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Respiratory System

Module F King 103- Assessment of the Respiratory System

Eupnea Normal breathing 12-20
Bradypnea Abnormally slow breathing pattern (Drug overdose)
Tachypnea Abnormally fast breathing pattern (COPD)
Apnea Temporary absence of breathing
Accessory muscles Use of muscles other than diaphragm & intercostals to breath
Hyperpnea Increased rte of breathing, deeper than during normal activity. (Electrolyte imbalance)
Dyspnea "Air Hunger" labored/difficulty breathing
Orthopnea Discomfort breathing in any position other than erect sitting/standing position
Excursion Movement/depth of the chest wall
Hypoventilation Decreased rate & depth of breathing (<12 adult; <20 child (12 & under))
hyperventilation Increased rate & depth of breathing (>20 adult; >30 child (12 & under))
Atelectasis collapse of alveoli, no air movement in small airways
Pneumon Lung
Thorax Chest
Pleural Cavity Space within the thorax containing the lungs
Pneumothorax Collection of air or gas in the pleural space
Pleural Space Space betweenn visceral (organ) & parietal layers of the pleurae. (10 to 20 ML) of fluid
Pleural Effusion Abnormal accumulation of fluid(blood or other body fluids) in intrapleural spaces of lungs.
Brochial Loud, high pitched with hollow quality-best heard over trachea
Bronchovesicular Blowing sound, medium pitch & intensity- heard over upper thorax
Vesicular Soft, breezy, low pitch- heard over lower thorax
Mucus Membrane Beings at Mouth & ends... At rectum
Which side has 2 lobes? Left side
Which side has 3 lobes? Right side
Ventilation Exchange of oxygen/carbon dioxide gases in & out of lungs
Diffusion Movement of oxygen & carbon dioxide between alveoli & red blood cells
Purfusion Distribution of red blood cells to & from pulmonary capillaries (smallest structures)
Respiratory system plays important role in maintaining... Acid-base balance
Resonance Sound created by air- heard over posterior thorax (Heard more in children than adults)
Dull/Flat Sound created by bone/mass- heard over scapula, ribs, spine, muscle, liver, & heart
Hyperresonant Sound created by hyperinflation (too much air or emptiness)COPD
Tympany Clear, hollow, drum-like, heard over (organs) cavity
Systematic Pattern Posterior, Lateral, Anterior
Auscultate what at each position of the stethoscope? The entire Inspiration & Expiration
Bronchophony Speak "ninety-nine" fluid compressing lung causes vibrations to be transmitted clearly to chest wall (not muffled) Abnormal finding
Sputum- If client has cough must Note: Amount- minimum, moderate, large
Color of Respiratory discharge.. Clear, White, Yellow, Green, Gray, Any hemoptysis- bright red, dark red,or brown
Oder Yes or No
Consistency Watery, thin, thick, Frothy, copious(thick large amounts)
Difficulty breathing Do you have a history of difficulty breathing?
Dyspnea (difficulty breathing) When? At rest or upon exertion. Minimal exertion or strenuous exercise. (Any Pain?)
Any O2 therapy What LPN & Route (NC or mask)
Ask about Chest X-ray's Last one, for what reason, results
Ask about Regular Medications... Prescribed, OTC, or herbal/home remedies
Rate Eupnea, Bradypnea, Or Tachypnea,document actual findings.
Rhythm Regular, Irregular, Apnea, Prolonged Inspration/Expiration
Depth Shallow, or Deep
Breathing Pattern Easy rise/fall of chest or pursed lip, nasal flaring
Chest Wall movement Symmetrical Or Asymmetrical
Nasal Discharge Color, odor, consistency
Lung Sounds Where ausultated, What area(posterior, lateral, or anterior), Which side, ICS, Lobe, What Sound
Skin Color Pink, Pallor (Pale), Cyanosis, Ashen, Motten, Or Yellow
Frequent colds... Treated or Untreated
Cough Productive or Non-Productive
Adventitous Sounds... Describe Sound, Location & When heard
Measure Infants circumference where? Under the arms at nipple line
Infants commonly breath from where? Nose & Abdominal areas
1st Respiratory Inspection Shape, Symmetry (compare anterior/posterior diameter with lateral is 1:2) Infants will be 1:1 & round Observe posture!!!
2nd Respiratory Palpation Palpate for lumps, masses, pulsations, or uneven movements. Measure vocal/tactile fremitus (siting or lying position)
3rd Respiratory Percussion Helps to determine the sounds whether underlining tissue is filled with air/fluid or soild. 2-3 inches into chest wall & cannot detect deep lesions
4th Respiratory Auscultation Assess movement of air through the tracheobronchial tree. Detects mucous or accumulation of mucus or obstructed airflow
Recognition of normal sounds allows detection of... Sounds caused by obstruction
Anatomical Landmarks of the Chest are.. Left/Right scapular line, Vertebral line, Posterior/Anterior axillary line, Midaxillary line, Midsternal line, Midclavicular line
Use these terms when assessing the Thorax... Manubrium, Xiphoid process, Body, Costal Cartilage
If abnormalities are assessed in tactile fremitus, percussion,ausculation what would be done next? Test for whispered words (Bronchophony or Whispered Pectoriloquy)
What may be high pitched, fine, medium or course sounds, random/sudden reinflation of alveoli? Rales/Crackles
What is whistling sounds, high pitched squeak, airflow in severely narrowed bronchus sometimes called musical? Wheezing
What is vibrations felt through the chest wall when client is speaking? Tactie or Vocal fremitus
What is a sonorous wheeze loud low pitched muscular spasm fluid mucous in trachae bronchi? Rhonchi
Created by: maliakaye5