Respiratory Assessment Flashcards
Functions of Respiratory System
- Ventilation
- Diffusion
- Perfusion
Ventilation
- Air going in
- Air coming out
Diffusion
- Gas exchange
- At capillaries
- Movement of O2/CO2
Perfusion
- Oxygenated red blood cells
- Get to tissue
- Delayed capillary refill
Anterior Respiratory Muscles
- Sternocleidomastoid
- Scalenus
- Pectoralis minor
- External intercostal
- Abdominal rectus
Accessory Muscles Definition
- Additional muscles used for breath
- Outside normal respiration muscles
- Sign of respiratory distress
- Must document
Posterior Respiratory Muscles
- Trapezius
- Internal intercostal
- Diaphragm
Asthma Triggers
- Pollen
- Bugs
- Chemical fume
- Cold air
- Fungus spores
- Dust
- Smoke
- Strong odors
- Pollution
- Ager
- Stress
- Pets
- Exercise
Challenges to Respiratory System
- Asthma
- Smoking (1st, 2nd, 3rd)
- Environment
Environmental Factors
- Home
- Occupational
- Travel
3rd Hand Smoking
Smell lingering on walls/clothes
Subjective Data Collection
- Cough
- Dyspnea (SOB SOBOE)
- Chest pain
- Past medical history
- Family history
- Self-care activities
- Lifestyle
- Exercise levels
- Allergies
- Immunizations
- Determinants of health
Cough
- Inquire about mucus
- Colour
- Blood
- Odor
- Consistency (thick/thin)
- Quantity
SOB
- Shortness of breath
SOBOE
- Shortness of breath on exertion
Chest Pain
- Rib pain
- Stiff intercostal muscle
- Inflamed lung tissue
- CV/respiratory
Chest Pain Objective Data
- Inspection
- Chest x-ray
Irregular Findings of Chest Pain
- Irregular breathing
- Cyanosis
Palpation of Chest Pain
- Chest tenderness
- Chest excursion
- Tactile fremitus
Anterior Stethoscope Placement
- Mid clavicular line
- 2nd intercostal space
Posterior Stethoscope Placement
- C7
- Down 2 inches
- Left 2 inches
Chest Tenderness Areas
- Sternum
- Paravertebral muscles
- Point tenderness
Abnormal Findings in Chest
Crepitus (air in subcutaneous tissue)
Indicators of Emergency
- Dyspnea
- Decreased consciousness level
- Respiration rate 30+
- SpO2 <92
Respiratory Assessment Health Promotion
- Avoid smoking
- Occupational exposure to irritants
- Recreational drugs
- High risk travel
Common Symptoms of Respiratory
- Chest pain
- Dyspnea
- Orthopnea
- Cough
- Mucus
- Wheezing
- Change in functional ability
Auscultation Landmarks
- Suprasternal notch
- Angle of Louis (sternal)
- Costal angle
- Scapular, clavicular, axillary lines
- Cervical vertebra 7
Normal Auscultation Sounds
- Bronchial
- Vesicular (most common)
- Bronchovesicular
Abnormal Auscultation Sounds
- Diminished
- Absent
- Friction rub
- Crackles
- Wheezes
Bronchial Sound Characteristics
- Loud, hollow
- High pitched
- Distinct pause between in & exp
- In to exp 1:2
Vesicular Sound Characteristics
- Soft
- Low pitched
- Rustling inspiration
- Softer during expiration
- Majority of lung sounds
- In to exp 3:1
Bronchovesicular
- High pitch
- Mid chest
- In to exp 1:1
Fine Crackles
- Brief, discontinuous
- Popping
- High pitched
- Atelectasis
Course Crackles
- Brief, discontinuous
- Popping
- Louder & longer than fine crackles
- Low pitch
- Pneumonia
Friction Rub
- Low pitched
- Short, grating
- Inflammation of pleural surface
Promoting Respirations & Oxygenation
- Lung expansion
- Stasis of secretions
- Maintain airway
- Adequate O2/CO2 exchange
Alveoli
- Shrivel & deflate with immobility
- Gas exchange
- Air sacks
- Keep inflated
- Remove mucus
- Deep breathing & coughing exercises
Infants
- Nose breathing
- Bronchovesicular sounds heard
- Primarily abdominal
Bradycardia in Premature Babies
- Slow heartbeat
- Low blood oxygen
Apnea in Premature Babies
- Stopped breathing
- Low blood oxygen
Children Under 2 years
- Bronchovesicular sounds
- Irregular rhythm
- Breath from abdomen
- Abnormal respirations
- Apnea 15 seconds max
- Listen to apical (no radial)
Children Over 2
- Intercostal breathing
Pregnancy
Increase tidal volume
Later Pregnancy
- Out of breath regularly
- Diaphragm rises
- Costal angle widens
Elderly People Lungs
- Fibrose alveoli
- Decreased surface area for gas exchange
- Decrease lung capacity
- Muscle weakness
- Less elasticity
- Kyphosis (barrel chest)
