Respiratory Assessment Flashcards
What does the pulmonary system consist of
the airway and lungs
What does the airway consist of
nasal passages, mouth, pharynx, larynx, trachea, bronchi, and bronchioles
What is the function of the airway
to moisten, warm, and filter the air
What do the lungs contain
the apex, base, and alveoli
How many lobes does the right lung have and what are they
3
Superior/upper, middle, inferior/lower
How many lobes does the left lung have and what are they
2
superior/upper, inferior/lower
What does the left lung have that the right lung doesn’t
the cardiac notch (makes space for the heart)
Where are the lower lobes heard best
posterior
What does inhalation do
draws air in through the mouth and nose, expands the chest cavity and lungs, creates a negative pressure
What anatomy does inhalation use
diaphragm, intercostal muscles, pleural membrane
What does exhalation do
relaxes diaphragm and intercostal muscles, returning the lungs and chest to a normal size
Respiration
gas exchange within the lungs
How does gas exchange happen and where
occurs in the alveoli, O2 goes to the blood which carries O2 to the body, and CO2 is brought back to the alveoli to be breathed out
What is external respiration
alveolar –> capillary
What is internal respiration
capillary –> tissues
What do chemoreceptors do
measure the CO2 and O2 concentrations in our blood
Primary stimulus
measure increased levels of CO2 (hypercapnia)
Secondary stimulus
measure low levels of O2 (hypoxia)
Ventilation
the mechanical act of breathing
Thorax
the area of the body between the neck and abdomen containing the heart and lungs
Trachea
where air is transported through and is lined with mucous membranes and cilia
Mediastinum
the area between the lungs that contains the heart and great vessels
What is the pathway of air
trachea –> bronchus –> bronchiole –> alveoli
What are the respiratory assessment interview questions (10)
health history, medications, vaccines, family history, allergies, smoking, occupation (exposure to chemicals), demographic data, respiratory, environmental
Factors that influence oxygenation (9)
stress, allergies, air quality, altitude, temperature, pregnancy, obesity, exercise, smoking
How do allergies effect the respiratory system
cause inflammation to the nasal passage
How does air quality affect the respiratory system
trigger respiratory problems
How does the temperature affect the respiratory system
cold temperatures require the air to be moistened
How does pregnancy affect the respiratory system
increase the need of oxygen
How does exercise affect the respiratory system
increase metabolic demand
How does smoking affect the respiratory system
chemicals block airways and kill hairs, and decrease elasticity
What signs do the face give about respiratory status (4)
breathing effort and quality, pursed lips (abnormal), flared nostrils (abnormal), grunting (abnormal)
What signs does body position give about respiratory status (2)
client should be sitting up relaxed, tripod position (abnormal)
What signs do skin and nails give about respiratory status (2)
cyanosis is a sign of hypoxia (abnormal), clubbing indicates long term hypoxia (abnormal)
What signs does the chest give about respiratory status (4)
Breathing appears effortless, retractions (abnormal), accessory muscle use (abnormal), 1:2 anteroposterior to lateral ratio (equal in infants)
What signs does the thorax give about respiratory status (4)
scapula should be symmetric, shoulders at equal positions, straight spine, midline and straight sternum
Scoliosis
spine deviates laterally
Kyphosis
increased curve of the thoracic spine
What signs does palpation give about respiratory status (2)
lumps/masses (abnormal), pain/tenderness (abnormal)
Crepitus
air trapped under skin, feels like crackling when you touch skin
Fremitus
vibration that can be felt across the lung field
What does increase vibration in the lungs indicate
extra fluid
How to measure expansion of the lungs
place hand on anterior chest wall with thumbs pointed towards xiphoid process/place hands on posterior chest wall at T9 or T10
Thumbs should move apart symmetrically 5-10 cm
What do you percuss when you percuss the lungs and where
tone
over intercostal spaces
Resonance
the tone heard over normal lung tissue
How do you auscultate the lungs
instruct client to breathe slowly through their mouth, move stethoscope from side to side, compare sounds bilaterally, listen for one full respiration in each spot
Developmental variations in infants (6)
Immature lower airway/nervous system/immune system, narrow airways, breathe out of nose only until 6 months, diaphragmatic breathers (check rr in stomach until 1), normal rr=30-53, chest sound is smooth and round
Developmental variations in children (4)
upper respiratory infections are common, asthma presents, short/small airways, drowning in small amounts of water
Developmental variations in school-aged (3)
mature heart/lungs/circulatory system, URIs resolve easily, asthma
Developmental variations in older adults (7)
reduced lung expansion/less alveolar inflation, difficulty clearing airways because of weak muscles, declining immune response, chemoreceptors respond more slowly, kyphosis is common, loss of skeletal/accessory muscles and elasticity, calcification of cartilage,
What are the normal lung sounds (3)
bronchial, bronchovesicular, vesicular
Describe bronchial lung sounds
high pitched and harsh, short during inspiration and long during expiration
Describe bronchovesicular lung sounds
moderate pitch and amplitude, same length during both inspiration and expiration (1:1)
Describe vesicular lung sounds
low, breezy, and soft, expiration is shorter than inspiration, heard best on bases and periphery of lungs
What are the adventitious breath sounds (3)
crackles, wheezing, pleural rub
Describe crackle lung sounds
caused by fluid in small airways or atelectasis, intermittent popping sounds
Describe wheezing lung sounds
caused by air moving through narrowed airways, heard continuously on inspiration or expiration
sounds like a whale
Describe pleural rub lung sounds
low pitched dry grating sound, caused by restricted air flow or due to body type
sounds like rubber rubbing together
What is a normal rr rate
12-20 breaths per minute
What is normal rr rate called
eupnea
What is a normal oxygen saturation
95-100
Bradypnea
slow respirations, <10 per minute
Tachypnea
fast respirations >24 per minute
Apnea
absence of breathing
hypoxia
low oxygen in tissue
hypoxemia
low oxygen in blood
tympany
high, drum like sound
common over the stomach
dullness
present over fluid or solid tissue
flatness
heard over muscle mass or bones
hyperresonance
overly-resonant sounds, can indicate trapped air
What are some nursing interventions to support and maintain adequate oxygenation
end smoking, vaccinations, avoid pollutant, exercise weekly
What does hyperventilation cause
a decrease of CO2 in the body
