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HA- CH 17
Health Assessment
| Question | Answer |
|---|---|
| is a RR less than 12 breaths per mintue--the rate remains smooth and even | bradypnea |
| is a RR greater than 20 breathes per minute--the rate remains smooth and even | tachypnea |
| can be caused by fever, fear, activity | tachypnea |
| is characterized by increased rate and depth of respiration | hyperventilation |
| hyperventilation with ketoacidosis | Kussmaul breathing |
| is characterized by irregularly interspersed periods of apnea in a disorganized and irregular pattern, rate, depth | Biot breathing pattern |
| may be related to: persistent intracranial pressure, respiratory distress, or damage to the medulla | Biot breathing pattern |
| is characterized by intervals of apnea interspersed with a deep adn rapid breathing pattern | Cheyne-Stokes |
| may be seen with: severe illness, brain damage, or drug overdose | Cheyne-Stokes |
| is an abnormal respiratory pattern and is characterized by rapid inspirations with prolonged, forced expirations--air is not fully exhaled and becomes trapped in the lungs which can lead to barrel-chest | Air trapping |
| frequently seen in pt with chronic obstructive pulmonary disease | Air trapping |
| pitch of bronchial sounds | high |
| intensity of bronchial sounds | loud |
| ratio for duration of inspiration and expiration of bronchial sounds | insp < exp --- 1:2 |
| normal location of bronchial sounds | over trachea |
| abnormal location of bronchial sounds | over peripheral lung fields |
| pitch of bronchovesicular sounds | moderate |
| intensity of bronchovesicular sounds | medium |
| ratio for duration of inspiration and expiration | insp=exp --- 1:1 |
| normal location of bronchovesicular sounds | first and second intercostal spaces at sternal border anteriorly' posteriorly at T4 medial to scapula |
| abnormal location of bronchovesicular sounds | over peripheral lung fields |
| pitch of vesicular sounds | low |
| intensity of vesicular sounds | soft |
| ratio for duration of inspiration and expiration of vesicular sounds | insp > exp --- 2.5:1 |
| normal location of vesicular sounds | peripheral lung fields |
| abnormal location of vesicular sounds | not applicable |
| what are 4 things that may cause an inaccurate adventitious sound when listening to the chest? | 1. bumping the stethoscope or if the pt is touching the tubing 2. if the pt is cold and is shivering 3. the stethoscope unintentionally moving on a pt's chest hair causing false sounds of crackles or pleural rub 4. extraeous environmental noises |
| bronchovesicular sounds are found ___ | over main bronchi |
| vesicular sounds are found ___ | over lesser bronchi, bronchioles, and lobes |
| bronchial sounds are found ____ | over trachea |
| rales | crackles |
| high-pitched crackling and popping noises heard during the end of inspiration and are not cleared by a cough...examples? | fine crackles...pneumonia, congestive heart failure, chronic bronchitis, asthma |
| med-pitched, moist sound heard about halfway thru inspiration and are not cleared by a cough...examples? | medium crackles...same as fine crackles only the condition is worse |
| low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration...examples? | coarse crackles...same as fine crackles, but condition is worse or in terminally ill clients with no gag reflex...also heard in pulmonary edema and pulmonary fibrosis |
| should be heard over almost all of the posterior lung fields and all of the lateral surfaces and heard throughout the periphery of the anterior lung fields, including the apex of the lungs above the clavicles | vesicular breath sounds |
| are normally heard in the posterior chest over the upper center of the back on either side of the spine between the scapulae and over the center area of the anterior chest around the sternal border. These sounds are heard in an area that approximates the | bronchovesicular breath sounds |
| are normally heard over the trachea and the area immediately above the manubrium | bronchial breath sounds |
| high-pitched, musical sound similar to a squeak. Heard more commonly during expiration, but may also be heard during inspiration. occurs in small airways...examples? | wheeze...heard in narrowed airway diseases such as asthma |
| low-pitched, coarse, loud, low snoring or moaning tone. Heard primarily during expiration, but may also be heard during inspiration. coughing may clear...examples? | rhonchi...heard in problems causing obstructions of the traches or bronchus, such as bronchitis |
| a superficial, low-pitched, coarse rubbing or grating sound. Heard through INSPIRATION and EXPIRATION. Loudest over the lower anterolateral surface. not cleared by cough....examples? | pleural friction rub...heard in individuals with pleurisy (inflammation of the pleural surfaces) |
Created by:
TayBay15
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