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NURS 522: Health Assessments > Chapter 19: Thorax & Lungs > Flashcards

Chapter 19: Thorax & Lungs Flashcards

(59 cards)

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1
Q

What should the costal angle be?

A

90 degrees

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2
Q

What are the anterior reference lines?

A

Anterior axillary line, midclavicular line, midsternal line

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3
Q

What are the posterior reference lines?

A

Scapular line, vertebral line

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4
Q

What are the lateral reference lines?

A

Anterior axillary line, midaxillary line, posterior axillary line

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5
Q

Where should you assess if you suspect consolidation of gunk in the lungs?

A

Posterior

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6
Q

Developmental Competence for Infants

A

Newborns have a high RR baseline; obligate nose breathers

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7
Q

Developmental Competence for Pregnant Women

A

Pregnant women may have shortness of breath as a result of impact of enlarging uterus (physiologic dyspnea…not abnormal)

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8
Q

Developmental Competence for the Aging Adult

A

Decreased vital capacity and increased residual volume (can’t breathe in as much and can’t breathe out as much)…higher risk for lung disease or affects of

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9
Q

What is the most common chronic disease in childhood?

A

Asthma; consider triggers and SDOH

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10
Q

Subjective Data

A

Cough
Shortness of breath
Chest pain
History or smoking or respiratory infection
Environmental exposure (eg. work)
Patient-centered care (TB test, chest XR, vaccinations)

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11
Q

Sputum

A

White/clear = colds, bronchitis, viral infection
Yellow/green = bacterial infection
Rust colored = TB, pneumococcal pneumonia
Frothy pink = pulmonary edema

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12
Q

Dyspnea

A

Difficulty breathing

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13
Q

Orthopnea

A

Difficulty breathing when lying down (heart failure)

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14
Q

Paroxysmal Nocturnal Dyspnea (PND)

A

When you wake up feeling short of breath…startles you up and induces quick breathing to catch up

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15
Q

Hemoptysis

A

Bloody sputum

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16
Q

Inspection

A

Facial expression
LOC
Posterior/anterior cage
Quality of respirations
Finger clubbing

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17
Q

Facial Expression

A

Pursed breathing, nasal flaring

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18
Q

Posterior/Anterior Cage

A

Shape and configuration: AP < transverse diameter (0.7-0.75)
Positioning: tripoding, compensation
Skin color and condition: cyanosis, pallor

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19
Q

Quality of Respirations

A

Labored vs. unlabored
Use of accessory muscles: sternocleidomastoid, trapezius (watch neck)

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20
Q

Clubbing

A

180 degree angle; result of chronic O2 deficiency (smokers, COPD, lung disease, heart disease)

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21
Q

Crepitus

A

Coarse, crackling sensation caused by free air trapped in subcutaneous tissue

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22
Q

Palpation

A

Symmetrical chest expansion
Tacile fremitus

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23
Q

Symmetrical Chest Expansion

A

Place hands at T9-T10 level and feel expansion for full respiration (check anterior and posterior)…should be symmetrical

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24
Q

Tactile Fremitus

Study These Flashcards
A

Checks for palpable vibrations…decreased vibrations could indicate consolidation in the lungs
Have the patient say resonant words/phrases (“99” or “blue moon”) at each spot while you feel with the palmar assessment
5 posterior spots, 4 anterior spots
Move in pattern across and down the thorax
Avoid boney prominences

25
Decreased Fremitus
Obstructed bronchus, pleural effusion, pneumothorax, emphysema
26
Increased Fremitus
Compression or consolidation (pneumonia)
27
Percussion
The prominent note over the lungs is RESONANCE 9 posterior spots, 5 anterior spots
28
Hyper-resonance
LOWER pitched, booming sound Emphysema or pneumothorax
29
Dull
Soft, muffled thud Pneumonia, pleural effusion, atelectasis, tumor
30
Auscultation
Assessing the passage of air through tracheobronchial tree, which creates a characteristic set of noises Have patient breathe in and out at each spot 9 posterior spots, 5 anterior spots
31
"Normal" Breath Sounds
Bronchial Bronchovesicular Vesicular
32
Bronchial Sounds
Loud, high-pitched, coarse quality Heard over the larynx and trachea Inspiration < expiration
33
Bronchovesicular Sounds
Intermediate sound quality Heard over the major bronchi Inspiration = expiration
34
Vesicular Sounds
Soft, low-pitched, whispering quality Heard over fine airways near site of air exchange Inspiration > expiration
35
Decreased (absent) Breath Sounds
Bronchial tree is obstructed Emphysema Anything obstructing sound transmission TOP PRIORITY FINDING
36
Increased Breath Sounds
Sounds are louder than expected High-pitched, tubular Sound very close to your stethoscope Consolidation or compression causes a dense lung area
37
Adventitious (abnormal) Sounds
Crackles Wheeze Ronchi Stridor Pleural friction rub
38
Crackles
Fine = high-pitched, soft, brief sound Coarse = low-pitched, moist, bubbling sound Pneumonia, emphysema, heart failure
39
Wheeze
High-pitched, musical sounds Asthma
40
Ronchi
Low-pitched, snoring sound May clear with a cough Bronchitis, fluid in the lungs
41
Stridor
Loud, high-pitched, crowing or honking in upper airway Airway obstruction EMERGENCY
42
Pleural Friction Rub
Loud, low-pitched, grating or squeaky sounds Decrease in pleural fluid
43
Tachypnea
Fast breathing (20+)
44
Hyperventilation
Fast breathing that is too deep
45
Bradypnea
Slow breathing (under 12)
46
Hypoventilation
Slow and too shallow breathing
47
Cheyne-Stokes Respirations
Eb and flow between apnea and tachypnea Meningitis, heart failure
48
Atelectasis
Collapsed shrunken section of alveoli or an entire lung Causes = airway obstruction, compression of the lung, lack of surfactant Expected observations = uneven chest expansion
49
Objective Assessment for Atelectasis
Inspection: cough, increased respiratory rate and pulse, cyanosis Palpation: chest expansion and tactile fremitus decreased on the affected side, tracheal shift with large collapse Percussion: dull Auscultation: decreased or absent vesicular sounds over affected area
50
Pneumonia
Infection in the lung parenchyma leaves alveolar membrane edematous and porous...alveoli fill up with bacteria, cellular debris, fluid, etc...little to no room for air/gas exchange Symptoms: fever, cough with pleuritic chest pain, blood-tinged sputum, chills, fatigue
51
Objective Assessment for Pneumonia
Inspection: tachypnea, guarding and lag on affected side, nasal flaring and accessory muscle use for children Palpation: pulse > 100 bpm, decreased chest expansion on affected side, increased tactile fremitus if bronchus open, decreased tactile fremitus if bronchus obstructed Percussion: dull Auscultation: adventitious sounds...crackles in adults, diminished breath sounds in children
52
Emphysema
Destruction of pulmonary connective tissue, permanent enlargement of air sacs Produces hyper inflated lung and increase in lung volume
53
Objective Assessment for Emphysema
Inspection: increased AP diameter (barrel chest), use of accessory muscles, tripoding, tachypnea Palpation: decreased tactile fremitus and chest expansion Percussion: hyper-resonant Auscultation: decreased breath sounds
54
Asthma
Hypersensitivity reaction to certain allergens, irritants, microbes, etc. Creates complex bronchospasm and inflammation, edema in bronchiole walls, and mucous secretion Greatly increase airway resistance
55
Objective Assessment for Asthma
Inspection: tachypnea with audible wheeze, use of accessory muscles, cyanosis, barrel chest if chronic Palpation: tactile fremitus decreased, tachycardia Percussion: resonant Auscultation: diminished air movement, decreased breath sounds with prolonged expiration; adventitious sounds...wheezing on expiration
56
Pleural Effusion
Collection of excess fluid in intrapleural space with compression of overlying lung tissue Fluid subdues lung sounds
57
Objective Assessment for Pleural Effusion
Inspection: increased respirations, dyspnea, dry cough, tachycardia, cyanosis, asymmetrical expansion, abdominal distention Palpation: decreased or absent tactile fremitus, decreased chest expansion on the affected side Percussion: dull Auscultation: Decreased or absent breath sounds; adventitious sounds...crackles
58
Pneumothorax
Free air in the pleural space Partial or complete collapse of the lung
59
Objective Assessment for Pneumothorax
Inspection: unequal chest expansion Palpation: decreased or absent tactile fremitus, tracheal shift to (unaffected side), decreased chest expansion on affected side Percussion: hyper-resonant Auscultation: decreased or absent breath sounds; adventitious sounds...none

NURS 522: Health Assessments (12 decks)

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