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Nursing Assessment > Respiratory/Thorax/Lungs > Flashcards

Respiratory/Thorax/Lungs Flashcards

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1
Q

ABC of cardiac/pulmonary

A

airway, breathing, circulation

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2
Q

anterior thoracic landmarks

A

suprasternal notch, sternum, costal angle

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3
Q

posterior thoracic landmarks

A

spinous processes
inferior border of scapula
twelfth rib

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4
Q

upper lobes posterior landmarks

A

between c7 and t3

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5
Q

right lung is [shorter/narrower] and left lung is [shorter/narrower]

A

left lung is longer and narrower (2 lobes) - heart

right lung is shorter and wider (3 lobes) - liver

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6
Q

upper lobes are best heard on [posterior/anterior] chest

A

anterior

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7
Q

right middle lobe is best heard

A

anterior into mid axillary line – can’t hear posterior

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8
Q

lower lobes are best heard [anterior/posterior]

A

posterior

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9
Q

which lung has a middle lobe

A

right

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10
Q

respiratory hx

dx of concern

A

COPD, asthma, chronic bronchitis, lung cancer

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11
Q

respiratory hx

sx of concern

A

cough, dyspnea, chest pain with breathing

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12
Q

behavioral/lifestyle factors

A
  • smoking history (incl vaping), medications, self-care behaviors
  • environmental exposure, occupational exposure
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13
Q

sequence these:

  • percussion
  • auscultation
  • inspection
  • palpation
A
  • inspection
  • palpation
  • percussion (used occasionally)
  • auscultation

Complete whole sequence on front or back, then repeat. Order isn’t as important here as it is in GI.

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14
Q

t/f: auscultation is fine over the clothing

A

false, should be performed directly on the skin

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15
Q

inspection elements

A
  • ease/effort
  • dyspnea, orthopnea
  • chest movement and accessory muscle
  • sputum
  • skin color (natural light)
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16
Q

Qualities of breathing

A
  • rate (tachypnea, bradypnea, apnea)
  • volume (hyper/hypoventilation)
  • depth (deep, normal, shallow)
  • rhythm (regular, pauses)
  • ease (labored, unlabored)
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17
Q

breathing pattern with pneumonia, pulmonary edema, acidosis, septicemia, pain

A

tachypnea

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18
Q

breathing pattern with ICP, drug OD, alkalosis, benzos/alcohol

A

bradypnea

19
Q

hyperventilation vs. tachypnea

A

tachypnea is shallow. hyperventilation increases depth and rate >22

20
Q

hypoventilation vs bradypnea

A

bradypnea not always shallow. hypoventilation is depth and rate decreased <10.

21
Q

not breathing

A

apnea

22
Q

breathing pattern

with variable rate and depth. Regular-irregular rhythm cycles slow and shallow to deep and fast. Period of apnea. (crescendo and decrescendo)

A

Cheyne-Stokes: mostly dying – can be accompanied by death rattles/rales. But also TBI, altitude sickness, heart failure.

23
Q

breathing pattern

rate and depth can be variable. Irregular. Increased rate and depth with abrupt pauses.

A

Biot’s: head injury, trauma, stroke in medulla oblongata, prolonged opioid use

24
Q

breathing pattern

Regular but abnormally deep and increased in rate. Labored and using accessory muscles.

A

Kussmaul: DKA, exercise, metabolic acidosis, renal failure.

this is a type of hyperventilation

25
Q

markers of respiratory effort

A

labored/unlabored, retractions, nares flaring, pursed lip breathing

26
Q

kyphosis

A

abnormal anterior spine curvature

27
Q

scoliosis

A

abnormal lateral spine curvature

28
Q

spinal damage above this landmark can cause failure of spontaneous respiration

A

c5

29
Q

palpation assessment points

A
  • tenderness
  • temperature
  • skin integrity
  • position of trachea
  • symmetrical expansion
30
Q

normal breath sounds

sounds near the sternum and between the scapulae

  • moderate pitch and intensity
  • occur equally over inspiration and expiration
A

broncho-vesicular sounds

31
Q

normal breath sounds

hear around the trachea, high pitched and harsh with a long, loud expiration

A

bronchial sounds

32
Q

normal breath sounds

vesicular sounds

A

audible over anterior, soft breezy quality during inspiration

33
Q

adventitious breath sounds

crackling or popping sounds of varying intensity, not caused by cough

A

crackles

34
Q

adventitious breath sounds

low, coarse, gurgling, louder sounds. may be altered or cleared by coughing. may have a moaning or snoring quality. heard at end of inhale and beginning of exhale.

A

rhonchi (gurgles)

35
Q

adventitious breath sounds

breath sound caused by air passing through fluid or mucus

A

crackles

36
Q

adventitious breath sounds

breath sound caused by air passing through narrowed air passages due to secretions, swelling, or tumors

A

rhonchi (gurgles)

37
Q

whistling sound, could be musical, moaning, sonorous

A

wheeze

38
Q

squeaking or grating heard in lateral lung fields during inspiration and expiration

A

pleural friction rub

39
Q

caused by air passing through a constricted bronchus due to asthma, secretions, swelling, or tumors

A

wheeze

40
Q

caused by the rubbing together of inflamed pleural surfaces

A

pleural friction rub

41
Q

crowing noise heard during inspiration

A

stridor – obstruction or swelling (croup)

42
Q

dullness to percussion, crackles, increased tactile fremitus suggest

A

consolidation

43
Q

dullness to percussion, decreased breath sounds, decreased tactile fremitus suggest

A

pleural effusion

Nursing Assessment (13 decks)

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