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53 Cards in this Set
- Front
- Back
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What are the four major functions of the respiratory system? |
a) supplying ocygen to the body for energy production b) removing carbon dioxide as a waste product of energy reactions c) maintaining homeostasis of arterial blood d) maintaining heat exchange |
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vital capacity |
maximum amount of air that a person can expel from the lungs after first filling the lungs to maximum |
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residual volume |
amount of air remaining in the lungs even after the most forceful expiration |
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What is the pitch, amplitude, duration, and quality of bronchial breath sounds? |
Pitch: high Amplitude: loud Duration: inspiration less than expiration Quality: harsh, hollow, tubular |
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Where are bronchial breath sounds located? |
Over the trachea and larynx |
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What is the pitch, amplitude, duration, and quality of bronchovesicular breath sounds? |
Pitch: moderate Amplitude: moderate Duration: inspiration = expiration Quality: mixed |
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Where are bronchovesicular breath sounds located? |
Over major bronchi, where fewer alveoli are located: posterior, between scapulae especially on right; anterior, around upper sternum in 1st and 2nd intercostal spaces |
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What is the pitch, amplitude, duration, and quality of vesicular breath sounds? |
Pitch: low Amplitude: soft Duration: Inspiration greater than expiration Quality: rustling, like the sound of the wind in the trees |
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Where are vesicular breath sounds located? |
Over peripheral lung fields, where air flows through smaller bronchioles and alveoli |
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emphysema |
permanent enlargement of air sacs distal to terminal bronchioles and rupture of interalveolar walls - airway resistance is increased, especially on expiration - causes hyperinflation of lung and increase in lung volume |
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midsternal line |
through the center of the sternum |
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scapular line |
through the inferior angle of the scapula |
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pleurae |
thin, slippery lining that forms an envelope between the lungs and the chest wal |
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dyspnea |
difficulty breathing |
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orthopnea |
shortness of breath while lying down, relieved by sitting or standing |
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paroxysymal |
severe attack or sudden increase in intensity of disease |
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nocturnal dyspnea |
sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position |
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tripod position |
leaning forward with arms braced against their knees, chair, or bed. this gives the patient leverage so that their rectus abdominis, intercostal, and accessory neck muscles all can aid in expiration |
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crepitus |
coarse crackling sensation palpable over the skin surface - occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue |
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crackles |
high pitched fine, short, interrupted crackling sounds heard during inspiration; not cleared with coughing |
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Where are crackles heard, and what are they caused by? |
- common in dependent lobes: right and left lung bases - caused by random sudden reinflation of groups of alveoli; disruptive passage of air through small airways |
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wheezes |
high pitched, continuous musical sounds as air passes through narrowed or obstructed airways during inspiration or expiration; usually louder on expiration |
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Where are wheezes heard, and what are they caused by? |
- heard over all lung fields - caused by high-velocity airflow through severely narrowed or obstructed airway |
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barrel chest |
increased anteroposterior diameter, producing a round barrel shape of the thoracic cage |
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What are the causes of barrel chest? |
- common with normal aging - also common with chronic emphysema and asthma due to hyperinflation of lungs |
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pleural friction rub |
dry, rubbing, or grating quality heard during inspiration or expiration; does not clear with coughing |
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Where is pleural friction rub heard, and what is it caused by? |
- heard over anterior lateral lung field - caused by inflamed pleura; parietal pleura rubbing against visceral pleura |
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rhonchi |
loud, low-pitched, rumbling coarse sounds heard most often during inspiration or expiration; sometimes cleared by cough |
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Where is rhonchi heard, and what is it caused by? |
- heard over trachea and bronchi - caused by muscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulence |
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Identify factors that may influence clients during a chest and lung assessment |
- physical activity - chest pain - pulmonary problems, such as clients confined to bed - illness |
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Information that needs to be included in a nursing health history of assessment of the chest and lungs |
- smoking history - persistent cough - environmental conditions - allergies - family history of diseases - shortness of breath - chest pain with breathing - self-care behaviours |
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What to look for when inspecting posterior thoracic cavity |
- shape and symmetry - note anteroposterior diameter - position of spine - slope of ribs - retraction of ICS during inspiration, bulging during expiration - assess rate and rhythm of breathing - assess for deformities |
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What to look for when inspecting anterior thoracic cavity |
- accessory muscle use with respiration - clients' facial expression - level of consciousness - skin color and condition - quality of respirations |
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Assessment technique for auscultation of anterior and posterior chest |
- use systemic pattern to allow side-to-side comparison - listen to an entire inspiration and expiration at each position of the stethoscope - have client take deep breath with an open mouth each time you move the stethoscope - place stethoscope directly on skin |
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Normal/expected findings of posterior thoracic cavity |
- chest contour symmetrical - anteroposterior diameter is half the transverse diameter - scapulae symmetrical and closely attached to thoracic wall - spine is straight without lateral deviation - ribs tend to slope down and across - no bulging or active movement occurs within ICS during breathing |
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Normal/expected findings of anterior thoracic cavity |
- accessory muscles move little with normal passive breathing - breathing is quiet and barely audible near open mouth - bronchial sounds are heard over trachea - chest expands and relaxes regularly with equality of movement bilaterally during breathing |
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Developmental considerations for older adults during assessment of chest and lungs |
- costal cartilages become calcified, reduced mobility of thorax - decrease in the ability to take a deep breath and exhale it - increased risk for shortness of breath with exertion beyond older person's usual workload |
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Information included in a nursing health history for assessment of the breasts |
- pain - lumps - tenderness - discharge - rash - swelling - trauma - surgery - family history of breast cancer - self-care behaviours - perform BSE - last mammogram |
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What to inspect for during breast assessment |
- size and symmetry, contour or shape - note masses, flattening, retraction, or dimples - skin colour, venous pattern - presence of lesions, edema, inflammation - inspect nipple and areola for size, colour, shape, discharge, and direction the nipples point |
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What to palpate for during breast assessment |
- condition of breast tissue - lymph nodes - lumps |
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Expected findings of breast assessment |
- breasts firm, dense, elastic, and without lesions or nodules - areolae are round or oval, and nearly equal bilaterally - breasts are the colour of the neighbouring skin, and venous patterns are the same bilaterally - nipples point in symmetrical directions, are everted, and no drainage - breast tissue glandular or lumpy bilaterally in some women |
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Guidelines to teach BSE |
- inspect unrobed infront of mirror - palpate during shower - 2 or 3 days after menstruation ends - postmenopausal women should perform BSE on the same day of each month - use 3 or 4 fingers, press flat part of fingers in small circles, moving the circles slowly around the breast - be sure to cover the entire breast - pay special attention the area around the armpit and the armpit itself - repeat on opposite breast - note any unusual changes, and get checked out right away |
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Developmental considerations for older adults during assessment of the breasts |
- breast glandular tissue undergoes atrophy due to decrease in ovarian secretion of estrogen and progesterone - decrease in breast size and elasticity - lactiferous ducts are more palpable around the nipples and feel firm and stringy because of fibrosis and calcification |
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gurgle |
to flow in a broken irregular current with a bubbling sound |
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What is soft rustling-like breath called? |
vesicular |
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What is the purpose of using percussion? |
to reveal abnormalities |
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What is assessed during palpation of the chest? |
- size and shape - ICS - scars/skin abnormalities - temperature - tenderness + pain |
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To check central cyanosis, what part of the body is examined? |
lips and tongue |
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Cheyne Stokes breathing? |
abnormal pattern of breathing - ranges from very shallow breaths to alternating periods of apnea and deep rapid breathing |
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What are the kinds of chest retractions? |
- subcostal - intercostal - supraclavicular |
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Tachynpnea |
rapid breathing |
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Bradynpea |
slow breathing |
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What are 2 abnormal findings of the thorax? |
- barrel chest - funnel chest |
