Wk 2 Throax And Breast Flashcards by Jade Ring

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

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Trail Sign Cause

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

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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

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

Left upper lobe. Right middle and upper

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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.

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Causes of Pulmonary Edema

Sever Heart Failure & Sever Hyper Tension

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

Diaphragmatic Excursion

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

Lung consolidation or lung density

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Normal Anterior Ausculation includes (3)
Vesicular sounds

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

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

True

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

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

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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

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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.

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

True or False

True

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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

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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

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Inspection of a person with breathing troubles will reveal

Sweaty, palid skin color, leaning forward

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Ineffective Airway Clearance

Interventions

Assessment:

Positioning: Position the patient appropriately. Elevate the head

Mobilization:

Chest Physiotherapy:

Breathing Exercises:

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

Forced Expiratory Time
Pulse Oximeter
6 minute distant walk

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How does the breast exam end?

Squeezing the nipple
Looking for drainage

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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. …

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Nursing interventions for pulmonary edema

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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

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Ausculate: Breath Sounds

Bronchial vesicular Breath Sounds (Anterior or Posterior)

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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

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

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

1. Symmetric chest expansion 2. 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

1. Asthma 2. Pulmonary Fibrosis 3. Cystic Fibrosis 4. 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)

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