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25 Nursing Assessment - Resp (c)

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1.

accessory muscles

internal intercostals
scalene (lateral neck)
trapezius
abdominals
sternocleidomastoid (ant. neck)

2.

Acute coughs are


most often ____

viral

3.

adventitious breath
sounds

includes crackles, rales, wheezing,


stridor, pleural friction rub

4.

anatomic
deadspace

air in the conducting airway - from mouth


to bronchioles
-not participating in gas exchange

5.

Causes of coughing

inflammation, tension in airways, tumors,


allergies, smoking, post nasal drip,
esophageal reflux, and less commonly
left-sided HF

Chronic Bronchitis
is a classic sign of
? (2)

lung cancer
tuberculosis

7.

clubbing

caused by chronic hypoxia

8.

Correct
auscultation form:

-Breathe normally through open mouth


-start at apices above scapula from left
to right down back
-compare sounds bilaterally
-Breath sounds on Left are heard 1 inch
Lower than right due to higher right
diaphragm/liver

9.

crackles

aka rales; predominately inspiration,


may clear with coughing, due to fluid in
lungs

10.

crepitus

may be used interchangeably with subq


emphysema but also refers to bone or
joint abnormalities

6.

17.

Dehydration and dry skin


is common in ____ pts

COPD (and asthma)

18.

dyspnea

subjective feeling of shortness of


breath/breathlessness
-pts may describe feeling
smothered or pins and needles
sensation

19.

Edema in lower
extremities is usually
related to ____ which is
common in patients with
____

right-sided heart failure, COPD

20.

Expiration

Relaxation: chest size reduces


which increases pressure
gradient

21.

Familial risk of lung


cancer is most likely
related to:

Smoking cigarettes inside the


house

22.

fremitus

vibration transmitted through the


lungs and chest wall and
palpated on the pts thorax during
low frequency vocalization
-increased with density in lungs:
neoplasm, atelectasis,
pneumonia, fibrosis
-decreased when fluid or air in
lung space: COPD, obesity

23.

hemoptysis

coughing up blood
-may indicate infection, pulm
vasculitits pulm emboli, pulm
edema, bronchitits, lung abcess,
TB or cancer

24.

hemothorax

blood in pleural cavity


-usually caused by trauma
-can lead to hemodynamic
compromise and shock

11.

CT angiography are
used to detect

pulm embolism

12.

Cultural
Considerations:
Amulets

Jewelry worn to ward off evil


-ask pt to wear on different part of body
for tests or leave it in view

25.

hyperpnea (Kussmaul
breathing)

Increased rate AND depth


-associated with metabolic
acidosis

13.

Cultural
Considerations:
Coining or Cupping

May leave marks, lesions, burns on skin


- may be mistaken for signs of abuse

26.

hypoxemia

decrease O2 in blood
low pO2 levels

27.

14.

Cultural
Considerations:
Herbal Remedies
and bathing

Some culturals believe that avoid water


and bathing will help resp illness
echinacea (Native American)
opium (Laos) used as analgesic

important info to obtain in


patient history:

culture, nutrition, exercise,


recent travel, social history,
occupational history

28.

Inspiration

15.

Cyanosis is usually
caused by ____,
____, and ____
disorders

cardiac, pulmonary, blood

Contraction: diaphragm drops,


external intercostals expand up
and out
REDUCES pressure inside lungs

16.

deadspace
ventilation

When blood flow to normally ventilated


alveoli is impaired
-example: pulm emboli, any condition
that reduces cardiac output (shock)

29.

Most common
risk factors
for resp
disorders
include

smoking (eventually leads to COPD, 85% of


lung cancers)
inactivity (risk for DVTs, pulm emboli)
CV disease
obesity (increased resistance, decreased lung
vol., Apnea)
substance abuse (CNS depressants can
contribute to pnemonia)
trauma (pneumonias, hypoventilation,
atelectasis)

41.

respiratory
alkalosis

pH > 7.45 high


pCO2 < 35 low
caused by hyperventilation and blowing
off of excess CO2

42.

resp. regulator in
brain

medulla oblongata (and pons)

43.

Role of the trachea

adds moisture
protects from dust, bacteria, ozone
warms/cools air to body temp

44.

shunt ventilation

When perfusion is normal but ventilation


is inadequate, blood flows past alveoli
w/o being oxygenated
-s/s of hypoxia
-examples: atelectasis, pneumonia,
pulm edema, COPD

45.

stridor

harsh crowing high pitched,


predominately inspiration, does not
clear with coughing, caused upper
airway obstruction or croup
-moderate to severe stridor is a sign of
airway obstruction and is considered a
medical emergency

46.

subcutaneous
emphysema

crackling sensation felt during palpation


caused by air in the subcutaneous
tissue
-etiology includes pneumothorax,
ruptured bronchial tube, ruptured
esophagus, gas gangrene

47.

Symptoms of
hypoxia

Mental status changes - agitation, poor


judgement, poor memory, attention
deficit

48.

Symptoms of
increased CO2 in
blood

lethargy, HA, decreased LOC

49.

Under normal
conditions, __% of
O2 is bound to
hemoglobin

98

50.

What does O2
attach to for
transport fro
cellular
consumption?

hemoglobin

51.

What does OPQRST


stand for?

Onset( - when did it start? What were


you doing?)
Provoking/palliative factors( - what
makes it better/worse?)
Quality( - describe your symptoms)
Region/Radiation( - location? does it
move?)
Severity( - pain scale)
Time( - When does it start? how long
does it last?)

30.

a
nonproductive
cough may be
related to: (2)

ACE inhibitors
irritation to airway

31.

non-rhythmic
breathing is a
classic sign
of:

neurological dysfunction

32.

Nursing
assessment
of resp status
includes:

interview
physical
careful monitoring
tests and labs

33.

Pallor +
increased HR
=

anemic and exercise intolerant

34.

Physical
Assessment:
What should
you LOOK for

signs of distress
use of accessory muscles/nasal flaring
General appearance

35.

Pink, frothy
sputum is
classic sign
of ?

pulm edema

plerual
friction rubs

high-pitched grating or squeking, heard on


inspiration AND expiration, does NOT clear
with coughing, caused by parietal and visceral
pleura rubbing together due to inflammtion

pneumothorax

air in the pleural space that prevents lung


from fully expanding and results in collapsed
lung

36.

37.

A pt with lots
of sputum
should have
more/less
water?

more

39.

Pulmonary
Function Test
PFT

determines the ability of the lungs to


efficiently exchange O2 and CO2
-spirometry, lung vol measurements, diffusing
capacity, ABG

40.

respiratory
acidosis

pH < 7.35 low


pCO2 > 45 high
causes drowsiness and unconsciousness
treat with increased ventilation

38.

52.

What to ask for PMH: Allergies

Allergies symptoms include congestion, coughing, wheezing, anaphaylaxis, airway


obstruction
Need to know about meds, plants foods, dusts, molds, and animals

53.

What to ask for PMH: Childhood

1. Immunizations (including flu),


2. premature birth (surfacant)
3. childhood diseases genetic or not (asthma and cystic fibrosis are most common)
-also ask about frequent colds, wheezing or SOB, swimming accidents, foreign body
accidents

54.

What to ask for PMH: Meds

bronchodilators
anticholinergics
steriods
Increased dosage or failure to take meds may increase pulm symptoms
Include OTC/herbals
Have pt demonstrate inhaler use
Bipap/Cpap and O2 are meds

55.

What to ask for PMH: Med/Surg

asthma exacerbation, infectious diseases, hospitalizations,


Trach, chest tube, intubation, prolonged O2 use, cardiac disease, thyroid tx for goiter,
liver failure

56.

wheezes aka rhonchi

musical, mostly expiration, usually not cleared with coughing, caused by airway
narrowing, secretions, inflammation

57.

Will a decrease/increase in pH stimulate


increased RR?

decrease (acidemia)