Respiratory Flashcards
What are Accessory Organs?
- group of muscles not used during normal ventilation, but can become engaged in respiratory distress.
Muscles include:
- sternocleidomastoid
- intercostals
What are adventitious sounds?
- extra sounds considered to be abnormal (ie. crackles or wheezes)
What are Alveoli?
- tiny air sacs at the end of the bronchioles responsible for gas exchange
What is Atelectasis?
- shrunken/collapsed alveoli (usually in base of lungs) that can NOT properly inflate interfering with oxygenation and gas exchange
- caused by lack of mobility and accumulation of secretions
- nurses teach clients to perform deep breathing and coughing exercises to help open the small air sacs in the lungs, and the coughing helps to mobilize secretions
RESULT: diminished/absent sound in lungs
What are the 3 NORMAL types of breath sounds?
Bronchial
- loud/coarse breathe sound
- heard over large/wide airways (ie. trachea - loud, hollow)
- abnormal if heard elsewhere in the lungs
Bronchovesicular
- combination sound of bronchial and vesicular
- heard best in the upper airways anteriorly
Vesicular
- normal breath sounds
- heard over the majority of lung fields
- soft and breezy sound
What is a Crackle VS. Wheeze?
Crackles: sound produced by fluid or mucous in the lungs
- The cracking sound comes from the ‘popping’ open of alveoli when fluid shifts in the lungs with breathing
Wheeze: sound caused by narrowed airways
- Can occur with inspiration and/or expiration
- described as ‘musical’ in nature
What is Excursion?
- measured by placing the hands over the lower rib cage posteriorly and noticing if the movement of the ribs outward and back with breathing is symmetrical
What is a Friction Rub?
- coarse sound cause by the rubbing together of the layers of the pleura around the lungs
- due to inflammation or loss of fluid between layers
- Friction rubs cause clients pain
What are Intercostal Spaces?
- spaces/muscles between the ribs
- used for landmarking
What is Kyphosis?
- outward curvature of the upper part of the thoracic sine
What is a Tripod Position?
- a position that involves arms/hands on knees with the head bent down
- used when an individual is having difficulty breathing
Types of Questions that can be asked during a Resp Assessment (using OLDCARTSS)
○ Onset: When did you first notice the symptoms?
○ Location: Where do you feel the pain?
○ Duration: Does it come and go or is it there all the time?
○ Characteristics: Can you describe how the rib pain feels? What does the sputum (phlegm) look like?
○ Aggravating Factors: Does anything make the cough or pain worse?
○ Relieving Factors: Have you found anything that helps?
○ Timing: Does the cough tend to improve or worsen throughout the day?
○ Severity: How would you rate the rib pain on a scale of 1-10?
○ Self-Perception: Do you have ideas about what is happening? Have you experienced this?
Upon inspection, a client who is poorly oxgenated…
- may exhibit signs of decreased level of consciousness such as sedation, agitation, restlessness, or even confusion
The nurse would inspect:
- for colour changes in the skin such as cyanosis (lips, nail beds, earlobes) or pallor
- observe rate/rhythm/depth/effort of respirations
- note signs of respiratory distress
What are the signs of respiratory distress?
- using accessory muscles (scalene, sternocleidomastoid - located in the neck/shoulder area)
- irregular rhythm
- fast/slow rate,
- noisy breathing
- diaphoresis
- tripod position
- cannot speak in full sentences without pausing to breathe
- panicked look/eyes
- nasal flaring
- pursed lip breathing
- low SpO2
What are the 3 different classifications of Cyanosis?
1) Perioral cyanosis: blue discolouration between upper lip and nose.
2) Central cyanosis: not in an extremity/limb.
3) Peripheral Cyanosis: located in the distal fingers of the upper limbs
What is Palpitation used for?
- assessing excursion (measures symmetry of chest wall movement when the client inhales/exhales)
- locating landmarks for auscultation
- More advanced palpation includes assessment of tactile fremitus or subcutaneous crepitus on the chest
- Intercostals (ribs) and the intercostal spaces between them are not necessarily palpable
- Mid-axillary, anterior axillary, and posterior axillary lines are also important landmarks to palpate
What are the 7 “imaginary lines” of the anterior and posterior thorax to help nurses place their stethoscopes?
- Sternal Line
- Right and Left midclavicular line
- Right and Left Anterior axillary line
- Right and Left Mid-axillary line
- Right and Left posterior axillary line
- Right and Left Mid-scapular line
- Vertebral Line
**there us variation in the shape/size of thorax **
What are the 3 adventitious breath sounds?
- Crackles
- popping sounds, usually caused by fluid/mucous in the lungs
- popping sound is alveoli shifting their position with each inhale/exhale - Wheeze
- High pitched, ‘musical’ sounds
- caused by narrow airways due to inflammation, hardened lung tissues, seen in Asthma, COPD - Friction Rub
- Harsh/coarse sound, usually short as pain accompanies this condition
- Caused by inflammation in the lining of the lungs (pleural space shrinks and 2 layers tub together causing pain)
What are the Risk Factors that Negatively Affect Respiratory Health?
- Smoking
- Allergies
- Pollution
- Hot/humid environment
- Second/third hand smoke
- Other inhaled substances
- History of lung disease
- Dust
- Stress
What elements of health that contribute to the respiratory system should nurses consider?
- Genetics/family history, lifestyle, personal habits, and the environment
- Lifestyle habits (ie. Smoking)
- the effects of the social determinants of health on individuals/families.
○ Assessing these while is how nurses understand what is within the client’s control and what is not.
○ Preventing illness and promoting health is meaningless if the client/family’s context is not at the centre of their own care plan.
Who is most at risk for respiratory compromise?
- clients who are ill/IMMOBILE, and post-op clients
- When clients are immobile, the lungs cannot expand as they normal would, secretions accumulate, and the risk for pneumonia increases
- 1 of the major causes of immobility in hospitals is clients who have undergone surgery
- nurses must monitor post-op clients carefully for signs of respiratory compromise
What are the 6 Nursing interventions to prevent complications for clients at risk for respiratory complications post-operatively?
- Preforming respiratory assessment as ordered, and as needed (PRN), based on clinical judgment
- Document findings to track improvement/deterioration promptly
- Teaching deep breathing and coughing exercises, reinforcing the practice ever 1-2 hours until mobile
- Mobilizing clients out of bed at the earliest opportunity, taking walks
- Changing the clients position often if they can not move/ambulate themselves
- Assist clients out of bed and into a chair for short periods throughout the day (ie. For meals)
What is involved in the Health Promotion aspect of an assessment?
- inquire about health promoting behaviours
- provide positive feedback and encouragement to support their effort.
- assess their understanding of how their risk factors, lifestyles, and other choices impact their respiratory health.
- introduce strategies for exploring new health promoting behaviours, reducing harmful behaviours (always remember that clients will make decisions that are best for themselves)
- Any discussion about health promotion that does not include the client’s SDoH’s are not relevant or meaningful.
- provide the most complete information possible so the client can make an informed choice
Which Factors should nurses emphasize with their clients to promote respiratory health?
- Being physically active
- Not smoking, QUITTING smoking
- Expanding the lungs with deep breathing
- Wear PPE when exposure to harmful inhalants is a risk
- Immunizations
- Hand hygiene to reduce the spread of infection
- Healthy diet to support the immune system
- Protecting infants/children/older adults from respiratory illness (eg. RSV)
