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NURS 1145 > Wk 2 Throax And Breast > Flashcards

Wk 2 Throax And Breast Flashcards

1
Q

Abnormal INSPECTIONS breathing

A

Nasal flaring,
Retractions (the intercostal muscles are sucked inward, between the ribs, when you breathe),
Pursed Lips,
Tripod,
Rate up/down,
Use of accessory muscles to breathe, Anxious

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2
Q

Trail Sign Cause

A

The prominence of sternal head of Sternomastoid due to the shift of the trachea to the same side

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3
Q

when the air in the small airways of the lungs is replaced with a fluid, solid, or other material such as pus, blood, water, stomach contents, or cells

Atelectasis, infection, pulmonary hemorrhage, aspiration, or lung cancer.

A

Consolidation

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4
Q

When Ausculating the Anterior Left Thorax which part of the lung are you listening to? Right?

A

Left upper lobe. Right middle and upper

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5
Q

Tactile Fremitus (Vibration)

Place hands in Wings posistion with Ulnar surface in contact

Have paitent say 99 while moving downward

What are you looking for?

A

Signs of Abnormalities
Equal vibrations both sides

Increases fremitus: denser or inflamed lung tissue. Pneumonia.

Decreased Fremitus:
Pleural effusion, pneumothorax or large pulmonary blebs.

Air or Fluid in the pleural spaces or a decrease in lung tissue density.

COPD /Asthma.

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6
Q

Causes of Pulmonary Edema

A

Sever Heart Failure & Sever Hyper Tension

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7
Q

This procedure to meaure how deep breath is: Paitent takes deep breath and nurse percusses down from Resonance to Dull sound.

A

Diaphragmatic Excursion

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8
Q

Abnormal findings on egophony test the EEE will sound lkke AAA due too

A

Lung consolidation or lung density

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9
Q

Normal Anterior Ausculation includes (3)
Vesicular sounds

A

Bronchial Tracheal (Throat)
Vescular (Lung Fields)
Bronchovescular (near sternum - lung fields)

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10
Q

Physical breast Exam: 2 Bimanual palpations. This is the first step in the breast exam True or False

A

True

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11
Q

Physical breast Exam: 3 Palpation patters. Describe, where it ends at

A

Cover whole breast,Up into the axilla into the Tail of Spence

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12
Q

Abnormal findings Breast Cancer
Signs of Retractions and Inflammation

Dimpling
Edema (peau d’orange) -Skin of orange
Fixation (breast tissue is adhered to thorasic wall)

&

(2)

A

Deviation of nipple pointing
Nipple retraction

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13
Q

Rhonci aka _______ is a continuous snore-like Deep, low pitched rumbling.

Cause

A

Sonorus Wheeze

Tracheal/ bronchial passages with the presence of Mucus or Respitory secretions.

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14
Q

Restraints maybe used immediately then after you may get the doctors orders for it.

True or False

A

True

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15
Q

Ineffective Airway Clearance Nurses Assessment

A
  1. Determine the causative factors: Obstruction or narrowing of the airway
  2. Assess the patient’s respiratory status.
    Closely monitor and document respiratory rate, depth, pattern, and O2 saturation as ordered.
  3. Observe for other dyspnea-related symptoms.
  4. Listen to the breath sounds.
    Vesicular or adventageous
  5. Review arterial blood gas (ABGs
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16
Q

Subjective Data- Health History- pneumothorax Questions (7)

A

Cough
Shortness of breath
Chest pain when breathing
History of respitory infections
Smoking History packs / day * number of years
Environmental exposure
Self-care behaviors

CSC HSES

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17
Q

Inspection of a person with breathing troubles will reveal

A

Sweaty, palid skin color, leaning forward

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18
Q

Ineffective Airway Clearance

Interventions

A

Assessment:

Positioning: Position the patient appropriately. Elevate the head

Mobilization:

Chest Physiotherapy:

Breathing Exercises:

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19
Q

Physical diagnostics, measurement of Pulmonary Function Status
(3) Test

A

Forced Expiratory Time
Pulse Oximeter
6 minute distant walk

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20
Q

How does the breast exam end?

A

Squeezing the nipple
Looking for drainage

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21
Q

Nursing interventions for pulmonary edema

A

Elevate the head of the bed or place the patient on their side. …
Apply oxygen. …
Regularly check the ABGs. …
Cautiously use diuretics as prescribed. …
Give vasodilators with diuretics as adjuvant therapy. …

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22
Q

Nursing interventions for pulmonary edema

A

Elevate the head of the bed or place the patient on their side. …
Apply oxygen. …
Regularly check the ABGs. …
Cautiously use diuretics as prescribed. …
Give vasodilators with diuretics as adjuvant therapy. …

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23
Q

Discontinuous sounds Crackles Fine (Rales) High Pitch

Associated with what disease?
Heard when?
Location inside lung?
Characteristics
Physical cause of the sound

A

Pulmonary edema, pulmonary fibrosis, and pneumonia, Atelectasis, Chronic Heart Failure CHF

End of Inspiration

Alveoli & Bronchioles

Doesn’t clear with cough

Air entering into deflated alveoli

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24
Q

Ausculate: Breath Sounds

Bronchial vesicular Breath Sounds (Anterior or Posterior)

A

Anterior

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25
Q

Disease associated with Rhonci (wheezes) ( continous low gargling or bubbling) In & Exhalation

A

Asthma, Emphysema, Chronic Bronchitis

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26
Q

Ausculate: Breath Sounds
Bronchovescular breath sounds (Anterior or Posterior)?

A

Both

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27
Q

Cause of Stridor (a continuous high-pitched crowing during inspiration)

Heard with which diseases

A

Partial obstruction of Lyrnx or Treache

Heard in: Croup & Foreign Bodies Obstruction

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28
Q

Cause of Stridor (a continuous high-pitched crowing during inspiration)

Heard with which diseases

A

Partial obstruction of Lyrnx or Treache

Heard in: Croup & Foreign Bodies Obstruction

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29
Q

Nursing interventions for Kussmauls breathing

A

Hydration

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30
Q

Health History question for Breast & Axilla

A

Pain
Lump
Discharge
Rash
Swelling
Trauma
History of breast diseaese
Surgery
Self-care behaviors; breast self-examination/ mammogram

Axilla
Tenderness
Lump
Swelling
Rash

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31
Q

Pleural rub is the Movement of inflammed pleural surface against eachother during Movement.

Describe the sound

Disease causes

Heard lower in the anterior lung.

A

Like leather rubbing against itself.

Causes: TB & Pneumonia

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32
Q

Patency

A

the condition of being open, expanded, or unobstructed.

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33
Q

buildup of fluid between the tissues that line the lungs and the chest.

Poor pumping by the heart or by inflammation.

Is called this.

It is associated with the palpation technique of tactile fremitus (increased or decreased)

A

Pleural Effusion

Decreased

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34
Q

Cheyne-Stroke-Respiration:

changes in the apnea threshold and the fluctuating PCO2 levels.

Heart failure or stroke

Describe breathing mannerisms

A

Gradual hyperpnea - Gradual hypopnea - apnea. Then the cycle repeats

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35
Q

deformity of the chest wall in which the breastbone and ribs are pushed outward

A

Pectus Carinatum

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36
Q

In the bronchophony test the paitent says 99 in a normal voice. If during auscultating with stethoscope the words sound louder this could suggest

A

Consolidation

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37
Q

Which intervention may a nurse do to reduce symptoms of Rhonci (wheezes) (continuous gurgling or bubbling sounds) Heard during In & Exhalation

Asthma, Chronic Bronchitis, Emphysema

A

Promote coughing

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38
Q

Describe Trail sign

A

Prominence of sternal head of Sternomastoid.

Due to shift of trachea to same side

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39
Q

When do we suggest Pursed Lips Breathing? What is the saying we use to teach it?

A

Pursed lip breathing helps control shortness of breath, and provides a quick and easy way to slow your pace of breathing, making each breath more effective.

Smell the Roses, blow out the Candles

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40
Q

Tachypnea is > 20 respirations 1 minute. Tachypnea is increased rate and ____ depth of breaths

A

Decreased

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41
Q

The Physical- Palpate (3)

A

Symmetric chest expansion
Tactile fremitus
Palpate the anterior chest wall

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42
Q

Diseases with decreased fremitus:

Cause of decreased decreased Fremitus

A

COPD / Astma. Pleural Effusion & Pneumothorax

Air or fluid in the pleural spaces / Decrease in Lung Density

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43
Q

Pink & Frothy sputum is an indication of…

A

Pulmonary Edema

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44
Q

Too much fluid, an outpouring of fluid.

For example: accumulation of fluid in the pleural space between the lungs and the chest wall _____

While a ______ is an abnormal amount of fluid in the knee joint.

A hemorrhagic ______ contains blood in the fluid.

A

Effusion

Pleural effusion

Knee effusion

Effusion

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45
Q

Crackles Course Low Discontinuous

Timing: Start of Inspiration but can extend to expiration

Location: Large airways Bronchi

Characteristics: Gurgling/ Bubbling
Cough No Help

Physical Cause:
Breathing air into partially blocked airways, Large-bronchi, that are filled with mucus

Found in Diseases:

A

Heart Failure due to Pulmonary Edema
Pneumonia
Bronchiectasis-Chronic Condition
Infection that causes mucus secretion

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46
Q

Fremitus more than nomal on one side = (which possible disease)

A

Pneumonia

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47
Q

Stridor is high pitched and louder in which area

A

Neck

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48
Q

Degenerative diseases of the spine (such as arthritis or disk degeneration)

Fractures caused by osteoporosis

(osteoporotic compression fractures)

Injury (trauma)

Slipping of one vertebra forward on another (spondylolisthesis)

A

Kyphosis

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49
Q

Physical breast Exam: Palpation use ___ fingers, lay on back and put small pillow under breas5

A

3

50
Q

History of Breast Cancer
Have a known BRCA1 or BRCA2 gene mutation

OR

________

A

1st degree relative with gene mutation

51
Q

Physical breast Exam: to access for Dimpling (2)

A

Lean forward or Hands clasped held together

52
Q

Sibilent wheeze aka _____ is a continuous, High Pitched Musical sound.

Caused by…

A

Classic wheeze

Air passing out of obstructed / narrowing airway.

Asthma

53
Q

Physical breast Exam: Posistion

A

Seated, leaning forward

54
Q

Egophony is when auscultating with stethoscope and the spoken EEE become an AAA. Goat like sound is a sign of this

A

Consolidation

55
Q

Consolidation / Pneumonia have (Increased / Decreased) Ausculation sound

A

Increased

56
Q

Tracheal Posistion: Midline
Towards Diseased Side / Away from diseased side

A

Towards: Surgery / Atelectasis

Away: Pneumothorax/ Mass

57
Q

When ausculting the posterior chest which part of the lung are you listening to?

A

Mostyl lower

58
Q

Good air entry, equal bilateraly, no adventitious sounds throughout all lobes on anterior thorax. Bronchovescular sounds heard in upper lobes close to sternum. Vesicular sounds heard throughout peripheral lung field.

Is an example of what?

A

Documentation of normal lung findings

59
Q

Adventitious sounds are…
Examples
Sounds heard in addition to normal breathing sounds

A

crackles, rhonchi, and wheezes, Stridor, Pleural Rub

60
Q

Whispered pectoriloquy: Ask the patient to whisper a sequence of words such as “one-two-three,” and listen with a stethoscope. Normally, only faint sounds are heard. However, over areas of tissue abnormality, the whispered sounds will sound ….

A

clear and distinct

61
Q

_______ is caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the outside of the lung. This is not the same as another type of collapsed lung called , which occurs when air escapes from the lung.

A

Atelectasis, pneumothorax

62
Q

Tripod posistion

A

Put your hands or elbows on your knees and lean forward as you breathe. Helps to get more air into the lungs

63
Q

Kussmauls breathing: Deep, Sighing respiration w/ normal / slow rate.

What is the cause of this

A

Acidosis below 7.35.

Normal 7.35 - 7.45

Body is expelling Carbon Dioxide

64
Q

Atelectasic crackles are Fine crackles with what difference

A

They come and go

65
Q

Stridor is a continuous high pitched, crowing, mostly during which part of respiration

A

Inspiration

66
Q

Obstruction, Emphysema, Pneumothorax, Pleurisy all have this in common in regards to Ausculation

A

Abnormal: Decreased/ absent sound

67
Q

Sputum Assessment:

White
Yellow or Green
Rusty colored
Pink frothy

A

White: usually indicates healthy lungs, but a lot of sputum may indicate a lung disease, allergy, or viral infection

Yellow or Green: This usually means your body is fighting off some sort of infection. People often develop yellow phlegm in the early stages, and it turns green the longer the infection lingers

Rusty: Streptococcus pneumonia

Pink foamy: pulmonary oedema (fluid in the lungs) – your sputum will be pink and frothy, and this usually occurs in people with pre-existing heart problems.

68
Q

How many lobes in the left lung? Right?

A

2 & 3

69
Q

If trachea (not centered) is posistioned towards the diseased side give 2 reasons why

A

After surgery
Atelectasis (Collapse of Aveoli)

70
Q

When do we self-check for breast cancer
Women before & after menopause

A

Before: 1 week after menstruation
After: once a month

71
Q

respiration is a specific form of periodic breathing (waxing and waning amplitude of flow or tidal volume) characterized by a crescendo-decrescendo pattern of respiration between central apneas or central hypopneas.

A

Cheyne-Stokes

72
Q

If pulse ox is below 87 during 6 minute walk test what happens on discharge

A

Home oxygen

73
Q

Ausculating the Left & Right Lateral Placement which part of the lungs are you listening to?

A

Equal lower and upper part of the lung

74
Q

Barrell Chest = Ribs spread more than 90° is an indicator of hypoxic conditions such as

A

COPD

75
Q

Patterns of Respirations Inspection: Eupnea

A

Slow, Regular, 10 - 16, variable

76
Q

During percussion HyperResonance over lungs may indicate…

A

COPD or Emphysema

77
Q

sensation felt by a hand placed on a part of the body (as the chest) that vibrates during speech.

A

Fremitus

78
Q

Kassmaul’s Respiration: Describe and what purpose

A

Deep,sighing respiration with normal or slow rate.

Expelling carbon dioxide due to acidosis associated with DM

79
Q

Sound associated with Atelectasis

A

Crackles in lung

80
Q

Causes of Atelectasis

A

Lack of deep breaths, laying in bed too much, weak

81
Q

Chronic cough is defined as more than ___ months in 2 years

A

3

82
Q

Lung consolidation occurs when the alveoli and bronchioles get filled with fluid, blood, cells qnd is associated with which diseases

A

Atelectasis, Pneumona,Infection, Pulmonary Hemorrhage, Aspiration, Cancer

83
Q

Trachea Posistion: Away from diseased side. 2 causes

A

Pneumothorax (Acute) ie. Accident
Mass

84
Q

Fremitus less vibration than normal on 1 side = (possible disease)

A

Pneumothorax

85
Q

To detect Bronchophony: Ask the patient to say _____ in this kind of voice

A

99 / normal

86
Q

Agonal Breathing: involuntary and insufficient respirations that are caused by low oxygen

Likely dying.

Give a common sign of this

A

Shaking

87
Q

Eupnea (True/Regular Breathing) Slow, Regular, ______ BMP

A

10 - 16

88
Q

Nursing intervention for fine crackles

A

Assessment: Conduct a thorough respiratory assessment to determine the extent and location of fine crackles. Assess the patient’s oxygen saturation, respiratory rate, and effort

Positioning: Position with head elevated

Oxygen Therapy:

Medications:

Auscultation:

Fluid Management:

89
Q

Smoking (2nd hand), Work Environment, & Genetic Alpha -1 defiency

Are causes of which disease

A

COPD

90
Q

What 2 areas are covered during a cough Assessment

A

Timing

Dry vs moist

91
Q

When is a sputum sample taken

A

Early AM

Before eat or drink

92
Q

Normal diaphragmatic excursión is _____ cm but can be increased to ____ in well-conditioned persons

A

3 - 5 / 7-8

93
Q

What does diaphragmatic excursion measure

A

Contraction of the diaphragm

94
Q

Diaphragmatic excursion test is looking for

Concerned with which diseases states

A

Movement of the diaphragm

Chronic Obstructive Pulmonary Disease (COPD)
Atelectasis:
Pulmonary Fibrosis:
Pneumonia:

95
Q

Diaphragmatic excursion < 3 - 5 cm paitent may have

A

Pneumonia or pneumothorax

96
Q

Why would one ausculate the posterior chest

A

Breath Sounds (vesicular sounds)

97
Q

Where do you ausculate normal bronchial sounds

A

Trachea & above manubrium (most superior portion of the sternum)

98
Q

Describe palpation of the anterior chest during a respitory physical exam

A
  1. Symmetric chest expansion
  2. Tactile fremitus
99
Q

Spirometry

A

Most common of the “Pulmonary Function Test”

Measures amount and / or speed of air that can be inhaled or exhaled

100
Q

Which conditions are assessed by spirometry

A
  1. Asthma
  2. Pulmonary Fibrosis
  3. Cystic Fibrosis
  4. COPD
101
Q

________ also known as breast skin dimpling or tethering, can be a sign of an underlying breast issue, including breast cancer.

A

Breast retractions

102
Q

Visible Dimpling or Puckering:
Changes in Texture: (peau d’orange).
Tethering to the Chest Wall
Nipple Changes:
Unilateral Symptoms:

Are signs of what

A

Breast retractions associated with breast cancer

103
Q

Bronchovescular sounds heard in upper lobes close to _____

A

sternum

104
Q

Examination noted diaphragmatic excursion of 4 cm on the right and 8 cm on the left side. What do these findings mean…

A

Possible Pleural Effusion

105
Q

What are normal breath sounds called

Abnormal

A

Vesicular

Adventitious

106
Q

Diaphragmatic excursion uses this type of assessment

What are normal findings

Abnormal findings

Diseases associated with abnormal findings

A

Percussion after exhaling to diaphragm.

Percussion after Inhalation, note difference.

Normal 3-5 cm

Ab normal <3 - 5 cm

Diseases associated: COPD

107
Q

Pink frothy sputum is from pulmonary edema.

How do you get pulmonary edema

A

Heart Failure

Hypertension

108
Q

Why would someone have pale nail beds?

A

Poor perfusion / anemia

109
Q

Heart rate with anemia is (up /down)

A

Up

110
Q

Thoracic chest expansion is less on 1 side.

Causes

A

Pneumothorax

111
Q

When auscultating more abnormal sounds are heard at (Top/ Bottom)

A

Bottom

112
Q

Closer to the vertebrae this type of vesicular sound is heard

A

Bronchovescular

113
Q

Posterior breathing sounds (2)

Anterior breathing sounds (3)

A

Vesicular, Bronchovescular

Vesicular, Bronchovescular, Bronchials(Closer Trachea)

114
Q

Pectus Excavatum

Which disease is associated with

A

Marfan syndrome

Inherited disorder that affects connective tissue — It affects the heart, eyes, blood vessels and bones.

People with the syndrome are usually tall and thin with long arms, legs, fingers and toes.

115
Q

Intervention to make crackles go away. (2)

A

Spirometry

Deep breathing exercises

116
Q

Siblant wheezes are (high / low) pitched

Sonorous wheezes (high / low) pitched

A

High

Low

117
Q

Sonorous wheezes is aka

Clears up with cough

A

Rhonci

118
Q

Striodr (croup) is caused by (bacteria, virus, Inflammation)

A

Virus

119
Q

Smaller airways, such as bronchioles.

Commonly heard in conditions like pneumonia, early congestive heart failure, or restrictive lung diseases.

High or Low pitched crackles

A

High

120
Q

Larger airways, bronchi, or the presence of secretions.

Commonly heard in conditions such as chronic bronchitis, bronchiectasis, or pulmonary edema.

High or low pitched crackles

A

Low pitched crackles

NURS 1145 (11 decks)

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