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19 Cards in this Set
- Front
- Back
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Prep PT
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Position client upright w/o support if possible.
If PT is unable to sit up, roll him from side to side, inspecting and auscultating both lungs in each position. |
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Prep PT
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Provide good lighting
*REMEMBER: With either technique (up or side to side, always compare one side to the other) |
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Questions to Ask
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*Are you having difficulty breathing?
*Are you coughing? If so, is the cough productive? Frequency? Amount? Color of Sputum? |
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Inspection
General Overview |
Alertness, Level of consciousness, Skin color, cyanosis (mouth, lips, earlobes, conjunctivae)
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Inspection
Chest shape |
Symmetry
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Inspection
Pattern of respirations |
Rate, Depth, Rhythm, Effort
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Inspection
Cough |
Productive? Nonproductive? Frequency?
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Auscultation Technique
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Use diaphragm of stethoscope placed firmly on uncovered skin
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Auscultation Technique
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Instruct client to breathe slightly slower and deeper than normal, with the mouth open
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Auscultation Technique
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Listen to at least one full inspiration and expiration in each location
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Auscultation Technique
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Avoid bone and breast tissue; place the diaphragm in the intercostal spaces
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Auscultation Technique
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If you note an abnormal sound, ask the client to cough and note changes in the sound
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Sequence of Events
1. RATE |
State the number
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Sequence of Events
2. Rhythm |
Even, Irregular (speak to pattern noted or use terminology listed)
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Sequence of Events
3. Depth |
Deep, Shallow, Moderate
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Sequence of Events
4. Use of accessory muscles |
Note
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Sequence of Events
5. Lung sounds |
Label the sounds or describe the characteristics. Are they heard on inspiration, expiration, anteriorly or posteriorly
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Sequence of Events
6. Oxygen |
Device- Nasal Cannula, Nasal catheter, Mask, Partial Rebreather, Venturi Mask, etc.
Flow Rate- State the number indicated on the flow meter Condition of mucous membranes: moist, dry, without lesions, drainage |
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Sequence of Events
7. Cough |
Frequency, consistency, productive, odor
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