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N1180 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are Accessory Organs?

A
  • group of muscles not used during normal ventilation, but can become engaged in respiratory distress.

Muscles include:
- sternocleidomastoid
- intercostals

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2
Q

What are adventitious sounds?

A
  • extra sounds considered to be abnormal (ie. crackles or wheezes)
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3
Q

What are Alveoli?

A
  • tiny air sacs at the end of the bronchioles responsible for gas exchange
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4
Q

What is Atelectasis?

A
  • 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

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5
Q

What are the 3 NORMAL types of breath sounds?

A

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

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6
Q

What is a Crackle VS. Wheeze?

A

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

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7
Q

What is Excursion?

A
  • 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
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8
Q

What is a Friction Rub?

A
  • 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
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9
Q

What are Intercostal Spaces?

A
  • spaces/muscles between the ribs
  • used for landmarking
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10
Q

What is Kyphosis?

A
  • outward curvature of the upper part of the thoracic sine
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11
Q

What is a Tripod Position?

A
  • a position that involves arms/hands on knees with the head bent down
  • used when an individual is having difficulty breathing
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12
Q

Types of Questions that can be asked during a Resp Assessment (using OLDCARTSS)

A

○ 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?

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13
Q

Upon inspection, a client who is poorly oxgenated…

A
  • 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

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14
Q

What are the signs of respiratory distress?

A
  • 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
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15
Q

What are the 3 different classifications of Cyanosis?

A

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

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16
Q

What is Palpitation used for?

A
  • 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
17
Q

What are the 7 “imaginary lines” of the anterior and posterior thorax to help nurses place their stethoscopes?

A
  1. Sternal Line
  2. Right and Left midclavicular line
  3. Right and Left Anterior axillary line
  4. Right and Left Mid-axillary line
  5. Right and Left posterior axillary line
  6. Right and Left Mid-scapular line
  7. Vertebral Line

**there us variation in the shape/size of thorax **

18
Q

What are the 3 adventitious breath sounds?

A
  1. Crackles
    - popping sounds, usually caused by fluid/mucous in the lungs
    - popping sound is alveoli shifting their position with each inhale/exhale
  2. Wheeze
    - High pitched, ‘musical’ sounds
    - caused by narrow airways due to inflammation, hardened lung tissues, seen in Asthma, COPD
  3. 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)
19
Q

What are the Risk Factors that Negatively Affect Respiratory Health?

A
  • Smoking
  • Allergies
  • Pollution
  • Hot/humid environment
  • Second/third hand smoke
  • Other inhaled substances
  • History of lung disease
  • Dust
  • Stress
20
Q

What elements of health that contribute to the respiratory system should nurses consider?

A
  • 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.
21
Q

Who is most at risk for respiratory compromise?

A
  • 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
22
Q

What are the 6 Nursing interventions to prevent complications for clients at risk for respiratory complications post-operatively?

A
  1. Preforming respiratory assessment as ordered, and as needed (PRN), based on clinical judgment
  2. Document findings to track improvement/deterioration promptly
  3. Teaching deep breathing and coughing exercises, reinforcing the practice ever 1-2 hours until mobile
  4. Mobilizing clients out of bed at the earliest opportunity, taking walks
  5. Changing the clients position often if they can not move/ambulate themselves
  6. Assist clients out of bed and into a chair for short periods throughout the day (ie. For meals)
23
Q

What is involved in the Health Promotion aspect of an assessment?

A
  • 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
24
Q

Which Factors should nurses emphasize with their clients to promote respiratory health?

A
  • 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)
25
Q

What are the lifespan considerations for Infants?

A
  • breath sound auscultated in infants is bronchovesicular (small bodies, compact).
  • The best time to auscultate an infant’s lungs is when they are asleep and warm (lungs cannot be auscultated easily on a crying baby)
  • Infants are abdominal breathers naturally, shift to intercostal breathing after age 2
  • It is NORMAL for infants’ respirations to be IRREGULAR
  • Apneic episodes in infants are normal but must not exceed 15 second.
  • Infants are nose-breathers naturally, congestion/mucous can make it difficult to breathe
26
Q

What are 3 Respiratory Considerations for a Pregnant Women?

A

1) A woman’s tidal volume (the amount of air that moves in or out of the lungs with each respiratory cycle) increases to accommodate the fetus’s oxygen requirements

  1. In late pregnancy, the diaphragm rises and the costal angle increases to accommodate the growing uterus
  2. In later pregnancy, the diaphragm displaces
    - why pregnant clients report fatigue and feeling out of breath with minimal exertion
27
Q

What are 3 Respiratory Considerations for Older Adults?

A
  1. Alveoli fibrose (walls thicken) with age resulting in a decreased surface area for gas exchange.
  2. Lung capacity decreases due to muscle weakness and decreased elasticity
  3. The thoracic spine curves outward (kyphosis) which can appear as a ‘hump’ on the upper back (teenagers experience this too).
28
Q

What is Perfusion?

A
  • Tissues are properly perfused if they receive adequate blood flow, and the blood contains the oxygen and nutrients that the tissues need.
  • nurses test perfusion by performing capillary refill assessment.
    * If the peripheral tissues are not perfused, the cap refill time will be longer than the normal 1-3 seconds, the fingers may be cool/cold, there may be cyanosis present on the nail beds, etc.
29
Q

Diffusion VS. Ventilation

A

Diffusion - the movement of oxygen and carbon dioxide between the alveoli in the lungs and bloodstream.

Ventilation - (technical term for breathing)–refers to air moving in and out of the lungs.

N1180 (13 decks)

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