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NURS 190-Physical Assessment > Week #3-Concept Review > Flashcards

Week #3-Concept Review Flashcards

Respiratory System & Axilla

1
Q

What is the functional unit of the lungs?

A

The Alveoli

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2
Q

What are the true ribs?

A

1 to 7th ribs

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3
Q

What are the false ribs and why are they called false ribs?

A

8th, 9th, and 10th ribs, because they are not connected to the sternum. They are connected to the cartilage of the 7th rib.

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4
Q

What are the floating ribs, where are they seen, and what are they connected to?

A

The 11th and 12th rib, they cannot be seen anteriorly, and are connected to the vertebra of the back.

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5
Q

Where do you find the “Angle of Louie”?

A

Articulated between the manubrium and the body of the sternum, in line with the 2nd rib

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6
Q

What is the initial step in respiration assessments and in any assessment?

A

Inspection

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7
Q

What are the sequence of assessment techniques in respiratory assessments?

A

1) Inspection
2) Palpation
3) Auscultations- is the last assessment technique
4) Percussion (optional)

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8
Q

What is the technique for percussing the lungs and what are the normal sounds called?

A

Indirect percussion & Resonant Sounds

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9
Q

What do the resonant sounds of the lungs sound like?

A

long, low-pitched, hollow sounds

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10
Q

On percussion, what sounds will be heard when air is trapped in the lungs?

A

Hyperresonant sounds

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11
Q

What is the technique used to assess bronchophony, egophony, and whispered pectoriloquy? What should you ask the patient to say during auscultation?

A

Auscultation for voice sounds assessed on the posterior thorax; bronchophony *99, egophony *E, whispered pectoriloquy *123.

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12
Q

What technique is used to assess tactile fremitus?

A

Palpation

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13
Q

What four things cause increased tactile fremitus?
(hint: FIFT)

A

1) fluid in the lungs
2) fibrosis
3) tumor
4) infection

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14
Q

What five things cause a decrease in tactile fremitus?
(Hint C-POTS)

A

1) soft voice
2) Thick chest muscles
3) Obesity
4) COPD
5) Pleural effusion

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15
Q

What technique is used to assess diaphragmatic excursion?

A

Percussion

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16
Q

What are normal diaphragmatic excursions? What can they go up to in fit individuals?

A

Normal= 3-5 cm
In a well fit individual= 7-8 cm

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17
Q

What are decreased diaphragmatic excursions, and what does this mean?

A

Decreased diaphragmatic excursions= less than 3 cm
This means the lungs are not fully expanding.

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18
Q

What can cause the lungs to not fully expand (4)?

A

Emphysema, atelectasis, respiratory depression, and pneumonia

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19
Q

What can asymmetric diaphragmatic excursion indicate?

A

Paralysis or pleural effusion of the higher side of the chest

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20
Q

What are the normal sounds when assessing for bronchophony on auscultation?

A

Muffled sounds

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21
Q

While auscultating bronchophony, when the lungs are filled with fluid (as in bilateral pneumonia), what are expected sounds?

A

Sounds are loud and clear

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22
Q

What are normal sounds when assessing for egophony?

A

“eeeeeee”

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23
Q

What auscultated sounds are present when assessing for whispered pectoriloquy when lungs are filled with fluid, as in bilateral pneumonia?

A

Sounds are loud and clear

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24
Q

What are normal sounds when assessing for whispered pectoriloquy?

A

Faint, muffled, and almost indistinguishable

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25
Q

What are Rhonchi Sibilant or Wheezing sounds? What patient may have them?

A

Continuously high pitched adventitious breath sounds, expected abnormal findings on auscultation with asthmatic patients.

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26
Q

What are Rhonchi Sonorous sounds? Which patient’s may have them?

A

continuous low pitched, snoring and rattling adventitious breath sounds. Common in clients with COPD, Pneumonia, Chronic Bronchitis, and Cystic Fibrosis

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27
Q

What adventitious breath sounds characterize blocked air flow?

A

High pitched and continuous upon auscultation.

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28
Q

What adventitious sound will you hear in clients with Lobar Pneumonia?

A

Crackles

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29
Q

What are pleural friction rub lung sounds?

A

Adventitious lung sounds heard outside the airway, rubbing and dry sounds.

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30
Q

Adventitious sounds heard upon auscultation when alveoli are filled with fluid.

A

A low pitch that has a loud, moist, and bubbly quality

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31
Q

What sounds are heard during the auscultation of atelectisis?

A

Decreased breath sounds at the lower lobes of the lungs.

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32
Q

What are the causes of atelectasis?

A

Prolonged bedrest of a post-op client, ineffective coughing, or hypoventilation

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33
Q

Describe external respiration.

A

Exchange of O2 and carbon dioxide at the alveoli level of the lungs.

34
Q

Describe internal respiration.

A

Exchange of O2 and carbon dioxide at the cellular level of the lungs

35
Q

What are the two phases of respiration?

A

1) Active phase- Inspiration
2) Passive phase- expiration

36
Q

Describe Eupnea (Normal Breathing)
R.R.E.U. R.

A

Regular, Rhythmic, even, unlabored, 12-20X per minute at rest in adults

37
Q

What is eupnea with the occasional sigh considered?

A

It is still considered normal breathing

38
Q

What will frequent sighs result in?

A

Hyperventilation

39
Q

Describe Choanal Atresia.

A

A congenital defect wherein there is membrane obstructing the nasal passages of a newborn. Must be managed right away because it can lead to respiratory failure.

40
Q

Describe tachypnea.

A

A RR over 20 times per minute that is rapid and deep

41
Q

Describe Bradypnea.

A

RR less than 12 times per minute, slow but regular.

42
Q

What is the normal respiration rate of a newborn>

A

Ranges from 40-80 X/ minute & irregular

43
Q

Describe hypoventialtion.
(hint: S.I.S.)

A

RR below 12 per minute, slow, irregular, and shallow

44
Q

Describe Cheyne-Stokes Respirations.

A

Periods of apnea but regular, common in elderly dying patient

45
Q

Describe Biots/ Ataxic respirations.

A

Periods of apnea with irregular pattern observed in brain damaged patients.

46
Q

What is obstructive breathing and what patients may experience this?

A

Prolonged expiration; observed in patients with COPD, Asthma, and Chronic Bronchitis

47
Q

Describe stridor.

A

Adventitious breath sounds heard without a stethoscope indicating an upper airway obstruction. Also known as an ominous sign.

48
Q

What do loud and scratchy breath sounds indicate?

A

These are adventitious sounds that indicate pleurisy caused by inflammation of the pleura.

49
Q

When using a spirometer what will you advise to the client?

A

Secure lips around the mouthpiece & and take a deep breath in.

50
Q

Describe elliptical.

A

Normal chest configuration for adults- lateral diameter is 2:1 with the anteroposterior diameter of the chest.

51
Q

Describe a barrel chest.

A

A normal configuration in an infant’s chest- rounded. Also, common in elderly and an unexpected finding for COPD patients.

52
Q

Describe Scoliosis.

A

Lateral deviation of the spinous process.

53
Q

Describe Kyphosis.

A

Exaggerated curvature of the thoracic vertebrae-elderly.

54
Q

Describe Lordosis.

A

Exaggerated curvature of the lumbar vertebrae- pregnant women

55
Q

Describe Pectus Excavatum or Funnel Chest

A

Congenital deformity wherein there is depression of the sternum and adjacent cartilage compressing the heart and lungs. Cardiac murmurs may be heard in severe cases surgery in indicated.

56
Q

Describe Pectus Carinatum or Pigeon Chest

A

A congenital deformity forward displacement of the sternum with depression of the adjacent cartilage.

57
Q

What causes clubbing of the fingers?

A

Chronic smoking, hypoxia, and poor tissue perfusion.

58
Q

How can clubbing of the fingers be assessed?

A

The nail angle of the client is over 160 degrees (normal is 160 degrees) when dorsal aspects of the fingers are brought together to create a mirror image with a diamond space observed between fingers.

59
Q

What is an early sign of hypoxia?

A

Altered level of consciousness

60
Q

What are late signs of hypoxia (6)?
(hint: B.C.D.D.R.S.)

A

restlessness, stupor, dyspnea, decreased respirations, bradycardia, cyanosis

61
Q

What is the most important question to ask a patient with Rhinitis?

A

History of allergies

62
Q

What are the normal findings on transillumination of the sinus?

A

“Red Glow”

63
Q

What is the indication of an absent red glow during transillumination?

A

When sinuses will not transilluminate red glow, the sinuses are filled with fluid.

64
Q

How should a patient with the complaint of a sinus headache be assessed?

A

Assess by transillumination of the sinus or direct percussion of the sinuses.

65
Q

What are the two assessment techniques of the breast?

A

Inspection and palpation

66
Q

What structures of the breast are responsible for milk production.

A

Acini Cells

67
Q

Describe Supernumerary Nipples.

A

A minor congenital malformation that consist of additional nipples which occurs along the breast line from the armpit to the groin. this is usually misdiagnosed as mole (s).

68
Q

Breast cancer facts.

A

The occurrence of breast cancer in men is less than 1 % that is why it is easily ignored. Early detection of breast cancer has a higher rate of cure.

69
Q

Where are most breast tumors located?

A

In the upper outer quadrant of the breast.

70
Q

When should an SBE (self breast examination) be performed

A

-For elderly advise to perform of same day at the same time every month.
-For female still menstruating- Advise to perform 3-5 days after menstruation when hormones are more stable.

71
Q

What is fibroadenoma?

A

A well defined breast tumor with no tenderness or discharge, most common in adolescent girls 15 years old to women up to 35 years old.

72
Q

Describe Intraductal Papilloma.

A

The most common cause of benign nipple discharge ( serous or bloody) in post-menopausal female.

73
Q

What is Peau D’Orange

A

Orange peel appearance on the skin of the breast, a sign of breast cancer or cancer.

74
Q

When there is a change in the consistency of the breast lump, what must be performed?

A

It must be further evaluated by a physician.

75
Q

What are examples of “expected variation on breast”?

A

1) Flat nipples since puberty
2) Veins on the breast since puberty

76
Q

What are examples of “expected findings of clients with Asthma”?

A

1) Rhonchi Sibilant
2) Chronic Hyperactive Bronchospasms

77
Q

What are examples of “expected variations of COPD”?

A

1) Barrel Chest
2) Clubbing of the fingers
3) O2 Sat 90% or less

78
Q

What is the sequence for a breast examination?

A

1) Inspection
2) Palpation

79
Q

What is the location, ratio of inspiration: expiration, and quality for the tracheal sound?

A

Over the trachea, inspiration less than expiration, harsh and high-pitched

80
Q

What is the location, ratio of inspiration: expiration, and quality for the bronchial sound?

A

Next to the trachea, superior to each clavicle, and in the first intercostal space. Inspiration less than expiration, loud and high-pitched.

81
Q

What is the location, ratio of inspiration: expiration, and quality for the bronchovesicular sound?

A

Over major bronchi, in second and third intercostal space, between the scapula. Inspiration is equal to expiration, medium loudness, medium pitched.

82
Q

What is the location, ratio of inspiration: expiration of the vesicular lung sounds.

A

The remainder of the lungs, inspiration is greater than expiration, soft and low pitched

NURS 190-Physical Assessment (7 decks)

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