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Nursing 6410 - Health Assessment > Respiratory Assessment > Flashcards

Respiratory Assessment Flashcards

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1
Q

Where does the trachea split? And where can tracheal sounds be heard?

A

T4 vertebrae the trachea splits into the left and right bronchus. Breath sounds heard at bottom cervical spine.

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2
Q

Diaphragm

A

Moves down and pressure increases during inspiration and moves up and decreases pressure during expiration. Negative pressure during inspiration.

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3
Q

Right lobe of lungs

A

Contains three lobes contains right oblique fissure and horizontal fissure. Right upper, middle and lower lobe

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4
Q

Left lobe of lungs

A

Contains two lobes left upper and left lower with one oblique fissure separating the lobes.

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5
Q

Lower border of lungs

A

Normally found on T10, but during inspiration, moves down to T12

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6
Q

Pneumonia is most commonly found it what lobes?

A

Middle and lower

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7
Q

When documenting, be sure to indicate location of sounds.

A

Crackles heard at posterior axillary line at 6th ICS

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8
Q

HPI

A

Coughing - ACE?
Onset/duration - w/ fever could be infection (without fever could be foreign body, inhaled irrittant)
Nature of cough - frequency, regularity, pitch, loudness, quality, circumstances
Sputum production
Sputum character - bloody could be viral infection
Pattern - regular cough may be pertussis
Severity
Associated symptoms
Efforts to treat

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9
Q

HPI: SOB

A 
Onset/duration
Pattern
Position most comfortable, pillows used
Related to exercise, certain activities, time of day, eating 
Harder to inhale or exhale 
Severity 
Associated symptoms
Efforts to treat
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10
Q

HPI: Chest Pain

A 
Palpatable? Bone/Muscle 
Onset and duration - no radiation? constant  achiness? Fleeting, needle-like jab? Situated in shoulders
Associated symptoms
Effort to treat 
Medications (recreational?)
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11
Q

PMHx

A

Thoracic trauma or surgery, dates of hospitalization for pulmonary disorders
Use of CPAP, BiPAP or home oxygen
Chronic pulmonary diseases
Other chronic disorders
Testing
Immunization against Strep pneumoniae and influenza

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12
Q

FHx

A 
TB
CF
Emphysema (smokers)
Allergies, asthma, atopic dermatitis 
Malignancy (solid mass in lungs)
Bronchiecstaiss 
Bronchitis 
Clotting disorders
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13
Q

What increases clotting risk

A

Sedentary lifestyle
Birth control (women older than 35 should not be on birth control)
Smoking
Positive homon sign may be DVT

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14
Q

Personal and Social Hx

A 
Employment (landscaping, miner)
Home environment 
Tobacco or VAPOR use
Exposure to infections like TB or flu
Nutrition 
Use of herbal or other remedies 
Travel exposure
Hobbies
alcohol or drugs 
Exercise
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15
Q

What is walking pneumonia?

A

Patch pneumonia all over lungs

common in younger

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16
Q

Older Adults

A

Increased risk of exposure and frequency (Hx of vaccines)
Weather effects on respiratory efforts and infection occurrence
Immobilization and sedentary habits
Dysphagia
Altered activities from respiratory symptoms

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17
Q

What should be emphasized in older adults?

A 
Smoking hx
Cough 
Dyspnea on exertion 
Fatigue
Weight changes 
fever and night sweats
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18
Q

Infants and Children

A 
Low birth weight and prematurity
Coughing and sudden SOB (aspiraton)
Possible ingestion of aerosols/household cleaners
Apneic episodes
Swallowing dysfunction (GERD)
Hx of vaccienes
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19
Q

Sound travels best through what medium?

A

Solid > liquids > gas
Solid objects (mucus, phlegm or others) in the lungs allow for enhanced sounds
Lower sound means only air

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20
Q

Observing Respirations

A

Inspect chest wall for movement
Symmetry
Retractions = concave at sternum, between ribs and suprasternal notch, above clavicles and lowest costal margins (using accessory muscles)
Suggestive of obstruction to inspiration

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21
Q

Tripodding

A

Leaning forward, uses sternocleidomastoid and clavicles to support breathing

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22
Q

Paradoxic breathing

A

On inspiration, lower thorax is drawn in, and on expiration, the opposite occurs

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23
Q

Inspection

A 
Shape and symmetry 
Chest wall movement
Superficial venous patterns
Prominence of ribs
Anteroposterior vs transverse diameter (Barrel chest)
Sternal protrusion (pidgeon chest)
Spinal deviation (scoliosis)
Funnel chest (pectus excavatum)
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24
Q

Inspection of peripheries

A 
Clubbing
Odor on breath
Cyanosis or pallor of skin, nails and lips
Pursed lip breathing 
Flaring of nostrils (more so in infants)
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25
Q

Inspection of Respiration

A

Rate
Quality
Pattern
Count rate

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26
Q

Palpation

A 
Pulsations
Tenderness
bulges and depressions
Masses
Unusual movement or positions
Elasticity of rib cage
Immovability of sternum 
Ridgidity of thoracic spine 
Crepitus
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27
Q

Thoracic Expansion

A

Look for loss of symmetry in the movement of the thumbs suggest a problem on one or both sides

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28
Q

Tactile Fremitus

A

Palpable vibrations of the chest wall that results from speech or other verbalizations
Use balls of hand and go side to side. Increased vibrations means obstruction in lungs. Easier posterioryl and underarm
Check for pleurisy

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29
Q

Respiratory excursion

A

Thumbs connected on posterior to see thumb movement

30
Q

Tracheal deviation

A

Take a deep breath. Is the trachea midline?
Thyroid enlargement or pleural effusion
Pneumothorax
Tumors

31
Q

Percussion

A

Percuss anterior, posterior and lateral
Compare tones bilaterally
Measure diaphragmatic excursion (3-5cm) Usually higher in right lobe because of liver
Dullness over lungs may be tumor or phlegm

32
Q

Percussion sounds

A

Palpate with hand hyperextended to use finger tips instead of finger pads
Resonance is normal and hyperressonance is normal in lower lobes of lungs
Dullness means obstruction

33
Q

Anterior percussion sounds

A

Flatness over heavy muscles and bones
Resonance over lungs
Dullness over cardiac, liver
Tympany over stomach

34
Q

Percuss for diagphragmatic excursion

A

T10-T12 is diaphragm
Measure distance diaphragm travels during inspirational hold and expirational hold
Should be between 2-4cm

35
Q

Auscultation

A 
Intensity 
Pitch 
Quality 
Duration
use diaphragm
36
Q

What are breath sounds

A

Length of inspiration vs expiration
wheezes, crackles
Should be same on both sides

37
Q

Vesicular breath sounds

A

3:1 (adults)

Low=pitched, low-intensity heard in healthy lungs

38
Q

Bronchovesicular

A

1:1 (Children)
Heard over major bronchi and are typically moderate in pitch and intensity
Middle of lungs

39
Q

Bronchial/trachial

A

Highest in pitch and intensity

Heard over trachea (1:1)

40
Q

When are bronchovesicular and bronchial considered abnormal?

A

When heard over peripheral lung tissue of adults

41
Q

Adventitious breath sounds

A 
Crackles (formerly called rales) more common on inspiration
POS for pneumonia 
Discontinuous sound heard on inspiration
Fine: high pitched, short in duration 
Coarse: low pitched, longer in duration
42
Q

Rhonchi (snorous weezes)

A

deeper, rumbling, pronounced on expiration, prolonged continuous
Airway obstructed by secretions, muscular spasm, new growth or external pressure
Expiratory wheeze = asthma

43
Q

Wheezes

A

Continuous, high-pitched, musical sound (almost whistle) heard on inspiration and expiration
High-velocity air flow through narrow or obstructed airway
Bronchospasm, or acute or chronic bronchitis

44
Q

Friction Rub

A

Pleural inflammation
Outside respiratory tree
Dry, crackle, grating, low-pitched, heard on both inspiraiton and expiration
Caused by inflammed, roughened surfaces rubbing together
Friction rub of heart is continuous

45
Q

Equal breath sounds

A

may be a sign of infiltration or obstruction

46
Q

Patterns of Respiration

A

Tachypnea - restrictive lung dx, pain, sepsis, obesity, anxiety, fever (faster than 20 breaths/min)
Bradypnea - CNS depression, tissue damage, diabetic coma (<12 breaths per min)

47
Q

Hyperpnea

A

Metabolic acidosis, pain, anxiety, hypoxia or hypoglycemia if comatose
>20 breaths per min, deep breathing
Hypopnea - shallow breaths

48
Q

Kussmaul

A

DKA

Rapid, deep, labored

49
Q

Cheyne-Stokes

A

CHF, Kidney failure, CNS damage, normal in sleep and elderly and children
Periods of increasing depth with apnea

50
Q

Biot’s

A

Severe CNS damage

Irregularly interspread periods of apnea in a disorganized sequence of breaths

51
Q

Adventitious Breath Sounds

A

Fine Crackles - discontinuous, heard during inspiration
Medium Crackles - moist sound heard mid inspiration
Coarse - loud and bubbly
Rhonchi - loud, low, coarse sounds during both phases

52
Q

Vocal Sounds

A

Egophony - say “eee” same as bronchophony
Bronchophony - stethescope over consolidated area (say a phrase to listen for muffles) Non-muffled sound is obstruction
Whispered Pectoriloquy - whisper instead

53
Q

Vocal Resonance

A

Diminishes and loses intensity when there is loss of tissue in respiratory tree (barrel chest of emphysema)
Classify as bronchophony, pectoriloquy and egophony

54
Q

Peak Flow

A

Deep breath in and forced expiration to test asthma
Measured by age/gender and height
Find expected, measured and actual peak flow
This check expiratory volume

55
Q

A&P of Respiratory

A

Sternum, manubrium, xiphoid process, costal cartilage, 12 pairs of ribs and 12 thoracic vertebrae
Ribs 11 and 12 are floating ribs
Lung apex is found about 4cm above first rib

56
Q

Increased AP diameter in adults d/t

A

loss of muscle strength in thorax and diaphragm
loss of lung resiliency - trapped air can lead to inflation of lungs
Air trapping = prolonged but ineffcient expiratory effort
dorsal curve of thoracic spine
stiffening, decreased expansion of chest wall

57
Q

Dry cough

A

nonproductive?

Could be cardiac problem, allergeis, GERD, with pharyngeal irritation

58
Q

Pain from Cocaine

A

Acute, severe?

Can cause tachycardia, HTN, coronary artery spasm (with infarction) and pneumothorax

59
Q

Causes of tachypnea

A

broken rib or pleurisy

liver enlargement, abdominal ascites

60
Q

Causes of bradypnea

A

neurological/electrolyte imbalance
infection
irritative pneumonia
cardiorespiratory fitness

61
Q

Depth and rate of breathing increases with

A 
acidosis 
CNS lesions (pons)
anxiety 
aspirin poisoning 
Hypoxemia 
Pain
62
Q

Depth and rate of breathing DECREASES with

A 
metabolic alkalosis
CNS lesions (cerebrum)
Myasthenia gravis 
Narcotic overdose 
Obesity (extreme)
63
Q

Chest asymmetry

A

Unequal expansion and respiratory compromise
D/t collapsed lung, extrapleural fluid or air or mass
Unilateral or bilateral bulging caused by obstruction
Prolonged exp c bulging could be airway outflow obstruction or compression d/t tumor,aneurysm,enlarged heart
Costal angle widens above 90 degrees

64
Q

Retractions in chest

A

Usually an inspirational obstruction
Muscles pull back in an effort overcome blockage on inspiration.
Obstruction high in the respiratory tree; breathing is characterized as stridor
Paradoxic breathing causes abdomen to be drawn in during inspiration d/t to weakened diaphragm, OAD, or during sleep

65
Q

Foreign body in bronchus (usually right side)

A

Causes unilateral retraction, but suprasternal notch is not involved.
Retraction of lower chest occurs with asthma and bronchiolitis

66
Q

Airway Patent or Obstructed

A

Obstructed when there is inspiratory stridor, hoarse cry or cough, flaring of nostrils, retraction at suprastern
Severely when: stridor is both insp and exp, cough is barking, retractions also involve subcostal and intercostal spaces, cyanosis is obvious

67
Q

When obstruction is above the glottis

A 
Stridor tends to be quieter
Voice is muffled 
Swallowing is difficult
Cough is not a factor
Head and neck awkwardly positioned to preserve airway. Could be an abscess
68
Q

Obstruction below glottis

A 
stidor tends to be loud and raspy
voice is hoarse
swallowing is not affected 
cough is harsh, barking
positioning of head is not a factor
69
Q

Hyperresonance of lungs

A

pneumothorax, emphysema, asthma

70
Q

Expected findings in lungs

A

On inspection - symmetry, absence of retractions
Palpation - Midline to trachea without tug, symmetric, unaccentuated tactile fremitus
Percussion - range of 3-5cm, resonant and symmetric percussion notes
Auscultation - absence of adventitious breath sounds
Vesicular breath sounds, except for bronchovesicular sounds beside the sternum, or in areas of larger bronchi

Nursing 6410 - Health Assessment (16 decks)

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