week 3: respiratory assessment

Question 1

what is ventilation?

Answer 1

the process of exchange of air between the lungs and the ambient air; also known as breathing

Question 2

what is diffusion?

Answer 2

movement of O2 and CO2 from or to blood cells either between alveoli in the lungs or the cells in the rest of the body

Question 3

what is perfusion?

Answer 3

distribution of the blood to the distal tissues

Question 4

what upper body muscles may a patient use to assist their breathing when they are struggling to get oxygen?

Answer 4

• scalenus
  -sternocleidomastoid
• pectoralis minor
• external intercostal
• abdominal rectus
• trapezius

Question 5

what should be included in subjective data during a respiratory assessment?

Answer 5

• cough
• dyspnea
• chest pain
• Past medical history
• Family history
• Self-care activities
• Allergies
• Immunizations
• Determinants of health

Question 6

what questions should the nurse ask the patient while continuing to gain subjective data during a respiratory assessment?

Answer 6

• Previous respiratory illness or previous abnormal chest X-rays
• Current medications. Many meds can produce respiratory problems including oral contraceptive (pulmonary embolism), cytotoxic agents (interstitial lung disease), ACE inhibitors (cough)
• Is there a history of possible exposure to occupational/domestic irritants such as molds, wood dust, spray paint, asbestos, coal, etc.
• Does the patient have high exposure to animals including birds (Q fever, psittacosis)

Question 7

what are the 3 abnormal chest shapes to look for when inspecting the chest during a respiratory assessment?

Answer 7

• barrel chest
• pectus excavatum (tunnel chest)
• pectus carinatum (pigeon breast)

Question 8

how can nurses promote respirations and oxygenation?

Answer 8

• promote lung expansion (get patient up and moving)
• prevent stasis of secretions (breathing and coughing)
• maintain patient airway
• promote adequate exchange of oxygen and carbon dioxide

Question 9

what are the respiratory developmental variations found in infants?

Answer 9

• Infants are obligatory nose breathers
• Bronchovesicular sounds are heard
• Respirations are primarily abdominal
• After the child is 2, the breathing shifts to intercostal
• The respiratory rhythm is irregular
• Apnea should never exceed 15 seconds!!
• A respiratory rate of 30-60 is normal

Question 10

what are the respiratory developmental variations found during pregnancy?

Answer 10

• There is an increase in tidal volume to meet the fetus’ need for oxygen
• Later in pregnancy, the diaphragm rises and the costal angle widens to accommodate the enlarging uterus
  
  • The lower ribs flare as the fetus and the uterus grow
• The respiratory rate remains approximately the same at rest
• Increased tidal volume meets the increased demands the growing fetus places on the woman

Question 11

what are the respiratory developmental variations found in aging older adults?

Answer 11

• Alveoli tend to fibrose with age resulting in decreased surface area for gas exchange
• Lung capacity decreases due to muscle weakness and less elasticity
• There is more “dead” space, trapped air and less vital capacity
• Often the thoracic spine curves (kyphosis) which gives the appearance of a barrel chest
  
  • This does not usually result in dysfunction
• Respiratory strength decreases with age
• Lungs lose elasticity, cartilage in the lungs loses flexibility, bones lose density, the AP diameter increases and the muscle mass decreases
• Decreased function of the cilia leads to pooling of secretions in the lungs
• Weaker chest muscles also decrease the older patient’s ability to cough up secretions and puts them at risk for pneumonia