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30 Cards in this Set
- Front
- Back
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Signs of respiratory distress |
SOB when speaking, tachypnea, adventitious breath sounds, intercostal/sternal retractions, cyanosis (late sign), diaphoresis, nasal flaring, decreased LOC, agitation/apprehension/anxiety |
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Signs of decreased LOC and reasons for it occuring |
Caused by lack of oxygen and increased CO2
-restlessness, anxiety, confusion |
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Crackles "rails" what are they? and when are they heard? |
INSPIRATORY only -sudden popping open of alveoli, fluid in alveoli -fine and course
*most common lung sound |
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Wheezes "musical sounds" what are they? and when are they heard? |
INSPIRATORY or EXPIRATORY -constriction of bronchi/bronchioles |
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Rhonchi "rattles" |
low pitched sounds heard during EXPIRATORY
*sound of a lot of fluid within alveoli and airway |
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what respiratory diagnoses will crackles be heard? |
atelectasis, pneumonia, CHF, bronchitis, scarring (fibrosis) |
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What respiratory diagnoses will wheezes be heard? |
COPD, asthma, foreign bodies |
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pursed lip breathing suggests what _________ in a respiratory assessment |
*gets rid of CO2 and helps relax patient -suggests increased in breathlessness |
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tripod position suggests____________ |
-moderate to severe respiratory distress
*patients typically find this position on their own w/o direction. |
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accessory muscle use suggests___________ |
severe respiratory distress, hypoxemia -scalene, sternocleidomastoid muscles |
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when would altered chest movements be seen? |
when a pneumothorax occurs. -unsymmetrical chest movement. One lung is collapsed, so only one side of chest moves. Will hear altered or absent lung sounds on collapsed side |
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stridor: |
continuous musical or crowing sound of constant pitch; partial obstruction of larynx/trachea
(squeeky on inspiration) |
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pleural friction rub |
creaking, grating sounds from roughened, inflamed surfaces of the pleura rubbing together
(pleural lining is rubbing together- will hear on inspiration and expiration) |
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Common interventions for abnormal respiratory assessment findings : -7 total |
-check for airway obstruction, proper positioning of patient -suctioning - admin oxygen - using mechanical ventilation - have IV access - IS, C&DB - calm enviornment |
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ongoing assessments |
resp rate, lung sounds, skin color, pulse ox, changes in mentation |
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changes that occur with normal aging process |
reduction in alveolar surface area; loss of elastic recoil; decrease in vital capacity and oxygen saturation; decline in lung hose defense, reduction in excercise tolerance |
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assessment with aging adult |
current meds, hx of exposure, coughing and sputum production, current problems with breathing or performing ADL's. |
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pulmonary function tests are used to |
-diagnose pulmonary disease -monitor disease progression -evaluate disability -evaluate response to bronchodilators |
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Spirometry tests what two things |
Vital capacity and forced expiratory volume |
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what is vital capacity? |
maximum amount of air expelled after a maximum inspiration (measures how much the lung holds) |
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what is forced expiratory volume (FEV) ? |
amount of air a patient can forcefully exhale in 1 second (measures bronchoconstriction) |
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Measure the VC and FEV and compare to what? |
the patients age, height, sex and ethnicity
- then the value is expresses as a percentage of the expected value |
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Obstructive lung disease |
the airways are narrowed, usually causing an increase in the time it takes to empty the lungs - emphysema, bronchitis, infection (which produces inflammation) and asthma
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what are the results of PFT's in obstructive lung disease ? |
PFT's= FEV decreased, VC normal |
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restrictive lung disease |
there is a loss of lung tissue, a decrease in the lungs ability to expand, or a decrease in the lungs ability to transfer oxygen to the blood (or carbon dioxide out of the blood) |
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restrictive lung disease is caused by what? |
pneumonia, lung cancer, scleroderma and MS. -other restrictive conditions include: chest injuries, obesity, pregnancy, and loss of lung tissue due to surgery |
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results of PFT's in restrictive lung disease? |
PFT's= FEV normal, VC decreased |
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Peak expiratory flow meter measures what>? |
FEV -used as a baseline to determine how well asthma is being controlled -home spirometer; monitor lung function at home, adjust activity and meds in response to the results |
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bronchoscopy |
diagnostic and therupeutic tool (bronchial wash) -nasal pharynx and oral pharynx are anesthetized, a sedative will be given (concious sedation; pt to be NPO for 12 hours and must sign consent; be sure the gag reflex has returned prior to giving anything by mouth |
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Spiral CT scan |
looks for masses or PE; 3D look of the chest, more definitive and detailed test and quick |
