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z_NUR112: Exam 2 > Notes Ch: 31 - Assessment Pt. 3 > Flashcards

Notes Ch: 31 - Assessment Pt. 3 Flashcards

Lungs

1
Q

What is the order of examination when assessing the lungs?

A
  1. Inspection; visual
  2. Palpation; feel; light, then deep
  3. Auscultation; listen
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2
Q

What can be observed a visual sign of respiratory distress?

A
  • Irregular breathing patterns
  • Using accessory muscles to breathe
  • Cyanosis at lips/muscous membranes
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3
Q

What position is preferred for a patient having a hard time breathing, supine or fowler?

A

Fowler

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4
Q

When assessing the posterior thoracic area of a patient, what “lines” are used?

A
  • Left/Right scapular line
  • Vertebral line
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5
Q

When assessing the lateral thorasic area of a patient, what “lines” are used?

A
  • Posterior axillary line
  • Midaxillary line
  • Anterior axillary line
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6
Q

When assessing the anterior thorax of a patient, what “lines” are used?

A
  • Midsternal line
  • Midclavicular line
  • Anterior axillary line
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7
Q

How does one test for chest excursion?

A
  • Wrap hands around waste of patient
  • Place thumbs on either side of the spine
  • If there is separation of the thumbs on inhalation, there is chest excursion
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8
Q

Consolidation in the thorax is…

A

the accumulation of fluids in the pleural space

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9
Q

What is tactile fremitus?

How is it assessed?

A
  • A vibration felt on the patient’s chest during low frequency vocalization.
  • Transmitted through lungs to chest wall
  • Assessed by placing each hand under each scalpula and have the patient saying “99”, if there is no vibration, it can be indicative of blockage
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10
Q

What is Egophony?

How is it assessed?

A
  • An increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis.
  • While auscultating lungs, have patient say “E”. If it sounds like “A”, it indicates egophony and positive for consolidation.
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11
Q

What are abnormal lung sounds called?

A

Adventitious

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12
Q

What are the four adventitious lung sounds?

A
  1. Crackles
  2. Rhonchi
  3. Wheezes
  4. Pleural friction rub
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13
Q

Describe adventitious lung “crackles” and how the are described.

A
  • Caused by sudden reinflation of groups of alveoli or disruptive passage of air through small airways.
  • Described as fine, medium, coarse
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14
Q

What are crackles indicitive of?

A
  • Pneumonia
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15
Q

To open up airways, what kind of medication is needed?

A

Bronchodilator

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16
Q

Describe adventitious lung “Rhonchi”.

How is it cleared?

A
  • Low-pitched, continuous sounds caused by muscular spasm, fluid, or mucus in larger airways.
  • Cleared by coughing
17
Q

Describe adventitious lung “wheezes”.

A
  • high-pitched sound or squeak heard continuously during inspriation or expiration.
  • Usually louder on expiration
  • Often heard in asthma
18
Q

Describe adventitious lung “pleural friction rub”.

A
  • Dry rubbing or grating sound
  • Caused by inflamed pleura; parietal pleura rubbing against visceral pleura
19
Q

During auscultation of breath sounds, what must be indicated?

A
  • Location
  • Characteristics of sound
  • Absence of breath sounds
20
Q

What is the one assessment you must do on your patients everytime?

A

Respiratory

21
Q

What do the following prefixes mean?

Supra-

Infra-

Inter-

A
  • Supra- above
  • Infra- below
  • Intra- between
22
Q

What are the terms used for regions of the lungs assessed?

A
  • Upper, middle, lower lung fields
  • Base of lungs; lowermost portions
23
Q

What/how is generally observed during a respiratory assessment?

A
  • Auscultate vesicular and bronchial sounds
  • Observation of accessory, sterocleidomastoid, trapezius and abdominal muscles
  • Palpation of muscles and skeleton
  • Assessment of tactile fremitus
  • Semetry comparison of right/left sides
24
Q

What are the three classifications of breath sounds?

Name the location, lung region assessed and describe the sound of each.

A

Bronchial

  • Location: supraclavicular/trachea
  • Assessed: apex/upper of lungs - expiration longer than inspiration at 3:2 ratio
  • Sound: loudest, high pitch w/ audible pause between inspiration and expiration

Bronchovesicular

  • Location: mid-thorax/intrascapular
  • Assessed: middle of lungs - larger airways
  • Sounds: medium pitch

Vesicular

  • Location: base of thorax/around kidneys
  • Assessed: lower/base of lungs - smaller airways
  • Sounds: Low pitch

z_NUR112: Exam 2 (13 decks)

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