Respiratory System

Question 1

Order of assessment for Respiratory

Answer 1

INSPECTION
PALPATION
PERCUSSION (advanced)
AUSCULTATION

Question 2

Inspection
Shape and configuration

Answer 2

spinous process should appear in a straight line posterior, scapulae should be symmetric

Thorax is symmetric with an elliptical shape and downward sloping ribs about 45 degrees relative to the spine

Abnormalities – scoliosis and kyphosis

Question 3

Inspection
AP diameter

Answer 3

AP diameter should be less than the transverse diameter about 0.7

abnormalities eg..Pigeon chest (pectus carinatum) cartilage and ribs don’t form properly and chest becomes pushed outward

or Barrel-chest – AP diameter = transverse diameter with hyperinflation of the lungs

Neck and trapezius muscles should be developed normally for age
-Muscles can be hypertrophied in COPD

Note the position the person takes to breathe
Should be relaxed posture and the ability to support ones own weight with arms comfortably at sides

Tripod position is abnormal and can be seen in COPD, person leans forward with arms braced against knees

Question 4

Inspection
Assess skin: color, condition, lesions.

Answer 4

Color should be consistent with genetic background
Check nail beds, lips, & mucous membranes
Cyanosis is abnormal and occurs with tissue hypoxia

Question 5

Tachypnea

Answer 5

24 per minute
rapid, shallow

Normal response to fear, anxiety, exercise

Abnormal with respiratory insufficiency, pneumonia, alkalosis, lesions in the pons

Question 6

Bradypnea

Answer 6

<10 per minute
Slow, Regular rate

Drug induced respiratory depression of the medulla, Increased ICP, diabetic coma

Question 7

Orthopnea

Answer 7

shortness of breath when laying flat

sign of heart failure but can occur with lung disease and obesity

Question 8

Dyspnea

Answer 8

-harder to breath
-shortness of breath

Question 9

Paroxysmal nocturnal dyspnea

Answer 9

occurs at night, awaking with Shortness of Breath and needing to sit up to feel comfort

Caused by OSA, heart failure, lung diseases

Question 10

Periodic or Cheyne-Stokes respirations

Answer 10

abnormal breathing pattern that can occur while awake but usually when asleep.

It is a period of fast, shallow breathing followed by slow heavier breathing followed by moments of apnea (absence of breathing

Common in infants and older adults

Can signal pathology such as heart failure, renal failure, drug OD

Question 11

Biot’s (irregular Cheyne-Stokes)

Answer 11

The pattern is very irregular
Occurs with head trauma, brain abscess, encephalitis

Question 12

Fremitus

Answer 12

is a palpable vibration

“99” or “blue moon”

sounds generated from the larynx and transmitted through patent bronchi and lung parenchyma to the chest wall where you feel them as vibrations

Question 13

Pneumothorax

Answer 13

collapsed lung

Question 14

Rhonchal Fremitus

Answer 14

Vibration felt when inhaled air passed through thick secretions in the larger bronchi (felt anteriorly)

Question 15

Pleural Friction Fremitus

Answer 15

Inflammation of the parietal or visceral pleura

-feels like 2 pieces of leather grating together

Question 16

Crepitus

Answer 16

Coarse, crackling ~over skin surface

Occurs when air escapes from lungs and enters subcutaneous tissue

Question 17

subcutaneous emphysema

Answer 17

occurs with open thoracic injury or surgery

Question 18

Hyperresonance

Answer 18

too much air

– lower pitched booming sound

Found with pneumothorax or emphysema

Question 19

Bronchial Sounds

Answer 19

high pitch, loud amplitude,

inspiration is shorter than expiration

Sounds harsh, hollow or tubular
Heard over trachea and larynx

Question 20

Bronchovesicular

Answer 20

pitch is moderate, amplitude is moderate,

inspiration = expiration

Quality is mixed

Heard over major bronchi, posterior between scapulae closer to spinal column

Question 21

Vesicular

Answer 21

low pitch, soft amplitude,

inspiration is longer than expiration

Rustling sound like wind in the trees

Heard over peripheral lung fields

Question 22

Crackles (rales)

Answer 22

Crackles are discontinuous popping sounds heard over inspiration

Question 23

Wheeze (rhonchi)

Answer 23

Wheezes are continuous musical sounds heard mainly over expiration.

Question 24

Atelectatic crackles-

Answer 24

short popping sounds. Only for few breaths
not pathologic.

This occurs when sections are alveoli are closed and when they take a deep breath, they pop them open, making crackle noise.

They disappear with a cough or a few deep breaths.

Question 25

Pleural friction rub sound

Answer 25

Very superficial sound that is coarse, low pitched, grating quality, sounds like crackles but very close to the ear Caused when pleurae become inflamed and lose their normal lubricating fluid Occurs with pleuritic, accompanies by pain

Question 26

Stridor sound

Question 27

Mediastinum

Answer 27

Esophagus, trachea, heart, great vessels Pleural cavity contain lungs

Question 28

Lower lobes

Answer 28

T4-T12, Expiration on T10 Inspiration on T12

Question 29

acinus

Answer 29

is a functional respiratory unit the consists od bronchioles, alveolar ducts and alveolar sacs and the alveoli.

Question 30

Kussmals breathing

Answer 30

The body hyperventilates in response to severe metabolic acidosis particularly with Diabetic ketoacidosis (DKA) in an effort to reduce CO2 in the blood

Question 31

Tuberculosis (TB)-

Answer 31

airborne lung disease Incidence low in the USA Affects crowded\congested areas Top 5 countries – Mexico, Philippines, India, Vietnam and China 68% of US cases are found in foreign-born people Reactivation of latent TB in most cases Increase risk with HIV and homeless

Question 32

When recording data about a symptom or problem include the following:

Answer 32

Onset (date, sudden or gradual) Duration Frequency Precipitating factors Aggravating or alleviating factors Treatment/self-care Outcome

Question 33

Pectus Excavatum-

Answer 33

Pigeon chest - sternum sunken

Question 34

Barrel chest

Answer 34

when anterior posterior diameter = transverse diameter, caused by hyperinflation of the lungs common sign of COPD

Question 35

hypercapnia

Answer 35

increase in carbon dioxide in the blood

Question 36

hypoxemia

Answer 36

A decrease of oxygen in the blood also increases respirations but is less effective than hypercapnia.

Question 37

Anterior chest inspection

Answer 37

is the costal angle within 90 degrees Facial expression – relaxed or pursed lipped breathing (pursed lips for COPD) Level of consciousness Cerebral hypoxia may be reflected in excessive drowsiness, anxiety or restlessness – are the lips and nailbeds free of cyanosis or pallor, is clubbing present s – is breathing relaxed, no chest bulging or retractions should be seen (bulging seen with trapped air from emphysema or asthma, retractions seen with obstruction of respiratory tract for with increased respiratory effort Respiratory rate – is it normal 10-20 per minute

Question 38

Pectus carinatum-

Answer 38

Sternum malformed, sticking out

Question 39

Pleural effusion-

Answer 39

fluid in pleural space (wont expand as much with water)

Question 40

atelectasis

Answer 40

collapsed lung

Question 41

Lobar pneumonia-

Answer 41

pus in lungs, less air to expand

Question 42

Pneumothorax

Answer 42

(neo-thorax)- Air that got into potential space (penetration (pierced) in lungs)

Question 43

Dull precussion

Answer 43

note signals density in the lungs with pneumonia, pleural effusion, atelectasis, tumor

Question 44

emphysema

Answer 44

A lung disease which results in shortness of breath due to destruction and dilatation of the alveoli

Question 45

Adventitious Lung Sounds

Answer 45

Caused by moving air colliding with secretions in tracheobronchial passageways or by popping open of previously deflated airways You want to describe them as Inspiratory or expiratory Loudness and pitch Location

Question 46

Atelectatic crackles-

Answer 46

short popping sounds. Only for few breaths not pathologic. clear after a few breaths When sections are alveoli are not fully aerated, they deflate and accumulate secretions, crackles are heard when these secretions reexpand with a few deep breaths This occurs when sections are alveoli are not fully aerated. Crackles are heard when these sections are expanded by a few deep breaths. They are heard in the periphery, usually in dependent portions of the lungs. They disappear with a cough or a few deep breaths

Question 47

Crackles—fine

Answer 47

Discontinuous, high-pitched short crackling sounds heard during inspiration that are not cleared by coughing inspiratory crackles inhaled air collides with previously deflated airways then airways suddenly pop open Occurs with restrictive disease, pneumonia, heart failure, interstitial fibrosis, COPD, bronchitis, asthma

Question 48

Crackles—course

Answer 48

Loud, low pitched and gurgling sounds that start early in inspiration and may be present in expiration, may decrease with coughing but reappear Inhaled air collides with secretions in the trachea and large bronchi Occurs with pulmonary edema, pulmonary fibrosis, terminally ill who have depressed cough reflex

Question 49

Pleural friction rub

Answer 49

Very superficial sound that is coarse, low pitched, grating quality, sounds like crackles but very close to the ear Caused when pleurae become inflamed and lose their normal lubricating fluid Occurs with pleuritic, accompanies by pain

Question 50

Wheeze— high pitched (silbiant)

Answer 50

High pitched, musical squeaking that sound polyphonic (multiple notes as in a musical chord) Predominate on expiration but can be heard in both expiration and inspiration Air squeezed or compressed through very narrowed passageways due to collapsing, swelling, secretions or tumors Heard in diffuse airway obstruction from acute asthma or chronic emphysema

Question 51

Wheeze— low pitched (sonorous rhonchi)

Answer 51

Low pitched, monophonic (single note, musical), snoring, moaning sounds heard throughout the cycle although more prominent on expiration, may clear somewhat with coughing Airflow obstruction causing vibration Heard in bronchitis, single bronchus obstruction or from airway tumor

Question 52

Stridor

Answer 52

High pitched, monophonic, crowing sound, louder in neck than over chest wall Originating in larynx or trachea, upper airway obstruction from swollen, inflamed tissues or lodged foreign body Heard in croup and acute epiglottitis in kids and foreign body inhalation

Question 53

Pulmonary Function Studies (PFTs)

Answer 53

measure forced expiratory time. It is a measure for airflow obstruction PFTs are usually done “in the lab”

Question 54

Spirometer

Answer 54

is a handheld device used in ambulatory care to measure lung health in chronic conditions

Question 55

Pediatric

Answer 55

Diaphragm is newborn’s major respiratory muscle. Count respiratory rate for 1 full minute; normal rates for newborn are 30 to 40 breaths per minute but may spike up to 60 breaths per minute. Brief periods of apnea less than 10 or 15 seconds are common; this periodic breathing is more common in premature infants. Infant has a rounded thorax with an equal AP to transverse diameter, by 2 years old it is 1:2 Chest circumference is smaller than head circumference until age 2 Ribs and xiphoid are prominent Thoracic cage is soft and flexible Place bell over infant’s interspaces and not over ribs. Auscultation normally yields bronchovesicular breath sounds in peripheral lung fields of infant and young child up to ages 5 to 6 years. Fine crackles are adventitious sounds commonly heard in immediate newborn period from opening of airways and clearing of fluid. Babies are born with fluid in lungs

Question 56

Older adults

Answer 56

Tire easily (don’t hyperventilate) Increase AP diameter, Chest may become more barrel Kyphosis – an outward curve of the thoracic spine Chest expansion may be decreased

Question 57

Pulse Oximetry

Answer 57

measurement of hemoglobin oxygen saturation Normal Values: 96%-100% Six minute walk oximetry test is a test of functional status in aging adults. Used to measure pulmonary rehab. A person who walks >300 meters in 6 minutes is more likely to engage in ADLS Measurements can be skewed by low heart rate or poor peripheral perfusion

Question 58

Sputum culture

Answer 58

specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells Have patient rinse mouth, take a few deep breaths, and then cough (not spit) into the container

Question 59

Arterial Blood Gas (ABGs)

Answer 59

Measures the dissolved oxygen and carbon dioxide in the arterial blood and reveals the acid-base state and how well the oxygen is being carried to the body tissues Usually obtained from radial, brachial or femoral artery NORMAL ABG VALUES pH: 7.35-7.45 PCO2: 35-45 mmHg PO2: 80-100 mmHg HCO3: 22-27 mEq/L O2 saturation: 96% to 100%

Question 60

PULMONARY FUNCTION TEST

Answer 60

Include a number of different tests used to evaluate lung mechanics, gas exchange, and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gases Preprocedure Determine if an analgesic that may depress the respiratory function is being administered Consult with physician regarding holding bronchodilators prior to testing Instruct client to void prior to procedure and to wear loose clothing Remove dentures Instruct client to refrain from smoking or eating a heavy meal for 4 to 6 hours prior to the test Postprocedure Resume normal diet and any bronchodilators and respiratory treatments that were held prior to procedure

Question 61

Lung Capacity

Answer 61

TV: Normal resting breath IVR: Sucking in as much as you can after normal inspiration ERV: Breathing out forcefully after normal expiration

Question 62

BRONCHOSCOPY

Answer 62

Direct visual examination of the larynx, trachea, and bronchi with a fiber optic bronchoscope Preprocedure Obtain informed consent NPO from midnight prior to the procedure Obtain vital signs Monitor coagulation studies Remove dentures or eyeglasses Prepare suction equipment Administer medication for sedation as prescribed Have emergency resuscitation equipment readily available

Question 63

THORACENTESIS

Answer 63

Removal of fluid or air from the pleural space via a transthoracic aspiration Preprocedure Obtain consent Obtain baseline vital signs Prepare client for ultrasound or chest x-ray if prescribed prior to procedure Assess coagulation studies Note that client is positioned sitting upright, with arms and head supported by a table at the bedside during the procedure If the client cannot sit up, the client is placed lying in bed on the unaffected side with the head of the bed elevated 45 degrees Inform client not to cough, breathe deeply, or move during the procedure Postprocedure Monitor vital signs Monitor respiratory status Apply a pressure dressing and assess puncture site for bleeding and crepitus Monitor for signs of pneumothorax, air embolism, and pulmonary edema

Question 64

Pneumothorax

Answer 64

means there is air in the pleural space causing pressure on the lung and the lung will collapse. The nurse will hear no sounds of air movement on auscultation.

Question 65

Movement of air through mucus or fluid produces crackles, wheezing occurs when airways are obstructed, Dullness on percussion indicates increased density of the lung tissue usually caused by an accumulation of fluid.

Question 66

The hallmark signs of asthma

Answer 66

are chest tightness, audible wheezing and coughing