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Respiratory System
Module F King 103- Assessment of the Respiratory System
| Question | Answer |
|---|---|
| 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
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