Wk 2 Throax And Breast Flashcards
Abnormal INSPECTIONS breathing
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
Trail Sign Cause
The prominence of sternal head of Sternomastoid due to the shift of the trachea to the same side
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.
Consolidation
When Ausculating the Anterior Left Thorax which part of the lung are you listening to? Right?
Left upper lobe. Right middle and upper
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?
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.
Causes of Pulmonary Edema
Sever Heart Failure & Sever Hyper Tension
This procedure to meaure how deep breath is: Paitent takes deep breath and nurse percusses down from Resonance to Dull sound.
Diaphragmatic Excursion
Abnormal findings on egophony test the EEE will sound lkke AAA due too
Lung consolidation or lung density
Normal Anterior Ausculation includes (3)
Vesicular sounds
Bronchial Tracheal (Throat)
Vescular (Lung Fields)
Bronchovescular (near sternum - lung fields)
Physical breast Exam: 2 Bimanual palpations. This is the first step in the breast exam True or False
True
Physical breast Exam: 3 Palpation patters. Describe, where it ends at
Cover whole breast,Up into the axilla into the Tail of Spence
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)
Deviation of nipple pointing
Nipple retraction
Rhonci aka _______ is a continuous snore-like Deep, low pitched rumbling.
Cause
Sonorus Wheeze
Tracheal/ bronchial passages with the presence of Mucus or Respitory secretions.
Restraints maybe used immediately then after you may get the doctors orders for it.
True or False
True
Ineffective Airway Clearance Nurses Assessment
- Determine the causative factors: Obstruction or narrowing of the airway
- Assess the patient’s respiratory status.
Closely monitor and document respiratory rate, depth, pattern, and O2 saturation as ordered. - Observe for other dyspnea-related symptoms.
- Listen to the breath sounds.
Vesicular or adventageous - Review arterial blood gas (ABGs
Subjective Data- Health History- pneumothorax Questions (7)
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
Inspection of a person with breathing troubles will reveal
Sweaty, palid skin color, leaning forward
Ineffective Airway Clearance
Interventions
Assessment:
Positioning: Position the patient appropriately. Elevate the head
Mobilization:
Chest Physiotherapy:
Breathing Exercises:
Physical diagnostics, measurement of Pulmonary Function Status
(3) Test
Forced Expiratory Time
Pulse Oximeter
6 minute distant walk
How does the breast exam end?
Squeezing the nipple
Looking for drainage
Nursing interventions for pulmonary edema
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. …
Nursing interventions for pulmonary edema
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. …
Discontinuous sounds Crackles Fine (Rales) High Pitch
Associated with what disease?
Heard when?
Location inside lung?
Characteristics
Physical cause of the sound
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
Ausculate: Breath Sounds
Bronchial vesicular Breath Sounds (Anterior or Posterior)
Anterior
Disease associated with Rhonci (wheezes) ( continous low gargling or bubbling) In & Exhalation
Asthma, Emphysema, Chronic Bronchitis
Ausculate: Breath Sounds
Bronchovescular breath sounds (Anterior or Posterior)?
Both
Cause of Stridor (a continuous high-pitched crowing during inspiration)
Heard with which diseases
Partial obstruction of Lyrnx or Treache
Heard in: Croup & Foreign Bodies Obstruction
Cause of Stridor (a continuous high-pitched crowing during inspiration)
Heard with which diseases
Partial obstruction of Lyrnx or Treache
Heard in: Croup & Foreign Bodies Obstruction
Nursing interventions for Kussmauls breathing
Hydration
Health History question for Breast & Axilla
Pain
Lump
Discharge
Rash
Swelling
Trauma
History of breast diseaese
Surgery
Self-care behaviors; breast self-examination/ mammogram
Axilla
Tenderness
Lump
Swelling
Rash
Pleural rub is the Movement of inflammed pleural surface against eachother during Movement.
Describe the sound
Disease causes
Heard lower in the anterior lung.
Like leather rubbing against itself.
Causes: TB & Pneumonia
Patency
the condition of being open, expanded, or unobstructed.
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)
Pleural Effusion
Decreased
Cheyne-Stroke-Respiration:
changes in the apnea threshold and the fluctuating PCO2 levels.
Heart failure or stroke
Describe breathing mannerisms
Gradual hyperpnea - Gradual hypopnea - apnea. Then the cycle repeats
deformity of the chest wall in which the breastbone and ribs are pushed outward
Pectus Carinatum
In the bronchophony test the paitent says 99 in a normal voice. If during auscultating with stethoscope the words sound louder this could suggest
Consolidation
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
Promote coughing
Describe Trail sign
Prominence of sternal head of Sternomastoid.
Due to shift of trachea to same side
When do we suggest Pursed Lips Breathing? What is the saying we use to teach it?
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
Tachypnea is > 20 respirations 1 minute. Tachypnea is increased rate and ____ depth of breaths
Decreased
The Physical- Palpate (3)
Symmetric chest expansion
Tactile fremitus
Palpate the anterior chest wall
Diseases with decreased fremitus:
Cause of decreased decreased Fremitus
COPD / Astma. Pleural Effusion & Pneumothorax
Air or fluid in the pleural spaces / Decrease in Lung Density
Pink & Frothy sputum is an indication of…
Pulmonary Edema
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.
Effusion
Pleural effusion
Knee effusion
Effusion
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:
Heart Failure due to Pulmonary Edema
Pneumonia
Bronchiectasis-Chronic Condition
Infection that causes mucus secretion
Fremitus more than nomal on one side = (which possible disease)
Pneumonia
Stridor is high pitched and louder in which area
Neck
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)
Kyphosis
Physical breast Exam: Palpation use ___ fingers, lay on back and put small pillow under breas5
3
History of Breast Cancer
Have a known BRCA1 or BRCA2 gene mutation
OR
________
1st degree relative with gene mutation
Physical breast Exam: to access for Dimpling (2)
Lean forward or Hands clasped held together
Sibilent wheeze aka _____ is a continuous, High Pitched Musical sound.
Caused by…
Classic wheeze
Air passing out of obstructed / narrowing airway.
Asthma
Physical breast Exam: Posistion
Seated, leaning forward
Egophony is when auscultating with stethoscope and the spoken EEE become an AAA. Goat like sound is a sign of this
Consolidation
Consolidation / Pneumonia have (Increased / Decreased) Ausculation sound
Increased
Tracheal Posistion: Midline
Towards Diseased Side / Away from diseased side
Towards: Surgery / Atelectasis
Away: Pneumothorax/ Mass
When ausculting the posterior chest which part of the lung are you listening to?
Mostyl lower
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?
Documentation of normal lung findings
Adventitious sounds are…
Examples
Sounds heard in addition to normal breathing sounds
crackles, rhonchi, and wheezes, Stridor, Pleural Rub
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 ….
clear and distinct
_______ 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.
Atelectasis, pneumothorax
Tripod posistion
Put your hands or elbows on your knees and lean forward as you breathe. Helps to get more air into the lungs
Kussmauls breathing: Deep, Sighing respiration w/ normal / slow rate.
What is the cause of this
Acidosis below 7.35.
Normal 7.35 - 7.45
Body is expelling Carbon Dioxide
Atelectasic crackles are Fine crackles with what difference
They come and go
Stridor is a continuous high pitched, crowing, mostly during which part of respiration
Inspiration
Obstruction, Emphysema, Pneumothorax, Pleurisy all have this in common in regards to Ausculation
Abnormal: Decreased/ absent sound
Sputum Assessment:
White
Yellow or Green
Rusty colored
Pink frothy
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.
How many lobes in the left lung? Right?
2 & 3
If trachea (not centered) is posistioned towards the diseased side give 2 reasons why
After surgery
Atelectasis (Collapse of Aveoli)
When do we self-check for breast cancer
Women before & after menopause
Before: 1 week after menstruation
After: once a month
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.
Cheyne-Stokes
If pulse ox is below 87 during 6 minute walk test what happens on discharge
Home oxygen
Ausculating the Left & Right Lateral Placement which part of the lungs are you listening to?
Equal lower and upper part of the lung
Barrell Chest = Ribs spread more than 90° is an indicator of hypoxic conditions such as
COPD
Patterns of Respirations Inspection: Eupnea
Slow, Regular, 10 - 16, variable
During percussion HyperResonance over lungs may indicate…
COPD or Emphysema
sensation felt by a hand placed on a part of the body (as the chest) that vibrates during speech.
Fremitus
Kassmaul’s Respiration: Describe and what purpose
Deep,sighing respiration with normal or slow rate.
Expelling carbon dioxide due to acidosis associated with DM
Sound associated with Atelectasis
Crackles in lung
Causes of Atelectasis
Lack of deep breaths, laying in bed too much, weak
Chronic cough is defined as more than ___ months in 2 years
3
Lung consolidation occurs when the alveoli and bronchioles get filled with fluid, blood, cells qnd is associated with which diseases
Atelectasis, Pneumona,Infection, Pulmonary Hemorrhage, Aspiration, Cancer
Trachea Posistion: Away from diseased side. 2 causes
Pneumothorax (Acute) ie. Accident
Mass
Fremitus less vibration than normal on 1 side = (possible disease)
Pneumothorax
To detect Bronchophony: Ask the patient to say _____ in this kind of voice
99 / normal
Agonal Breathing: involuntary and insufficient respirations that are caused by low oxygen
Likely dying.
Give a common sign of this
Shaking
Eupnea (True/Regular Breathing) Slow, Regular, ______ BMP
10 - 16
Nursing intervention for fine crackles
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:
Smoking (2nd hand), Work Environment, & Genetic Alpha -1 defiency
Are causes of which disease
COPD
What 2 areas are covered during a cough Assessment
Timing
Dry vs moist
When is a sputum sample taken
Early AM
Before eat or drink
Normal diaphragmatic excursión is _____ cm but can be increased to ____ in well-conditioned persons
3 - 5 / 7-8
What does diaphragmatic excursion measure
Contraction of the diaphragm
Diaphragmatic excursion test is looking for
Concerned with which diseases states
Movement of the diaphragm
Chronic Obstructive Pulmonary Disease (COPD)
Atelectasis:
Pulmonary Fibrosis:
Pneumonia:
Diaphragmatic excursion < 3 - 5 cm paitent may have
Pneumonia or pneumothorax
Why would one ausculate the posterior chest
Breath Sounds (vesicular sounds)
Where do you ausculate normal bronchial sounds
Trachea & above manubrium (most superior portion of the sternum)
Describe palpation of the anterior chest during a respitory physical exam
- Symmetric chest expansion
- Tactile fremitus
Spirometry
Most common of the “Pulmonary Function Test”
Measures amount and / or speed of air that can be inhaled or exhaled
Which conditions are assessed by spirometry
- Asthma
- Pulmonary Fibrosis
- Cystic Fibrosis
- COPD
________ also known as breast skin dimpling or tethering, can be a sign of an underlying breast issue, including breast cancer.
Breast retractions
Visible Dimpling or Puckering:
Changes in Texture: (peau d’orange).
Tethering to the Chest Wall
Nipple Changes:
Unilateral Symptoms:
Are signs of what
Breast retractions associated with breast cancer
Bronchovescular sounds heard in upper lobes close to _____
sternum
Examination noted diaphragmatic excursion of 4 cm on the right and 8 cm on the left side. What do these findings mean…
Possible Pleural Effusion
What are normal breath sounds called
Abnormal
Vesicular
Adventitious
Diaphragmatic excursion uses this type of assessment
What are normal findings
Abnormal findings
Diseases associated with abnormal findings
Percussion after exhaling to diaphragm.
Percussion after Inhalation, note difference.
Normal 3-5 cm
Ab normal <3 - 5 cm
Diseases associated: COPD
Pink frothy sputum is from pulmonary edema.
How do you get pulmonary edema
Heart Failure
Hypertension
Why would someone have pale nail beds?
Poor perfusion / anemia
Heart rate with anemia is (up /down)
Up
Thoracic chest expansion is less on 1 side.
Causes
Pneumothorax
When auscultating more abnormal sounds are heard at (Top/ Bottom)
Bottom
Closer to the vertebrae this type of vesicular sound is heard
Bronchovescular
Posterior breathing sounds (2)
Anterior breathing sounds (3)
Vesicular, Bronchovescular
Vesicular, Bronchovescular, Bronchials(Closer Trachea)
Pectus Excavatum
Which disease is associated with
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.
Intervention to make crackles go away. (2)
Spirometry
Deep breathing exercises
Siblant wheezes are (high / low) pitched
Sonorous wheezes (high / low) pitched
High
Low
Sonorous wheezes is aka
Clears up with cough
Rhonci
Striodr (croup) is caused by (bacteria, virus, Inflammation)
Virus
Smaller airways, such as bronchioles.
Commonly heard in conditions like pneumonia, early congestive heart failure, or restrictive lung diseases.
High or Low pitched crackles
High
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
Low pitched crackles
