Week 5: Respiratory Assessment Flashcards
Define adventitious sounds:
Adventitious sounds refer to sounds that are heard in addition to the expected breath sounds mentioned above. The most commonly heard adventitious sounds include crackles, rhonchi, and wheezes.
Define apnea:
temporary cessation of breathing, especially during sleep.
Define bradypnea:
abnormally slow breathing rate; less than 10 breaths per minute
Define Cheyne–Stokes
Cheyne–Stokes respiration is an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.
Define crackles
Crackles are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation.
Define cyanosis (central & peripheral)
Central cyanosis: generalized bluish discoloration of the body and the visible mucous membranes, which occurs due to inadequate oxygenation
Peripheral cyanosis is when the hands, fingertips, or feet turn blue because they are not getting enough oxygen-rich blood.
Define dyspnea:
shortness of breath
Define eupnea:
normal respiration
Define hyperventilation:
You upset normal breathing balance when you hyperventilate by exhaling more than you inhale leading to fast breathing.
- can be triggered by anxiety, infections, drugs, or acid-base imbalance; hypoxia associated with pulmonary embolus or shock; fever; chemical-induced (aspirin and amphetamines increase CO2 levels); metabolic acidosis (over-breathing occurs naturally in hopes of fixing the balance)
Define hypoventilation
breathing that is too shallow or too slow to meet the needs of the body. due to low o2 levels. Co2 levels rise causing the person to feel sleepy.
Define hypoxia
low levels of O2 in tissues or organs
Define hypoxemia
low levels of O2 in blood
Define manubrium of sternum:
the most superior portion of the sternum.
Define pleural friction rub
A pleural fric.tion rub is a raspy breathing sound caused by inflammation of the tissues around your lungs. The sound is usually “grating” or “creaky.” It’s also been compared to the sound of walking on fresh snow.
Indicative of: pneumonia, pulmonary embolism, malignant pleural disease, and pleurisy secondary to viral infection or pancreatitis, among other causes. NOT the same as pericardial rub which indicates pericarditis (inflammation of the pericardium)
Define orthopnea
Orthopnea is the sensation of breathlessness in the recumbent position, relieved by sitting or standing.
Define pneumonia
Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing. A variety of organisms, including bacteria, viruses, and fungi, can cause pneumonia.
Define pneumothorax
collapsed lung; occurs when air leaks into the space between your lung and chest wall. This air pushes on the outside of your lung and makes it collapse.
Define stridor
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may also be called musical breathing or extrathoracic airway obstruction.
Define supra-sternal notch
The suprasternal notch, also known as the fossa jugular sternalis, or jugular notch, Plender gap or “neck dent” is a large, visible dip in between the neck in humans, between the clavicles, and above the manubrium of the sternum.
Define tachypnea
abnormally rapid breathing.
Define tidal volume
Tidal volume (symbol VT or TV) is the lung volume representing the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied. In a healthy, young human adult, tidal volume is approximately 500 ml per inspiration or 7 ml/kg of body mass.
Define vital capacity
Vital capacity (VC) is the maximum amount of air a person can expel from the lungs after a maximum inhalation. It is equal to the sum of inspiratory reserve volume, tidal volume, and expiratory reserve volume. … A normal adult has a vital capacity between 3 and 5 litres.
Define wheeze
Wheezing is a high-pitched whistling sound made while you breathe. It’s heard most clearly when you exhale, but in severe cases, it can be heard when you inhale. It’s caused by narrowed airways or inflammation. Wheezing may be a symptom of a serious breathing problem that requires diagnosis and treatment.
What are the normal o2 levels?
95-100%
A decrease in 02 levels results in what?
a decrease in functioning body systems
Air is made of what percent of O2 and Co2
21% O2 and 0.04% CO2
What are ways to expel foreign materials?
coughing, swallowing, sneezing
Dyspnea can trigger what psychological aspect?
Anxiety
What interventions can decrease O2 needs?
Hyperoxia (too much O2) results in oxygen toxicity! (causes: underwater diving, hyperbaric oxygen therapy, and the provision of supplemental oxygen, particularly to premature infants)
- avoid over-exertion
- provide rest
- maintain normal body temp
- decrease stress
- balanced diet of small, frequent meals
- respiratory therapy/treatment before meals
- adequate hydration
When doing a respiratory assessment what factors need to be considered (think SDOH)
- developmental considerations (infants/children; pregnant females; aging adult)
- psychosocial considerations (use of harmful substances such assmoking increases resp rate)
- physiological considerations (obesity, musculoskeletal abnormalities, trauma, neuromuscular diseases such as peripheral neuropathy, MS, muscular dystrophy, etc)
- environmental considerations (workplace hazards, altitute, 2nd hand smoke, pets)
What kinds of subjective data/questions are asked when performing a respiratory assessment?
- any pain?
- fatigue?
- any cough?
- any sob (dyspnea)?
- hx of smoking?
- environmental exposure that affects breathing?
- self-care behaviours?
- past hx of resp disease/infections?
- allergies?
- medications?
What does a peak flow meter assess?
- measures expiratory flow rate; used to determine 1. respiratory status, 2. response to bronchodilator tx (e.g asthma)
How is a peak flow meter used?
- measure top 3 exhalations with sudden forced expiration (fast and hard through the mouth)*
Move the marker to the bottom of the numbered scale.
Stand up straight.
Take a deep breath.
Hold your breath while you place the mouthpiece in your mouth, between your teeth.
Blow out as hard and fast as you can in a single blow.
Write down the number you get.
Peak expiratory flow (PEF) is measured in litres per minute. Normal adult peak flow scores range between around 400 and 700 litres per minute
What is the normal range for pulse oximetry reading?
95-100%
Where can an O2 sensor be applied for pulse oximetry reading?
finger, toe, bridge of the nose, ear lobe
What does pulse oximetry assess?
estimated O2 saturation of Hgb in pulsating arterial blood vessels
What should inspection including when doing respiratory assessment?
- LOC
- facial expression
- respirations
- skin color
- nail beds (fingers)
- IPPA (Inspection, Palpation, Percussion, and lastly Auscultation)
- CWMS (Colour, Warmth, Movement, and Sensation)
Compare normal RR, tachypnea, and bradypnea?
normal = 12-20 breaths/min tachypnea = exceeds 24 breaths/min bradypnea = less than 10 breaths/min
What is an MDI?
Inhaled respiratory medications are often taken by using a device called a metered-dose inhaler, or MDI which delivers a measured dose of medication with each push of the canister.
The MDI is a pressurized canister of medicine in a plastic holder with a mouthpiece (spacers/aero chambers. They make it easier to use the MDI and help get the medication into the lungs better.
What is a DPI?
A dry powdered inhaler. Doesn’t need the use of a spacer/aero chamber.
Disadvantages of DPIs:
- An adequate inspiratory flow required for medication delivery.
- May result in high pharyngeal deposition.
- Humidity potentially causes powder clumping and reduced dispersal of fine particle mass.
How are MDI’s and DPI’s timed in terms of administration?
- 1 min between each puff of bronchodilators
- use bronchodilators before other inhalation meds
- 2-5 minute interval between last puff of bronchodilator and 1st puff of anti-inflammatory
- rinse mouth following administration
What is an incentive spirometer?
- a device that measures the inspiratory volume
- therapeutic device that increases lung function and improves pulmonary ventilation
- it is designed to increase the depth and duration of lung inflation
- deep breathing assists alveoli to fully expand and mobilize secretions
When is an incentive spirometer usually used?
post-surgery and or chronic lung conditions such as COPD and asthma
What physiological processes affect oxygenation?
- anemia
- toxic inhalant (decreases the oxygen-carrying capacity of blood)
- airway obstruction (limits O2 inspiration to alveoli)
- high altitude (02 concentration of air is low so decreases 02 concentration within)
- fever (increases metabolic rate and tissue oxygen demand)
- decreased chest wall motion (maybe from musculoskeletal impairments) - prevents lowering of the diaphragm which reduces the volume of air inspired
What device is used to measure the volume of air entering or leaving the lungs?
spirometer
What is atelectasis?
the collapse of the alveoli that prevents normal gas exchange between carbon dioxide and oxygen
Where in the respiratory system does diffusion occur?
gas exchange “diffusion” occurs at the alveolocapillary membrane (movement of molecules from high to low concentration)
What is hypovolemia?
extracellular fluid loss and reduced circulating blood volume caused by conditions such as shock or severe dehydration.
fluid loss = increased HR and peripheral vasoconstriction to increase the volume of blood returned to the heart and in turn, increase the cardiac output.
What are hypoxemia and hypercapnia?
hypoxemia = low levels of O2 in blood hypercapnia = increased levels of CO2 in the blood (more than normal)
How do anemia and toxic substances affect oxygenation in the body?
- they decrease the oxygen-carrying capacity of blood by reducing the amount of available hemoglobin to transport oxygen.
What lifestyle factors affect the respiratory system?
- poor nutrition (obese/malnutritional pt’s @ risk for anemia)
- inadequate exercise (exercise lowers BP and increases the body’s metabolic demands and oxygenation)
- smoking (causes vasoconstriction to peripheral and coronary blood vessels which decrease blood flow to peripheral vessels - it the leading cause of lung cancer, heart disease, chronic obstructive lung disease, stroke)
- substance abuse (impairs tissue oxygenation either due to poor nutritional intake or direct tissue damage to lungs)
- stress (increases body’s metabolic rate and oxygen demand - most can tolerate this but people with life-threatening illnesses such as MI cannot)
What is hemoptysis?
blood sputum
What is the purpose of percussion?
used to detect the presence of abnormal fluid or air in the lungs
What is the purpose of the spacer/aero chamber that is used optionally with MDI’s?
A spacer/chamber holds the puff from the MDI in a tube or “chamber” for a few seconds, so that you don’t have to both breathe in AND spray the MDI exactly at the same time. This helps get more medicine into your lungs and lessens the risk of side effects (such as hoarseness or thrush when inhaling corticosteroids).
How are respiratory meds administered (3 forms)?
MDI and spacers
DPI
Nebulizers
How long does nebulizer tx take?
10-20 mins depending on # of mls
- check w/ pt or have pt call when done*
- rinse mouth after use*
- f/u with respiratory assessment*
What are the key differences in MDI’s, DPI’s, and nebulizers (all administer respiratory meds deep into lungs):
MDI’s (aerosol) - requires coordination between releasing meds “push” and breathing in at the same time; have to breathe slowly and deeply.
DPI’s (dry powder)- there is no “push” rather your inward breath activates the medicine; usually need to breathe harder than MDI’s
Nebulizers - turn liquid meds into mist inside a mask
List advantages and disadvantages of DPi’s:
A - no spacer; requires less manual dexterity than MDI’s
D - may clump in humid environments; some pts cannot inspire at the speed needed to administer an entire dose of meds.
List adventitious sounds:
Crackles (brief popping sounds)
Wheezes (continuous musical sounds, high or low pitched, usually pronounced during expiration)
Pleural rub (creaking or grating sounds - similar to walking on fresh snow)
What are the purposes of respiratory therapy?
- increase O2 saturation of arterial blood (e.g O2, bronchodilators)
- assist respirations (e.g O2, bronchodilators)
- mobilize/liquefy secretions (e.g mucolytics, expectorants (meds))
- prevent complications (e.g DB&C, incentive spirometer)
What protocols are to be followed for O2 therapy?
- use only when needed
- treat it as a drug
- routine check MD’s orders
- apply 7 rights
- consider dangerous side effects (atelectasis or O2 toxicity)
- dosage and concentration should be continuously monitored (check O2 state & titrate or d/c prn)
What safety measures need to be considered for O2 therapy?
- COMBUSTION
- teach re: safety precautions
- eliminate sparks
- avoid static electricity
- avoid volatile, flammable materials (i.e alcohol, petroleum-based lip agents (vaseline), nail polish remover, oil-based lotions)
- use water-soluble lubricants
List ‘low flow delivery systems’ used for O2 therapy:
- nasal cannula
- simple face mask
- partial and non-breather masks
- oxygen-conserving cannula (oxygenizer)
List ‘high flow delivery systems’ used for O2 therapy:
- venturi masks
- misty Ox
- face tent
- T piece
- star wars mask
- tracheostomy collar
What does nursing care look like for O2 therapy?
- see doctors order
- inspect placement and safety with every interaction
- assessment (daily, before & after tx - includes respiratory assessment, O2 stat)
- interventions (change equipment, oral/nares care, teaching)
- documentation (of assessment oxygen therapy used, the effect on the patient)
When is the ‘high flow delivery system’ for O2 therapy used?
When low flow delivery system is not effective enough to maintain O2 stats
Which type of ‘low flow delivery system’ provides the highest O2 level?
Non-breather mask
What are the benefits and indications of humidification use?
Indications:
- continuous O2 therapy
- when giving O2>4L/min
- as per the doctor’s order/nurse’s discretion
Benefits:
- prevents drying of mucous membranes
- keeps mucous secretions moist
- helps mobilize secretions to prevent obstruction & infection
