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health assessment > Respiratory System > Flashcards

Respiratory System Flashcards

1
Q

Order of assessment for Respiratory

A

INSPECTION
PALPATION
PERCUSSION (advanced)
AUSCULTATION

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2
Q

Inspection
Shape and configuration

A

spinous process should appear in a straight line posterior, scapulae should be symmetric

Thorax is symmetric with an elliptical shape and downward sloping ribs about 45 degrees relative to the spine

Abnormalities – scoliosis and kyphosis

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3
Q

Inspection
AP diameter

A

AP diameter should be less than the transverse diameter about 0.7

abnormalities eg..Pigeon chest (pectus carinatum) cartilage and ribs don’t form properly and chest becomes pushed outward

or Barrel-chest – AP diameter = transverse diameter with hyperinflation of the lungs

Neck and trapezius muscles should be developed normally for age
-Muscles can be hypertrophied in COPD

Note the position the person takes to breathe
Should be relaxed posture and the ability to support ones own weight with arms comfortably at sides

Tripod position is abnormal and can be seen in COPD, person leans forward with arms braced against knees

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4
Q

Inspection
Assess skin: color, condition, lesions.

A

Color should be consistent with genetic background
Check nail beds, lips, & mucous membranes
Cyanosis is abnormal and occurs with tissue hypoxia

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5
Q

Tachypnea

A

24 per minute
rapid, shallow

Normal response to fear, anxiety, exercise

Abnormal with respiratory insufficiency, pneumonia, alkalosis, lesions in the pons

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6
Q

Bradypnea

A

<10 per minute
Slow, Regular rate

Drug induced respiratory depression of the medulla, Increased ICP, diabetic coma

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7
Q

Orthopnea

A

shortness of breath when laying flat

sign of heart failure but can occur with lung disease and obesity

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8
Q

Dyspnea

A

-harder to breath
-shortness of breath

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9
Q

Paroxysmal nocturnal dyspnea

A

occurs at night, awaking with Shortness of Breath and needing to sit up to feel comfort

Caused by OSA, heart failure, lung diseases

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10
Q

Periodic or Cheyne-Stokes respirations

A

abnormal breathing pattern that can occur while awake but usually when asleep.

It is a period of fast, shallow breathing followed by slow heavier breathing followed by moments of apnea (absence of breathing

Common in infants and older adults

Can signal pathology such as heart failure, renal failure, drug OD

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11
Q

Biot’s (irregular Cheyne-Stokes)

A

The pattern is very irregular
Occurs with head trauma, brain abscess, encephalitis

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12
Q

Fremitus

A

is a palpable vibration

“99” or “blue moon”

sounds generated from the larynx and transmitted through patent bronchi and lung parenchyma to the chest wall where you feel them as vibrations

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13
Q

Pneumothorax

A

collapsed lung

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14
Q

Rhonchal Fremitus

A

Vibration felt when inhaled air passed through thick secretions in the larger bronchi (felt anteriorly)

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15
Q

Pleural Friction Fremitus

A

Inflammation of the parietal or visceral pleura

-feels like 2 pieces of leather grating together

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16
Q

Crepitus

A

Coarse, crackling ~over skin surface

Occurs when air escapes from lungs and enters subcutaneous tissue

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17
Q

subcutaneous emphysema

A

occurs with open thoracic injury or surgery

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18
Q

Hyperresonance

A

too much air

– lower pitched booming sound

Found with pneumothorax or emphysema

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19
Q

Bronchial Sounds

A

high pitch, loud amplitude,

inspiration is shorter than expiration

Sounds harsh, hollow or tubular
Heard over trachea and larynx

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20
Q

Bronchovesicular

A

pitch is moderate, amplitude is moderate,

inspiration = expiration

Quality is mixed

Heard over major bronchi, posterior between scapulae closer to spinal column

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21
Q

Vesicular

A

low pitch, soft amplitude,

inspiration is longer than expiration

Rustling sound like wind in the trees

Heard over peripheral lung fields

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22
Q

Crackles (rales)

A

Crackles are discontinuous popping sounds heard over inspiration

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23
Q

Wheeze (rhonchi)

A

Wheezes are continuous musical sounds heard mainly over expiration.

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24
Q

Atelectatic crackles-

A

short popping sounds. Only for few breaths
not pathologic.

This occurs when sections are alveoli are closed and when they take a deep breath, they pop them open, making crackle noise.

They disappear with a cough or a few deep breaths.

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25
Q

Pleural friction rub sound

A

Very superficial sound that is coarse, low pitched, grating quality, sounds like crackles but very close to the ear

Caused when pleurae become inflamed and lose their normal lubricating fluid
Occurs with pleuritic, accompanies by pain

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26
Q

Stridor sound

A
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27
Q

Mediastinum

A

Esophagus, trachea, heart, great vessels

Pleural cavity contain lungs

28
Q

Lower lobes

A

T4-T12,
Expiration on T10
Inspiration on T12

29
Q

acinus

A

is a functional respiratory unit the consists od bronchioles, alveolar ducts and alveolar sacs and the alveoli.

30
Q

Kussmals breathing

A

The body hyperventilates in response to severe metabolic acidosis particularly with Diabetic ketoacidosis (DKA) in an effort to reduce CO2 in the blood

31
Q

Tuberculosis (TB)-

A

airborne lung disease

Incidence low in the USA

Affects crowded\congested areas

Top 5 countries – Mexico, Philippines, India, Vietnam and China

68% of US cases are found in foreign-born people

Reactivation of latent TB in most cases
Increase risk with HIV and homeless

32
Q

When recording data about a symptom or problem include the following:

A

Onset (date, sudden or gradual)
Duration
Frequency
Precipitating factors
Aggravating or alleviating factors
Treatment/self-care
Outcome

33
Q

Pectus Excavatum-

A

Pigeon chest - sternum sunken

34
Q

Barrel chest

A

when anterior posterior diameter = transverse diameter, caused by hyperinflation of the lungs
common sign of COPD

35
Q

hypercapnia

A

increase in carbon dioxide in the blood

36
Q

hypoxemia

A

A decrease of oxygen in the blood
also increases respirations but is less effective than hypercapnia.

37
Q

Anterior chest inspection

A

is the costal angle within 90 degrees

Facial expression – relaxed or pursed lipped breathing (pursed lips for COPD)

Level of consciousness
Cerebral hypoxia may be reflected in excessive drowsiness, anxiety or restlessness

– are the lips and nailbeds free of cyanosis or pallor, is clubbing present

s – is breathing relaxed, no chest bulging or retractions should be seen (bulging seen with trapped air from emphysema or asthma, retractions seen with obstruction of respiratory tract for with increased respiratory effort

Respiratory rate – is it normal 10-20 per minute

38
Q

Pectus carinatum-

A

Sternum malformed, sticking out

39
Q

Pleural effusion-

A

fluid in pleural space (wont expand as much with water)

40
Q

atelectasis

A

collapsed lung

41
Q

Lobar pneumonia-

A

pus in lungs, less air to expand

42
Q

Pneumothorax

A

(neo-thorax)- Air that got into potential space (penetration (pierced) in lungs)

43
Q

Dull precussion

A

note signals density in the lungs with pneumonia, pleural effusion, atelectasis, tumor

44
Q

emphysema

A

A lung disease which results in shortness of breath due to destruction and dilatation of the alveoli

45
Q

Adventitious Lung Sounds

A

Caused by moving air colliding with secretions in tracheobronchial passageways or by popping open of previously deflated airways

You want to describe them as
Inspiratory or expiratory
Loudness and pitch
Location

46
Q

Atelectatic crackles-

A

short popping sounds. Only for few breaths
not pathologic. clear after a few breaths

When sections are alveoli are not fully aerated, they deflate and accumulate secretions, crackles are heard when these secretions reexpand with a few deep breaths

This occurs when sections are alveoli are not fully aerated. Crackles are heard when these sections are expanded by a few deep breaths. They are heard in the periphery, usually in dependent portions of the lungs. They disappear with a cough or a few deep breaths

47
Q

Crackles—fine

A

Discontinuous, high-pitched short crackling sounds heard during inspiration that are not cleared by coughing

inspiratory crackles inhaled air collides with previously deflated airways then airways suddenly pop open

Occurs with restrictive disease, pneumonia, heart failure, interstitial fibrosis, COPD, bronchitis, asthma

48
Q

Crackles—course

A

Loud, low pitched and gurgling sounds that start early in inspiration and may be present in expiration, may decrease with coughing but reappear
Inhaled air collides with secretions in the trachea and large bronchi
Occurs with pulmonary edema, pulmonary fibrosis, terminally ill who have depressed cough reflex

49
Q

Pleural friction rub

A

Very superficial sound that is coarse, low pitched, grating quality, sounds like crackles but very close to the ear
Caused when pleurae become inflamed and lose their normal lubricating fluid
Occurs with pleuritic, accompanies by pain

50
Q

Wheeze— high pitched (silbiant)

A

High pitched, musical squeaking that sound polyphonic (multiple notes as in a musical chord)
Predominate on expiration but can be heard in both expiration and inspiration
Air squeezed or compressed through very narrowed passageways due to collapsing, swelling, secretions or tumors
Heard in diffuse airway obstruction from acute asthma or chronic emphysema

51
Q

Wheeze— low pitched (sonorous rhonchi)

A

Low pitched, monophonic (single note, musical), snoring, moaning sounds heard throughout the cycle although more prominent on expiration, may clear somewhat with coughing
Airflow obstruction causing vibration
Heard in bronchitis, single bronchus obstruction or from airway tumor

52
Q

Stridor

A

High pitched, monophonic, crowing sound, louder in neck than over chest wall

Originating in larynx or trachea, upper airway obstruction from swollen, inflamed tissues or lodged foreign body

Heard in croup and acute epiglottitis in kids and foreign body inhalation

53
Q

Pulmonary Function Studies (PFTs)

A

measure forced expiratory time. It is a measure for airflow obstruction

PFTs are usually done “in the lab”

54
Q

Spirometer

A

is a handheld device used in ambulatory care to measure lung health in chronic conditions

55
Q

Pediatric

A

Diaphragm is newborn’s major respiratory muscle.

Count respiratory rate for 1 full minute; normal rates for newborn are 30 to 40 breaths per minute but may spike up to 60 breaths per minute.

Brief periods of apnea less than 10 or 15 seconds are common; this periodic breathing is more common in premature infants.

Infant has a rounded thorax with an equal AP to transverse diameter, by 2 years old it is 1:2
Chest circumference is smaller than head circumference until age 2
Ribs and xiphoid are prominent
Thoracic cage is soft and flexible

Place bell over infant’s interspaces and not over ribs.

Auscultation normally yields bronchovesicular breath sounds in peripheral lung fields of infant and young child up to ages 5 to 6 years.

Fine crackles are adventitious sounds commonly heard in immediate newborn period from opening of airways and clearing of fluid.

Babies are born with fluid in lungs

56
Q

Older adults

A

Tire easily (don’t hyperventilate)
Increase AP diameter, Chest may become more barrel
Kyphosis – an outward curve of the thoracic spine
Chest expansion may be decreased

57
Q

Pulse Oximetry

A

measurement of hemoglobin oxygen saturation

Normal Values: 96%-100%

Six minute walk oximetry test is a test of functional status in aging adults. Used to measure pulmonary rehab.

A person who walks >300 meters in 6 minutes is more likely to engage in ADLS

Measurements can be skewed by low heart rate or poor peripheral perfusion

58
Q

Sputum culture

A

specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells

Have patient rinse mouth, take a few deep breaths, and then cough (not spit) into the container

59
Q

Arterial Blood Gas (ABGs)

A

Measures the dissolved oxygen and carbon dioxide in the arterial blood and reveals the acid-base state and how well the oxygen is being carried to the body tissues

Usually obtained from radial, brachial or femoral artery

NORMAL ABG VALUES
pH: 7.35-7.45
PCO2: 35-45 mmHg
PO2: 80-100 mmHg
HCO3: 22-27 mEq/L
O2 saturation: 96% to 100%

60
Q

PULMONARY FUNCTION TEST

A

Include a number of different tests used to evaluate lung mechanics, gas exchange, and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gases

Preprocedure
Determine if an analgesic that may depress the respiratory function is being administered

Consult with physician regarding holding bronchodilators prior to testing

Instruct client to void prior to procedure and to wear loose clothing

Remove dentures

Instruct client to refrain from smoking or eating a heavy meal for 4 to 6 hours prior to the test

Postprocedure
Resume normal diet and any bronchodilators and respiratory treatments that were held prior to procedure

61
Q

Lung Capacity

A

TV: Normal resting breath
IVR: Sucking in as much as you can after normal inspiration
ERV: Breathing out forcefully after normal expiration

62
Q

BRONCHOSCOPY

A

Direct visual examination of the larynx, trachea, and bronchi with a fiber optic bronchoscope

Preprocedure
Obtain informed consent
NPO from midnight prior to the procedure
Obtain vital signs
Monitor coagulation studies
Remove dentures or eyeglasses
Prepare suction equipment
Administer medication for sedation as prescribed
Have emergency resuscitation equipment readily available

63
Q

THORACENTESIS

A

Removal of fluid or air from the pleural space via a transthoracic aspiration

Preprocedure
Obtain consent
Obtain baseline vital signs
Prepare client for ultrasound or chest x-ray if prescribed prior to procedure
Assess coagulation studies
Note that client is positioned sitting upright, with arms and head supported by a table at the bedside during the procedure
If the client cannot sit up, the client is placed lying in bed on the unaffected side with the head of the bed elevated 45 degrees
Inform client not to cough, breathe deeply, or move during the procedure

Postprocedure
Monitor vital signs
Monitor respiratory status
Apply a pressure dressing and assess puncture site for bleeding and crepitus
Monitor for signs of pneumothorax, air embolism, and pulmonary edema

64
Q

Pneumothorax

A

means there is air in the pleural space causing pressure on the lung and the lung will collapse.
The nurse will hear no sounds of air movement on auscultation.

65
Q

Movement of air through mucus or fluid produces crackles, wheezing occurs when airways are obstructed, Dullness on percussion indicates increased density of the lung tissue usually caused by an accumulation of fluid.

A
66
Q

The hallmark signs of asthma

A

are chest tightness, audible wheezing and coughing

health assessment (9 decks)

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