal.

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7
Q

Rapid Shallow Breathing (Tachypnea)

A

Rapid shallow breathing has a number of causes, including restrictive lung discase, pluritic chest pain, and an elevated diaphragm.

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8
Q

Cheyne-Stokes Breathing

A

Periods of deep breathing alternate with periods of apnea (no breathing). Chidren and aging people normally may show this pattern in sleep. Other causes include heart failure, uremia, drug induced respiratory depression, and brain damage (typically on both sides of the cerebral hemispheres or diencephalon).

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9
Q

Obstructive Breathing

A

In obstructive lung disease, expiration is
prolonged because narrowed airways increase the resistance to air flow. Causes include asthana, chronse bronchstis, and COPD.

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10
Q

Rapid Deep Breathing (Hyperpnea, Hyperventilation)

A

Rapid deep breathing has several causes, induding exercise, anxicty, and metabolic acidosis. In the comatose patient, consider infarction, hypoxia, or hypoglycemia affecting the midbrain ce pons. Kussmaul breathing is deep breathing due to metabolic acidosis. It may be fast, normal in rate, or slow.

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11
Q

Ataxic Breathing (Biot’s Breathing)

A

Ataxic breathing, is characterized by unpredictable irregularity. Breaths may be shallow or deep, and stop for short periods. Causes include respiratory depression and brain damage, typically at the medullary levels

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12
Q

Flat percussion

A

sounds are a high-pitched sound with a soft quality. This sound is heard over dense tissue where there is no air.

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13
Q

Resonance

A

sounds are heard over normal lungs. These sounds usually have a low pitch.

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14
Q

Hyperresonance

A

sounds are also low-pitched. However, these sounds are lower than resonance sounds. You will hear hyperresonance sounds over hyper-inflated lungs.

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15
Q

Nose

A

External nose
Nasal cavity
Septum
Turbinates

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16
Q

Developmental care for infants and chidren

A

Salivation
Teeth
Nose

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17
Q

Developmental care for aging adult

A

Diminished smell and taste
Atrophic tissues
Dental changes

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18
Q

Developmental care for pregnant female

A

Nasal stuffiness
Epistaxis - nose bleed
Hyperemic gums - inflamed red gums

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19
Q

Subjective Data—
Health History Questions

A

DFSTEAA
Nose

Discharge
Frequent colds
Sinus pain
Trauma
Epistaxis
Allergies
Altered smell

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20
Q

Choanal atresia

A

narrowed and blocked

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21
Q

Epistaxis

A

Bleeding nose

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22
Q

Sinuses (FEMS)

A

Frontal - above eyes
Maxillary - upper jaw
Ethmoidal and Sphenoidal - smaller, located deeper in the skull

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23
Q

Abnormal findings on the nose

A

Abnormal findings:
- Allergies – swollen, pale, bluish gray.
- Upper respiratory infection – red, swollen
mucosa
- Purulent – contains pus.

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24
Q

Kiesselbach area

A

Epitaxis / nosebleed

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25
Q

C7; can be easily felt with the
client’s neck flexed.

A

Vertebra Prominens

26
Q

True Ribs
False Ribs
Floating Ribs

A

1-7
8-12
11-12

27
Q

3 vertical reference lines

A

Midsternal line
Right midclavicular line
Left midclavicular line

28
Q

Lined by pleural membranes
Consists of mediastinum and the lungs

A

Thoracic cavity

29
Q

Central area in thoracic cavity that contains trachea, bronchi, esophagus, heart and great vessels

A

Mediastinum

30
Q

Humps on left

A

Levoscoliosis

31
Q

Humps on right

A

Dextroscoliosis

32
Q

Chest deformities

A

A. Pigeon - Pectus carinatum
B. Funnel - Pectus excavatum
C. Barrel - COPD, emphysema (pink puffer) Chronic bronchitis (blue bloater)
D. Kyphosis - thoracic and lumbar
E. Scoliosis

33
Q

How many lobes are in right and left lung

A

Right - 3
Left - 2

34
Q

Thin double layered serous membrane

A

Pleura
Parietal - lines chest
Visceral - covers external surface

35
Q

Types of external respiration

A

Vertical - contract diaphragm
Horizontal - elevate ribs

36
Q

strongest stimulus to breath; increase
in carbon dioxide level in the blood.

A

Hypercapnia

37
Q

decrease in oxygen which increases respiration but is less effective.

A

Hypocapnia

38
Q

1 lung up 1 lung down

A

Chest lagging

39
Q

Accumulation of air in pleural cavity

A

Pneumothorax

40
Q

Accumulation of blood in pleural cavity

A

Hemothorax

41
Q

Accumulation of water in pleural cavity

A

Hydrothorax

42
Q

Accumulation of pus

A

Pyothorax - emphyema

43
Q

Altered smell

A

Anosmia

44
Q

When you overuse nasal sprays eg. white flower

A

Rhinitis medicamentosa

45
Q

Abnormal findings for inspection

A

Alar flaring – nares expanding and enlarging to assist in labored breathing.

Pursed lip – helps patient to slow down their breathing.

Cyanosis – bluish discoloration of skin due to decreased oxygen.

Clubbing of nails – hypoxia

46
Q

How to palpate lungs

A

Ulnar edge of hand; say 99 and assess

47
Q

How to percuss thorax (to see if there is liquid air or solid)

A

Percuss in ICS about 5 cm in systematic sequence

48
Q

Types of percussion sounds in lung

A

Flat percussion sounds - a high-pitched sound with a soft quality. This sound is heard over dense tissue where there is no air.

Dullness - usually has a medium pitch. You will hear the dullness when there is a combination of a solid and a fluid-filled area.

Resonance sounds - heard over normal lungs. These sounds usually have a low pitch.

Hyperresonance sounds - also low-pitched. However, these sounds are lower than resonance sounds. You will hear hyperresonance sounds over hyper-inflated lungs.

Tympany sounds - drum-like sounds. A gas-filled area can cause tympanic breath sounds. Also, a pneumothorax can cause tympanic breath sounds.

49
Q

99 sounds while palpating

A

Vocal tactile fremitus

50
Q

Percussion notes

A

Lungs - resonance
Flatness - ribs

51
Q

How to percuss thorax

A

Deep breath and percuss along scapular line until dullness is produced at level the diaphragm

Client breathes and percuss

52
Q

What is excursion of percussion

A

Women - 3 to 5 cm bilaterally
Men - 5 to 6

53
Q

Auscultation of thorax

A

Zig zag percuss and ask client to take deep breaths from mouth

54
Q

Percussion notes at anterior thorax

A

Resonance at 6th rib
Flat over bone or muscle
Dull over heart and liver
Tympanic - stomach

55
Q

Auscultation normal breathing sounds type, location and characteristics

A

Vesicular - base of lung - longer inspiration
Bronco-vesicular - 1st and 2nd ICS - equal inspiratory and expiratory
Bronchial - over trachea - longer expiration

56
Q

Abnormal breathing sounds (adventitia) name and cause

A

Crackles - fluid and mucus
Gurgles (rhonchi) - narrowing
Friction rub - rubbing
Wheeze - constricted bronchus

57
Q

Hyperresonance

A

Emphysema

58
Q

Dyspnea

A

Aging changes of lungs

59
Q

Normal breathing

A

Eupnea

60
Q

Slow breathing below 12 rr

A

Bradypnea

61
Q

More than 20 rr

A

Tachypna

62
Q

Allergies

A

Hay fever

Health Assessment (7 decks)

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