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Nursing Skills
Test 2 - LP 21
| Question | Answer |
|---|---|
| What are the components of the upper respiratory system? | Nose, Pharynx, Larynx |
| What are the components of the lower respiratory system? | Trachea Bronchial Tree, Lungs |
| Area where the exchange of oxygen and carbon dioxide takes place | Alveoli |
| Alveoli gives off | Carbon dioxide |
| Alveoli take in | Oxygen |
| Fatty protein that decreases surface tension of the alveoli | Surfactant |
| Surfactant prevents the ____ of the alveoli | Collapse |
| Surfactant increases lung_____. | Compliance |
| Surfactant _______ the work of breathing. | Decreases |
| The movement of air between the atmosphere and lung alveoli | Breathing |
| There is an exchange of CO2 for O2 between the pulmonary capillaries and alveoli. | Diffusion |
| Movement of oxygen and carbon dioxide via the blood stream to and from tissues. | Transport |
| What is purse lip breathing, who uses it and why? | Used by individuals with emphysema to prolong exhalations |
| A person with blue lips suffers from | Circumoral cyanosis |
| A person with clubbed fingers suffers from | Poor circulation |
| When the accessory muscles of the abdomen, neck and back are used to maintain respiratory movements at time when breathing is difficult. | Retractions |
| What are the three areas that we look for retractions | Intercostal, sub sternal, suprasternal |
| Loud, high-pitched and hollow, Like air blowing through a hollow tube, heard over the throat | Bronchial |
| Heard over the main bronchi-aound sternum | Bronchovesicular |
| Heard over most of the peripheral lung tissue | Vesicular |
| An abnormal breath sounds is also called | Adventitious Breath Sounds |
| High pitched short crackling, popping sounds, sound like rice crispies or crushing cellophane | Crackles/Rales |
| What causes crackles/rales | Usually caused by fluid in airways or alveoli. Sign of fluid overload |
| Low pitched continuous sounds . Can be described as sonorous or coarse | Gurgles ( Rhonchi) |
| What causes Gurgles (Rhonchi) | Fluid or mucus in LARGER airways |
| high-pitched musical squeaking sounds, Heard during inspiration or expiration, Do not clear with coughing | Wheezing |
| What causes wheezing | Narrowing of bronchioles |
| rubbing/grating sound of sandpaper rubbing in chest | Pleural friction rub |
| What causes a pleural friction rub | Inflammation of pleural lining |
| Harsh/high pitched sound heard in the upper airway (larynx-trachea), sounds like a barky seal | Stridor |
| Stridor is most often associated with | Croup |
| What three things are palpated for? | Chest expansion, tactile fremitius, abnormalities found on inspection |
| Percussion helps determine Lung _____ and _______ | Position, size |
| When using percussion we are checking for what three things within the lungs | Air, liquids or solids |
| When percussing what four things do we want to note about the sound? | Intensity, pitch, duration, quality |
| What is the normal percussion tone? | Resonance |
| What tone do we hear over bony prominences? | Flat |
| What tone do we hear over emphysematous tissue? | Hyperresonance |
| What labs tests are used to access respiratory functioning? | CBC, Hgb, Arterial Blood Gases |
| What are two examples of non-invasive diagnostic exams to access the respiratory system? | Pulse oximeter, Pulonary Function Tests |
| What is a pulomonary function test? | tests that measure how well the lungs take in and release air and how well they move gases such as oxygen from the atmosphere into the body's circulation. |
| What is an example of an invasive diagnostic exam to evaluate the respiratory system that uses an endoscope to visually examine the pleura, lungs, and mediastinum and to obtain tissue for testing purposes. | Thoracoscopy |
| Normal respiratory rate- 12-20 bpm | Eupnea |
| The absence of breathing | Apnea |
| Decreased rate <12 bpm | Bradypnea |
| Rapid rate >20 bpm | Tachypnea |
| Increased rate and depth of respirations | Hyperventilation |
| Abnormally deep respirations- sign of diabetic ketoacidosis | Kussmaul respirations |
| An abnormal type of breathing seen especially in comatose patients, characterized by alternating periods of shallow and deep breathing. | Cheyne Stokes |
| Difficulty breathing lying down | Orthopnea |
| Difficulty breathing, shortness of breath | Dyspnea |
| At what point in the lifespan is the respiratory rate the highest and most variable? | Newborn |
| What is the normal respiratory rate for infant? | 30-60 |
| What is the normal respiratory rate for preschool? | 25 |
| What is the normal respiratory rate for an adult? | 12-20 |
| What type of muscles do newborns use to breathe? | Abdominal |
| Heart rate in children varies with respirations | Sinus arrhythmia |
| Why are infants and preschoolers at risk for airway obstruction? | Small airways |
| Do infants have more or less mucus membranes lining the respiratory tract? | More |
| The immune system of children is immature. True/False | True |
| The action of the cilia in children is increased/decreased. | Decreased |
| The cough reflex in children is increased/decreased. | Decreased |
| The chest walls of children are thicker/thinner than adults. | Thinner |
| Chest retractions in children are more common/less common. | More common |
| The epiglottis in children is more/less relaxed. | More |
| What happens to the elastic recoil in the lungs as we age? | It decreases |
| What happens to the A-P diameter as we age? | Increases |
| As we age, deep breathing increases/decreases. | Decreases |
| As we age, the functional alveoli increase/decrease. | Decrease |
| As we age, our cough is more forceful, less forceful | Less |
| As we age, the cilia are few and less functional/more abundant and more functional. | Fewer and less functional |
| As we age, the immune system is more/less resilient. | Less |
| What three respiratory diseases are the elderly more at risk for? | Pneumonia, COPD, Chronic Bronchitis |
| What physiologically gives us the stimulus to breathe? | Rising levels of CO2 |
| What are some techniques for maintaining adequate respiratory functioning? | Positioning- HOB up , Exercises- Pursed lip breathing, Incentive Spirometer, Deep breathing and coughing, Increasing liquids, Ambultion, Turn side to side |
| Positioning to assist in removal of retained lung secretions by placing patient in a position that uses the force of gravity so the secretions will more to the main bronchi and trachea such that they can be coughed up. | Postural drainage |
| This technique creates a vibration with the cupping of hands to help loosen pulmonary secretions so they can be coughed up. | Chest clapping |
| Nursing Diagnosis - The state in which an individual experiences a threat to respiratory status related to inability to cough effectively. Ineffective or Absent cough. Inability to remove airway secretions | Ineffective airway clearance |
| Nursing Diagnosis – The state in which a client experiences an actual or potential loss of adequate ventilation related to an altered breathing pattern. Changes in respiratory rate or pattern (from baseline). Changes in pulse (rate, rhythm, quality). | Ineffective breathing pattern |
| Nursing Diagnosis – The state in which an individual experiences an actual (or potential) decrease in the passage of gases between the alveoli of the lungs and the vascular system. Dyspnea upon exertion. Decreased O2 saturation, cyanosis | Impaired Gas |
| Nursing Diagnosis - The state in which a person experiences a reduction in one’s physiologic capacity to endure activities to the degree desired or required. Activities tire the person out and increase respiratory rate and pulse rate | Activity Intolerance |
| What is an incentive spirometer used for? | To help your lungs clear after surgery, opens up alveoli to prevent pneumonia |
| How do you use incentive spirometer? | Seal lips around mouth piece, breathe in slowly raising piston toward top of column, yellow indicator should be in blue outlined area, hold breath 5 sec and allow piston to fall |
| How often do you use incentive spirometer? | Ten times every hour while you are awake |
| What should you do after using incentive spirometer? | Practice coughing, also walk. If you just had surgery place a pillow firmly against incision before doing so. |
Created by:
anastasia158
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