NURS 2910 > Respiratory Assessment > Flashcards

Respiratory Assessment Flashcards

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1
Q

Apex of lungs means

A

Top of lungs

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2
Q

Base of lungs means

A

Bottom of Lungs

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3
Q

Left lung has ? lobes

A

2 lobs (upper, lower) + cardiac notch

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4
Q

Right lung has ? lobes

A

3 lobes (upper, middle, lower)

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5
Q

Lung air sacs are the

A

Alveoli

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6
Q

the voice box is another name for the

A

pharynx

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7
Q

Airways in the body include:

A

Nasal passages, mouth, pharynx, larynx, trachea, bronchi, and bronchioles

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8
Q

The lungs sit on…

A

the diaphragm muscle

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9
Q

Ventilation is the…

A

expansion of chest, inspiration + expiration

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10
Q

Respiration is the…

A

Gas exchange, O2 in, CO2 out

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11
Q

Chemoreceptors tell…

A

tell the lungs when to breathe, they measure the O2 & CO2 levels in the body

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12
Q

Where does gas exchange occur externally

A

In the alveolar-capillary

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13
Q

Where does gas exchange occur internally?

A

In the Capillary-tissue

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14
Q

How many ribs & Intercostal spaces

A

12 ribs, 12 ICS, & 1 vertebrae

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15
Q

The lungs are symmetrical T or F

A

False

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16
Q

Mediastinum is the….

A

Space between the lungs

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17
Q

Where does gas exchange take place?

A

Alveoli

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18
Q

The primary stimulus for breathing is…

A

Carbon Dioxide(CO2)

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19
Q

The secondary stimulus for breathing is…

A

Oxygen(O2)

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20
Q

Hypercapnia refers to…

A
  • high carbon dioxide in the blood(hyperventilating)
  • Stimulates the drive to breathe
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21
Q

Infants: What impacts oxygenation

A
  • Immature lower airway, nervous system, and immune system
  • Narrow airways
  • Risk of choking
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22
Q

Children: What impacts oxygenation

A
  • Upper respiratory infections are common
  • Asthma can start & diagonsed
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23
Q

Adolescents: What impacts oxygenation

A
  • Smoking & E-cig usage occurs more often
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24
Q

Adults: What Impacts oxygenation

A
  • 15% of US adults are cigarette smokers
  • Changes in the resp. system begins in middle age and increases with age
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25
Older Adults: What Impacts oxygenation
- Reduced lung expansion and less alveolar inflation - Difficulty clearing airways> muscles are weaker - Declining immune response - Chemoreceptors respond more slowly
26
Factors that impact oxygenation
- Stress - Obesity - Allergies - Exercise - Air quality - Smoking - Altitude - Second-hand smoke - Temperature - Pregnancy
27
Health history questions (subjective data)
- Past health history - Demographic data - Medications - Health - Vaccines - Environment - Family history - Resp. questions - Smoking/vaping - Occupation
28
Physical assessment (objective data)
- General survey - Vital signs - Inspect - Palpate - Auscultate - Percussion
29
What to look for in General survey
- items in the room> medications, O2 - family/ friends present - Alertness and orientation - Inspection> breathing status/ positioning
30
Normal respiratory rate
12-20
31
Eupnea
normal respiration rate, 12-20
32
Bradypnea
slow respirations, <10
33
Tachypnea
Fast respirations, <24
34
Apnea
Absence of breathing
35
Dyspnea
Shortness of breath
36
Inspection: Face
- look for signs that give us more info about the resp. system - breathing pattern, breathing effort, and quality - Pursed lips - Flared nostrils - grunting
37
Inspection: position
- tripod sitting, look at positioning - How are they positioned
38
Inspection: nails/skin
- cyanosis/ pallor of skin or nails - clubbing of nails
39
Inspection: chest
- chest movement - Anteroposterior to lateral ratio - Do they have barrel chest?
40
Inspection: Thoracic Cage
- observe the thorax with the client sitting up - scapulas should be symmetrical - straight spine
41
Inspection: Posture
- look for scoliosis and kyphosis
42
Palpitation
- Feel for lumps & masses, any pain or tenderness, crepitus, fremitus - watch for guarding of body due to pain
43
Palpitation: expansion
- Assess chest expansion - Place hands on the anterior chest, have client take deep breaths - Hands should move symmetrically
44
Percussion
- Percus for tone - place client in sitting position - start at the top of the lung - move down and outward - compare L and R - Percuss over intercoastal spaces - top-down in latter formation
45
Percussion: Abnormal findings
- Tympany(common over stomach, not lungs) - Dullness(over fluid or solid tissue) - Flatness( over muscle mass and bones) - Hyperresonance( can indicate trapped air)
46
Auscultation
- be in a quiet room - instruct patient to breathe slowly through their mouth - move stethoscope from side to side, going from top to bottom - listen for one full respiration in each spot - listen on skin directly - 6 spots anterior - 8 spots posterior
47
Normal breath sounds
- Bronchial: high pitched, loud - Bronchovesicular: moderate pitch,1:1, equal insp. & exsp. - Vesicular: soft, low, 3:1, insp>longer, exsp> shorter
48
Adventitious(abnormal) lung sounds
- Crackles - Wheezing - Pleural rub - Stridor - Grunting
49
What is hypoxia?
Low oxygen in your tissues
50
What is crepitus?
Crackling skin caused by air in the subcutaneous tissue
51
When percussing the lung, a normal finding is...
Resonance
52
Which lung has 3 lobes?
Right
53
Vesticular is an abnormal breath sound T or F
False
54
Developmental Variations: Infants
- normal resp. 30-53, higher when crying - infants are diaphragmatic breathers - <6 months, obligate nose breathers - uneven or irregular breathing patterns - Chest should be smooth and round
55
Developmental Variations: Toddler
- until 6, immunity lower so increased risk of upper resp. infections - short, small airways- easily obstructed - put anything in mouth - drowning can occur in little amounts of water
56
Developmental Variations: Preschool/school-age
- Mature heart, lungs, circulatory system - Upper resp. infection resolve easier - increase incident of asthma - exposure to viruses at daycare/school - chest size same ratio as adults
57
Developmental Variations: Older adults
- Kyphosis is common - decreased chest expansion, ability to take deep breaths, ability to cough - loss of muscle - Declining immune system - chemoreceptors respond slower
58
Indications of Hypoxia
-cyanosis of skin and nails - pain in back - cough green mucous - Developmental Variations - Pain
59
Hypoxia is
lack of, low O2
60
Normal data includes:
- chest rises symmetrically - Spine is straight - No masses or tenderness - Lungs are resonant when percussed
61
Abnormal data includes:
- labored breathing - ICS muscles retractions - Sitting in tripod position - crackles or wheezing
62
Possible education and interventions
- smoking cessation - vaccinations - Avoid pollutant - Exercise weekly
NURS 2910
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