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pulmonary assessment
foundations exam 2
| Question | Answer |
|---|---|
| What is each lung divided roughly in half by? | an oblique (major) fissure |
| What is the right lobe of the lung further divided by? | the horizontal (minor) fissure |
| What do the fissures divide the lungs into? | lobes |
| What is the right lung divided into? | upper, middle, and lower lobes |
| What is the left lung divided into? | upper and lower lobes |
| Why do we listen to the lungs? | to detect respiratory problems early and guide patient care |
| When we listen to the lungs what do we do? | assess the respiratory status, evaluate air movement through the lungs, identify abnormal lung sounds, monitor changes over time (treatment effectiveness), detect complication early |
| abnormal lung sounds | wheezes, crackles, rhonchi, stridor |
| What are we listening for in the lungs to detect complications early? | fluid in the lungs, narrowing airways, collapsed lung areas |
| pulmonary ventilation | the movement of air into and out of the lungs |
| respiration | gas exchange between alveoli and blood in the capillaries |
| perfusion | process where oxygenated blood passes through body tissues |
| oxygen is essential for? | cellular respiration- O2/CO2 exchange, aerobic glycolysis, ATP-> energy; supports brain, heart, muscle, organ function-> O2 gives cells energy to move, grow, repair, function |
| How much oxygen does the brain take? | 20% |
| how many minutes can we go without oxygen before we have brain damage? | 6 minutes |
| hypoxemia | decreased O2 in blood |
| hypoxia | decreased O2 in blood |
| hypoxia | decreased O2 in tissues |
| O2 in via lungs | crosses AC membrane into blood stream |
| What is O2 carried throughout systemic circulation on? | Hemoglobin |
| Tissues "offload" the O2 to tissues for? | utilization |
| What is needed for adequate oxygenation to tissues? | Lungs that get O2 in, Circulation to get O2 in blood stream and carry it to tissues/organs, Hemoglobin to transport that O2, tissues/organs able to offload O2 from Hgb |
| Nursing pulmonary assessment questions | history of lung problems? take any medications for breathing? SOB or DOE? Orthopnea? Do you use home O2? Do you have a cough? |
| Physical Assessment | inspection, palpation, percussion, auscultation |
| What do we do first in a pulmonary assessment? | airway, breathing, circulation; is LOC altered? |
| inspection | observe the patient's facial expression- should be relaxed and calm, observe level of consciousness, assess the patient's color for cyanosis, especially the face, mucous membranes, and nail beds |
| what does low oxygenation produce? | anxiety and restlesness |
| What does decreased level of consciousness indicate? | poor oxygenation to the brain and other disease processes |
| What to look for when doing an inspection? | shape, how chest moves, deformities, asymmetry, labored vs. easy |
| Inspect the neck | during inspiration, is there contraction of the accessory muscles, namely, the sternocleidomastoid and scalene muscle, or supraclavicular retraction? is the trachea midline? |
| What does inspiratory contraction of the sternocleidomastoids at rest signal? | severe difficulty in breathing |
| When may lateral displacement of the trachea be seen? | in pneumothorax, pleural effusion, atelectasis |
| Abnormal findings during breathing | supraclavicular retraction, sternocleidomastoid contraction, intercostal muscle use, intercostal space retractions or bulging, abdominal muscle use |
| Objective assessment | observe and document the rate (12-20), rhythm (regular or irregular) depth (normal, deep, shallow), and effort of breathing (easy and unlabored) |
| eupnea | normal respiratory rate |
| bradypnea | less than 12 breaths per minute |
| tachypnea | greater than 20 breaths per minute |
| apnea | few seconds or more of no breathing |
| rhythm | cheyne-stokes respirations, agonal, kussmaul's |
| What do Cheyne-stokes respirations indicate? | a poor prognosis |
| Cheyne stokes respirations | rare abnormal breathing pattern that can occur while awake but usually occurs during sleep |
| What does Cheyne stokes respiration pattern involve? | a period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all (apnea) |
| Agonal breathing | when someone who is not getting enough oxygen is gasping for air (cardiac arrest, stroke), natural reflex that occurs when your brain is not getting the oxygen it needs to survive |
| What is agonal breathing a sign of? | that a person is near death |
| Kussmaul's respirations | deep, rapid breathing pattern (stays at one pace unlike Cheyne-stokes); in an attempt to expel carbon dioxide (acidic), the body starts to breathe faster and deeper |
| What are kussmaul's respirations an indication of? | that the body or organs have become too acidic |
| Depth | deep breathing, shallow breathing |
| deep breathing | taking in more air/O2; normal in exercise, mindful relaxation, abnormal in some disease states |
| shallow breathing | taking in less air; seen with pain, opioid misuse/ overdose |
| What is depth measured as? | tidal volume (normal about 500mL) |
| What is depth controlled by? | brainstem |
| What do we inspect for color? | nail beds, conjuctiva, skin |
| clubbing | 180+ degree downward curvature of nail beds; systemic sign of pulmonary disease |
| pale conjuctiva | pale color around eye, not enough O2 to tissues |
| mottling | irregular discoloration of skin, very bad sign, indicate of poor perfusion |
| pursed lip breathing | problems getting air out, compensatory mechanism for patients who can't get air out |
| Signs and symptoms of respiratory compromise | altered mental status, dizziness, fainting, restlessness, blue color, straining neck/ facial/ chest/ abdominal muscles, sharp chest pains, numbness/ tingling in hands or feet, flaring nostrils, pursed lips, couching, crowing, high pitched barking |
| tripod breathing | sitting position where individual leans slightly forward with arms propped in fron on over-bed table, pillows, or knees |
| When is tripod position used? | when experiencing shortness of breath, especially orthopnea (dyspnea when lying down) |
| What does tripod breathing do? | decrease work necessary to breathe by allowing greater chest expansion, increase ability to use accessory muscles |
| deformities | scoliosis, kyphosis, pectus excavatum, pectus carinatum, barrel chest |
| How can scoliosis affect breathing? | can compromise ability of lung to fully expand |
| kyphosis | curvature of spine forward |
| pectus excavatum | depression in chest |
| pectus carinatum | also known as pigeon chest, sternum protrudes outward |
| barrel chest | common in chronic pulmonary diseases (most common in COPD), rounded, bulging chest shape |
| What to look for when palpating? | pain, skin abnormalities, respiratory expansion, fremitus, tracheal deviation |
| How to test chest expansion? | place thumbs at 9th rib w/ fingers loosely grasping and parallel to lateral rib cage, slide hands medially just enough to raise a loose fold of skin on each side between thumb and spine, ask pt to inhale deeply, watch distance between thumsb |
| fremitus | palpable vibrations transmitted to the chest wall as the patient is speaking |
| How to assess for tactile fremitus? | have the patient say 99, use either the ball or the ulnar surface of your hand to feel vibration |
| Normal tactile fremitus | symmetrical vibrations felt equally on both sides |
| Abnormal tactile fremitus | increased fremitus: consolidation (pneumonia), decreased/ absent fremitus: pleural effusion, pneumothorax, obstruction |
| percussion | flat, dull, resonant, hyperresonant, tympany |
| What does percussion help to establish? | whether the underlying tissues are air filled, fluid filled, or solid |
| percussion, flatness | pneumonia |
| percussion dullness | atelectasis |
| percussion resonance | normal |
| percussion hyperresonance | empysemapneumo |
| percussion tympany | pneumothorax |
| respiratory assessment auscultation- general | assessing air movement through tracheobronchial tree, patient breathes through open mouth, be careful patient does not "hyperventilate", listen over the same sites that are percussed, use diaphragm of stethescope |
| purpose of lung auscultation | assess airflow through the bronchial tree, identify normal breath sounds, detect abnormal/adventitious sounds, differentiate between respiratory and cardiac conditions, monitor changes over time or treatment effectiveness |
| normal breath sounds | vesicular, bronchial, bronchovesicular |
| abnormal/adventitious lung sounds | crackles, wheezes, ronchi, pleural rubs |
| Auscultation what to note: abnormal or adventitious | do you hear normal lung sounds in the correct areas? if not, it is abnormal breath sounds, do you hear extra or adventitious sounds? |
| If you hear extra or adventitious sounds listen for: | loudness/pitch, timing in the respiratory cycle, location on the chest wall, change after coughing, persistence of pattern from breath to breath (duration) |
| normal breath sounds trachea | very loud, harsh sounds with inspiratory and expiratory sounds equal in length, over the trachea in the neck |
| where are tracheal breath sounds heard? | heard over the tracheal notch |
| normal breath sounds bronchial | louder and higher in pitch, with a short silence between inspiratory and expiratory sounds, expiratory sounds last longer than inspiratory sounds. Heard just above the clavicles on each side of the sternum, over the manubrium |
| normal breath sounds bronchovesicular | inspiratory and expiratory sounds about equal in length, at times separated by a silent interval. Detecting differences in pitch and intensity is often easier during expiration. Heard next to sternum anteriorly and between scapula posteriorly |
| normal breath sounds vesicular | soft and low pitches, heard over the remained of the lungs |
| abnormal or adventitious breath sounds | absent, decreased/ diminished, crackles, wheezes, rhonchi, pleural friction rub, stridor |
| stridor | if you hear run to your patient, massive inflammatory process that constricts trachea and can occlude airway |
| when are crackles longest? | on inspiration |
| crackles | bubbling, crackling, popping; opening of deflated small airways and alveoli, or air passing through fluid in the airways |
| What are crackles heard in? | pneumonia, fibrosis, early congestive heart failure |
| when are rhonchi loudest? | on expiration/exhalation |
| What do rhonchi suggest? | secretions in large airways |
| What to do if rhonchi are heard? | ask patient to cough and see if the rhonchi clears |
| When are wheezes loudest? | on end-expiration |
| What does wheezing suggest? | narrowed airways as in asthma, COPD, or bronchitis |
| What does inspiratory and expiratory wheezing mean? | severe bronchocontriction, impending hypoxia, respiratory failure |
| What does pulse oximetry measure? | the arterial oxygenation saturation, or SpO2 |
| What SpO2 does a healthy person have? | greater than 92% |
| What can cause inaccurate readings when using a pulse oximeter? | poor perfusion, hypotension, dyes in some nail polishes, and excessive ambient light |
| oxygen therapy | nasal cannula, non-rebreather, simple face mask |
| nasal cannula low flow 1-2LPM | 24-28% |
| nasal cannula low flow 3-5LPM | 32-40% |
| nasal cannula low flow 6LPM | 44% |
| nasal cannula high flow 10LPM | 65% |
| nasal cannula high flow 15LPM | 90% |
| simple face mask | 5-8LPM 40-60% |
| Non-rebreather | 10-15LPM 80-95% |
| When using the non-rebreather mask maintain flow rate so that? | reservoir bag collapses only slightly with inspiration |
| What to look for when examining expectorations | color, consistency, odor, amount, dry, hacking, bloody, rusty, smells, purulent |
| pulmonary toilet | deep breathing (C and DB), incentive spirometer, teach effective coughing, splint abdomen with pillow, postural drainage/ chest physiotherapy, maintain hydration, bronchodilators- ie albuteral, environmental/ lifestlye changes |
Created by:
camrynfoster