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NURS 2910 > Respiratory Assessment > Flashcards

Respiratory Assessment Flashcards

1
Q

Apex of lungs means

A

Top of lungs

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2
Q

Base of lungs means

A

Bottom of Lungs

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3
Q

Left lung has ? lobes

A

2 lobs (upper, lower) + cardiac notch

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4
Q

Right lung has ? lobes

A

3 lobes (upper, middle, lower)

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5
Q

Lung air sacs are the

A

Alveoli

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6
Q

the voice box is another name for the

A

pharynx

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7
Q

Airways in the body include:

A

Nasal passages, mouth, pharynx, larynx, trachea, bronchi, and bronchioles

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8
Q

The lungs sit on…

A

the diaphragm muscle

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9
Q

Ventilation is the…

A

expansion of chest, inspiration + expiration

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10
Q

Respiration is the…

A

Gas exchange, O2 in, CO2 out

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11
Q

Chemoreceptors tell…

A

tell the lungs when to breathe, they measure the O2 & CO2 levels in the body

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12
Q

Where does gas exchange occur externally

A

In the alveolar-capillary

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13
Q

Where does gas exchange occur internally?

A

In the Capillary-tissue

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14
Q

How many ribs & Intercostal spaces

A

12 ribs, 12 ICS, & 1 vertebrae

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15
Q

The lungs are symmetrical T or F

A

False

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16
Q

Mediastinum is the….

A

Space between the lungs

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17
Q

Where does gas exchange take place?

A

Alveoli

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18
Q

The primary stimulus for breathing is…

A

Carbon Dioxide(CO2)

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19
Q

The secondary stimulus for breathing is…

A

Oxygen(O2)

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20
Q

Hypercapnia refers to…

A
  • high carbon dioxide in the blood(hyperventilating)
  • Stimulates the drive to breathe
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21
Q

Infants: What impacts oxygenation

A
  • Immature lower airway, nervous system, and immune system
  • Narrow airways
  • Risk of choking
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22
Q

Children: What impacts oxygenation

A
  • Upper respiratory infections are common
  • Asthma can start & diagonsed
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23
Q

Adolescents: What impacts oxygenation

A
  • Smoking & E-cig usage occurs more often
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24
Q

Adults: What Impacts oxygenation

A
  • 15% of US adults are cigarette smokers
  • Changes in the resp. system begins in middle age and increases with age
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25
Q

Older Adults: What Impacts oxygenation

A
  • Reduced lung expansion and less alveolar inflation
  • Difficulty clearing airways> muscles are weaker
  • Declining immune response
  • Chemoreceptors respond more slowly
26
Q

Factors that impact oxygenation

A
  • Stress - Obesity
  • Allergies - Exercise
  • Air quality - Smoking
  • Altitude - Second-hand smoke
  • Temperature - Pregnancy
27
Q

Health history questions (subjective data)

A
  • Past health history - Demographic data
  • Medications - Health
  • Vaccines - Environment
  • Family history - Resp. questions
  • Smoking/vaping - Occupation
28
Q

Physical assessment (objective data)

A
  • General survey
  • Vital signs
  • Inspect
  • Palpate
  • Auscultate
  • Percussion
29
Q

What to look for in General survey

A
  • items in the room> medications, O2
  • family/ friends present
  • Alertness and orientation
  • Inspection> breathing status/ positioning
30
Q

Normal respiratory rate

A

12-20

31
Q

Eupnea

A

normal respiration rate, 12-20

32
Q

Bradypnea

A

slow respirations, <10

33
Q

Tachypnea

A

Fast respirations, <24

34
Q

Apnea

A

Absence of breathing

35
Q

Dyspnea

A

Shortness of breath

36
Q

Inspection: Face

A
  • look for signs that give us more info about the resp. system
  • breathing pattern, breathing effort, and quality
  • Pursed lips - Flared nostrils - grunting
37
Q

Inspection: position

A
  • tripod sitting, look at positioning
  • How are they positioned
38
Q

Inspection: nails/skin

A
  • cyanosis/ pallor of skin or nails
  • clubbing of nails
39
Q

Inspection: chest

A
  • chest movement
  • Anteroposterior to lateral ratio
  • Do they have barrel chest?
40
Q

Inspection: Thoracic Cage

A
  • observe the thorax with the client sitting up
  • scapulas should be symmetrical
  • straight spine
41
Q

Inspection: Posture

A
  • look for scoliosis and kyphosis
42
Q

Palpitation

A
  • Feel for lumps & masses, any pain or tenderness, crepitus, fremitus
  • watch for guarding of body due to pain
43
Q

Palpitation: expansion

A
  • Assess chest expansion
  • Place hands on the anterior chest, have client take deep breaths
  • Hands should move symmetrically
44
Q

Percussion

A
  • Percus for tone
  • place client in sitting position
  • start at the top of the lung
  • move down and outward
  • compare L and R
  • Percuss over intercoastal spaces
  • top-down in latter formation
45
Q

Percussion: Abnormal findings

A
  • Tympany(common over stomach, not lungs)
  • Dullness(over fluid or solid tissue)
  • Flatness( over muscle mass and bones)
  • Hyperresonance( can indicate trapped air)
46
Q

Auscultation

A
  • be in a quiet room
  • instruct patient to breathe slowly through their mouth
  • move stethoscope from side to side, going from top to bottom
  • listen for one full respiration in each spot
  • listen on skin directly
  • 6 spots anterior
  • 8 spots posterior
47
Q

Normal breath sounds

A
  • Bronchial: high pitched, loud
  • Bronchovesicular: moderate pitch,1:1, equal insp. & exsp.
  • Vesicular: soft, low, 3:1, insp>longer, exsp> shorter
48
Q

Adventitious(abnormal) lung sounds

A
  • Crackles
  • Wheezing
  • Pleural rub
  • Stridor
  • Grunting
49
Q

What is hypoxia?

A

Low oxygen in your tissues

50
Q

What is crepitus?

A

Crackling skin caused by air in the subcutaneous tissue

51
Q

When percussing the lung, a normal finding is…

A

Resonance

52
Q

Which lung has 3 lobes?

A

Right

53
Q

Vesticular is an abnormal breath sound T or F

A

False

54
Q

Developmental Variations: Infants

A
  • normal resp. 30-53, higher when crying
  • infants are diaphragmatic breathers
  • <6 months, obligate nose breathers
  • uneven or irregular breathing patterns
  • Chest should be smooth and round
55
Q

Developmental Variations: Toddler

A
  • until 6, immunity lower so increased risk of upper resp. infections
  • short, small airways- easily obstructed
  • put anything in mouth
  • drowning can occur in little amounts of water
56
Q

Developmental Variations: Preschool/school-age

A
  • Mature heart, lungs, circulatory system
  • Upper resp. infection resolve easier
  • increase incident of asthma
  • exposure to viruses at daycare/school
  • chest size same ratio as adults
57
Q

Developmental Variations: Older adults

A
  • Kyphosis is common
  • decreased chest expansion, ability to take deep breaths, ability to cough
  • loss of muscle
  • Declining immune system
  • chemoreceptors respond slower
58
Q

Indications of Hypoxia

A

-cyanosis of skin and nails
- pain in back
- cough green mucous
- Developmental Variations
- Pain

59
Q

Hypoxia is

A

lack of, low O2

60
Q

Normal data includes:

A
  • chest rises symmetrically
  • Spine is straight
  • No masses or tenderness
  • Lungs are resonant when percussed
61
Q

Abnormal data includes:

A
  • labored breathing
  • ICS muscles retractions
  • Sitting in tripod position
  • crackles or wheezing
62
Q

Possible education and interventions

A
  • smoking cessation
  • vaccinations
  • Avoid pollutant
  • Exercise weekly

NURS 2910 (16 decks)

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