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Nursing 1J02 > Respiratory Assessment > Flashcards

Respiratory Assessment Flashcards

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1
Q

crackles (rales)

A

popping sounds heard on auscultation of the lung when air enters diseased airways and alveoli; occurs in disorders such as bronchiectasis or atelectasis and heard likely w/ inspiration in the lower lungs

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2
Q

wheezes

A

continuous high-pitched whistling sounds produced during breathing

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3
Q

friction rub

A

a coarse, grating, adventitious lung sound heard when the pleurae are inflamed

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4
Q

apnea

A

absence of breathing

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5
Q

cyanosis

A

a bluish discolouration of the skin resulting from poor circulation or inadequate oxygenation of the blood

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6
Q

inspiration

A

breathing in

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7
Q

expiration

A

breathing out

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8
Q

hypoventilation

A

ventilation of the lungs that does not fulfill the body’s gas exchange needs

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9
Q

hyperventilation

A

increased rate and depth of breathing

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10
Q

bradypnea

A

abnormally slow breathing

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11
Q

dyspnea

A

difficult or labored breathing

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12
Q

hypoxia

A

deficiency in the amount of oxygen reaching the tissues

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13
Q

vesicular breath sounds

A

soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue; inspiratory > expiratory

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14
Q

bronchial breath sounds

A

loud, high-pitched, hollow sounds normally heard over the trachea and the large bronchi

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15
Q

bronchiovesicular breath sounds

A

medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration = expiration

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16
Q

what are the anterior thoracic landmarks?

A

suprasternal notch, sternum, sternal angle, costal angle, Angle of Louis

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17
Q

what are the posterior thoracic landmarks?

A

vertebral prominens, spinous processes, inferior border of the scapula (at 7th or 8th rib), and the 12th rib

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18
Q

what does the mediastinum contain?

A

esophagus, trachea, heart, great vessels

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19
Q

lung apices

A

above clavicle and first rib, through superior thoracic aperture

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20
Q

lobes of the lungs

A

anterior (mainly upper and middle lobe), posterior (mainly lower lobe), and lateral

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21
Q

components of the tracheal & bronchial tree

A

trachea, bronchi, cilia and goblet cells, alveoli and alveolar ducts which create large SA for gas exchange

22
Q

what are the four functions of respiration?

A

O2 delivery, CO2 removal, homeostasis/acid-base balance, maintaining heat exchange

23
Q

how is respiration controlled?

A

main drive to breath is hypercapnia, inspiration is active movement (diaphragm and rib elevation) and expiration is passive recoil of lungs, abdomen and thorax

24
Q

anterior reference lines

A

midsternal, midclavicular, anterior axillary

25
Q

posterior reference lines

A

vertebral, scapular

26
Q

lateral reference lines

A

posterior, andterior and midaxillary lines

27
Q

respiratory system: developmental considerations for infants and children

A

surfactant produced continuously at 32 wks, vulnerability related to small size and immaturity of pulmonary system

28
Q

respiratory system: developmental considerations for pregnant women

A

enlarging uterus elevates diaphragm, decreases vertical cafe, compensated by increase in horizontal diameter

29
Q

respiratory system: developmental considerations for older adults

A
  • lungs more rigid + harder to inflate
  • decrease in VC
  • increase in RV
  • decrease in # alveoli
  • increased shortness of breath on exertion
  • above changes mean increased risk for postoperative complications
30
Q

preventable risk factors for respiratory disease

A

tobacco, smoke, poor air quality

31
Q

what can prenatal tobacco lead to?

A

low birth weight, chronic hypoxia

32
Q

questions to ask on a focused respiratory health history

A

cough, SOB, chest pain, history of resp. infections, past history of resp. disease, smoking history, environmental exposure, self-care behaviour, respiratory impact on daily living

33
Q

addition HH questions for infants

A

illness (frequent colds), allergies, chronic resp. illness, safety, environmental smoke

34
Q

additional HH questions for older adults

A

activity intolerance, SOB, fatigue, level of activity, lung disease (coping, energy lvls, impact on life), chest pain w/ breathing (rib fracture post-fall)

35
Q

what to consider when preparing a pt for a respiratory physical exam?

A

pt is upright, gown open in back

  • close draping
  • consider timing during complete examination (anterior, posterior, lateral)
  • cleaning stethoscope end piece
  • client breathing rate (rhythm, effort, use of accessory muscles, comfort)
36
Q

inspecting the posterior chest

A

straight spinous processes and symmetric scapulae, antero-posterior/transverse diameter, neck and trapezius muscles, position pt takes to breather, skin colour & condirion, location of lobes of lungs

37
Q

palpating the posterior chest

A

symmetrical expansion at T9 or T10, tactile or vocal fremitus, palpate the entire chest wall

38
Q

percussing the posterior chest

A
  • resonance is predominant note (clear, hollow, low pitched)

- start above the scapula and percuss at 5cm intervals (comparing bilaterally)

39
Q

auscultating the posterior chest

A

ask pt to breathe through mouth and slightly deeper than usual

  • assess for presence/absence of breath sounds, intensity, symmetry, quality
  • assess any adventitious sounds
40
Q

inspecting the anterior chest

A
  • shape & configuration of chest wall; downward sloping ribs and costal angle <90º
  • facial expression
  • LOC
  • skin colour & condition
    quality of respirations, RR, pattern
  • accessory muscles
41
Q

palpating the anterior chest

A

symmetrical chest expansion at the costal margin, tactile fremitus at 4 locations, palpating the anterior chest wall for moisture, tenderness, lumps and masses

42
Q

percussing the anterior chest

A

start in supraclavicular area, resonance is predominant, compare sounds bilaterally, borders of cardiac dullness, done at 5 locations bilaterally

43
Q

expected percussion notes over anterior chest

A

flat over muscle and bone, cardiac dullness near heart, resonance in IC spaces, liver dullness and stomach tympany

44
Q

auscultating the anterior chest

A

assess breath sounds while asking pt to breathe deeply through mouth, compare bilaterally at 5 locations, note presence and quality of sounds
- verbalise the location and quality of the normal lung sounds (B, BV and V), any abnormal breath sounds and include the lateral chest (RML)

45
Q

respiratory assessment: developmental considerations for infants & children

A

flexibility in exam sequence, thoracic cage soft & flexible, diaphragm main resp. muscle (will see abdomen move w/ respiration)s, sternal or IC retractions indicate distress, RR and pattern may be irregular, infants are nose breathers up to 3 months, localizing breath sounds are more difficult and percussion yields hyperresonance (limited use in newborns)

46
Q

respiratory assessment: developmental considerations for pregnant women

A

wider thoracic cage, wider costal angle, 40% increase in TV

47
Q

respiratory assessment: developmental considerations for older adults

A

round, barrel-shaped thoracic cage and kyphosis, chest expansion somewhat decrease and less mobile thorax

48
Q

respiratory assessment: developmental considerations for acutely ill patients

A

second examiner needed to support pt in upright position for exam

49
Q

Bronchial Sounds

A

heard over the trachea, high pitched; expiration > inspiration

50
Q

bronchiovesicular sounds

A

heard over main bronchi, medium pitched insp=expir

51
Q

vesicular

A

heard over tissue of the lungs, inspiration> expiration; low and soft pitched

52
Q

stidor

A

loud wheezes; caused by narrowing of larger airways

Nursing 1J02 (6 decks)

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