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FON exam 2
pulmonary assessment
| Question | Answer |
|---|---|
| oblique fissure | each lung is divided roughly in half by an oblique (major) fissure |
| horizontal fissure | the right lung is further divided by the horizontal (minor) fissure |
| lobes | the fissures divide the lungs into lobes |
| what is the right lung divided into | upper, middle, lower |
| what is the left lung divided into | upper and lower |
| why do we listen to lungs | to detect respiratory problems early and guide patient care |
| what does a pulmonary assessment entail | assess respiratory status, evaluate air movement through lungs, identify abnormal lung sounds (wheezes, crackles, rhonchi, stridor), monitor changes overtime (tx effectiveness), detect complications (fluid in lungs, narrowing airways, collapsed lungs) |
| how many auscultation points in the front? | 3 |
| how many auscultation points in the back? | 6 |
| 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 tissue |
| mechanics of respiration | exhalation and inhalation |
| what parts of the body are needed for respiration | lung, ribs, diaphragm |
| why do we need O2 | breathing = life |
| oxygen is essential for | cellular respiration, O2/CO2 exchange, aerobic glycolysis, ATP |
| how much O2 does the brain need | about 20% of our O2 |
| how many minutes without O2 leads to brain damage | 6 minutes |
| what does O2 support | heart, muscle, organ function O2 gives cells energy to move, grow, repair, function |
| decreased O2 | hypoxemia, hypoxia |
| O2 in via lungs | crosses alveolar capillary membrane into blood stream |
| how is O2 carried throughout systemic circulation | on Hgb (hemoglobin) |
| 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 assessment questions | History of lung problems? Take any medications for breathing? SOB or DOE? (shortness of breath, dyspnea on exertion) Orthopnea? (dyspnea in a supine position) Do you use home O2? If so, how much? Do you have a cough? |
| physical assessment | inspection, palpation, percussion, auscultation |
| what should you check first in a physical assessment? | ABCs - airways, breathing, circulation LOC - altered? |
| what can inadequate O2 lead to | change in LOC |
| inspection | observe pt facial expression, LOC, pt color |
| observe pt facial expression | should be relaxed and calm, lox oxygenation produces anxiety and restlessness |
| observe LOC | decreased LOC indicates poor oxygenation to the brain and other disease processes |
| observe pt color | inspect for cyanosis - especially in the face, in mucous membranes and nail beds |
| inspection of | shape, how the chest moves, deformities, asymmetry, labored vs easy breathing |
| what to inspect in the neck | during inspiration - is there contraction of the accessory muscles (SCM, scalene muscles, supraclavicular retraction? is the trachea midline? |
| what does inspiratory contraction of the SCMs at rest signal | difficulty breathing |
| when may lateral displacement of the trachea be seen | in pneumothorax, pleural effusion, or atelectasis |
| abnormalities in breathing | supraclavicular retraction, SCM contraction, intercostal muscle use, intercostal space retractions or bulging, abdominal muscle use |
| objective assessment: observe and document | rate: 12-20 rhythm: regular or irregular depth: normal, deep or shallow effort of breathing: easy and unlabored? |
| eupnea | normal |
| bradypnea | slow, less than 12 |
| tachypnea | fast, more than 12 |
| apnea | a few seconds or more of no breathing |
| rhythm | cheyne-stokes agonal kussmauls |
| cheyne-stokes respirations | problems with CO2 regulation |
| cheyne-stokes respirations indicate | a poor prognosis |
| cheyne-stokes respirations are a | 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 | near death!! guppy breathing |
| agonal breathing occurs when | someone who is not getting enough oxygen is gasping for air (cardiac arrest, stroke) |
| agonal breathing is a natural reflex that happens when | your brain is not getting the oxygen it needs to survive |
| kussmaul's respirations | deep, rapid breathing pattern stays at one pace |
| kussmaul's respirations are an indication that | the body or organs have become too acidic |
| kussmaul's respirations happen in an attempt to | expel carbon dioxide (acidic), so that body starts to breathe faster and deeper |
| normal depth | about 500 mL |
| deep breathing | taking in more O2 |
| deep breathing is normal in | exercise and mindful relaxation |
| deep breathing is abnormal in | some disease states |
| shallow breathing | taking in less air |
| when is shallow breathing seen | with pain, opioid misuse/overdose |
| what is depth of breathing controlled by | brainstem |
| inspection of | color, nail beds, conjuctiva, skin (pale, cyanotic) |
| clubbing is a long term consequence of | people with respiratory disease |
| motting | BAD, indicative of poor perfusion, check to see if it's unilateral or bilateral |
| pursed lip breathing | in through nose, out through mouth like "straw" |
| pursed lip breathing is | compensatory, its how they cope/helps with SOB |
| people with what use pursed lip breathing | COPD, CF |
| tripod position | pursed lips, tachypnic, hands on knees and kind of bent |
| tripod breathing used when | experiencing shortness of breath, especially orthopnea (dyspnea when lying down) |
| decreased work is necessary to breathe by | allowing greater chest expansion |
| increased ability to | use accessory muscles |
| deformities | scoliosis, kyphosis, pectus excavatum, pectus carinatum (pigeon chest), barrel chest |
| pectus excavatum | internal sternum |
| pectus carinatum (pigeon chest) | external sternum happens at birth, can get surgery to fix |
| palpation for | pain, skin abnormalities, respiratory expansion, fremitus, tracheal deviation |
| tactile fremitus | refers to the palpable vibrations transmitted to the chest wall as the pt is speaking |
| ask pt to say 99 | you feel for increase or decrease in vibration felt in our hands when they say it |
| what to use for palpations | ball or the ulnar surface of your hand |
| tactile fremitus: normal | symmetrical vibrations felt equally on both sides |
| tactile fremitus: abnormal, increase fremitus | increase vibration from one hand to another consolidation (pneumonia or tumor) |
| tactile fremitus: abnormal, decrease/absent fremitus | pleural effusion, pneumothorax, obstruction (air not getting thru) |
| percussion | flat, dull, resonant, hyperresonant, tympany |
| percussion helps to | establish whether the underlying tissues are air filled, fluid filled or solid |
| respiratory assessment auscultation assesses | assessing air movement through tracheaobronchial tree |
| respiratory assessment auscultation entails | pt breathes through open mouth, be careful pt does not hyperventilate, listen over the same sites that are percussed, use the diaphragm of stethoscope |
| purpose of lung auscultation | assess airflow through the bronchial tree |
| what do we do during lung auscultation | identify normal breath sounds (vesicular, bronchial, bronchovesicular), detect abnormal/adventitious sounds (crackles, rhonchi, pleural rubs) , differentiate between respiratory and cardiac conditions, monitor changes over time or treatment effectiveness |
| what to listen for when there are adventitious sounds | loudness/pitch, timing in the respiratory cycle, location on the chest wall, change after coughing, persistance of pattern from breath to breath |
| tracheal breath sounds: normal | very loud, harsh sounds with inspiratory and expiratory sounds equal in length, over the trachea in the neck, I=E |
| bronchial breath sounds: normal | louder and higher in pitch, with a short silence between inspiratory and expiratory sounds, expiratory sounds last longer than inspiratory, I<E |
| bronchovesicular breath sounds: normal | inspiratory and expiratory sounds about equal in length, at times separated by a silent interval, detecting differences in pitch and intensity is easer during E, I=E |
| vesicular breath sounds: normal | soft and low pitched, I>E |
| abnormal or adventitious breath sounds | absent, decreased/diminished, crackles/wheezes/rhonchi, pleural friction rub, stridor |
| crackles are loudest on | inspiration |
| crackles are | fluid! bubbling, crackling, popping |
| crackles are the opening of | deflated small airways and alveoli, or air passing through in the airways |
| when are crackles heard | in pneumonia, fibrosis, early congestive heart failure |
| rhonchi are loudest of | expiration/exhalation |
| rhonchi suggest | mucus! secretions in large airways |
| if rhonchi's are heard | ask pt to cough and see if the rhonchi clears |
| wheezes are loudest on | end-expiration |
| wheezes suggest | narrowed airways as in asthma, COPD or bronchitis |
| I&E wheezing | BAD!!!! severe bronchoconstriction, impending hypoxia, respiratoty failure |
| what to do when pt is I&E wheezing | give bronchodilators, report and run |
| pulse oximetry | infrared light detects hemoglobin and tells how much saturated with O2, can't distinguish O2 from CO2 |
| a health person has an SpO2 of | greater than 92% |
| what can cause inaccurate readings | poor perfusion, hypotension, dyes in some nail polishes, and excessive ambient light |
| what does POX rely on | on adequate signal of a pulse |
| nasal canula | low flow, 1-6 LPM |
| low flow NC | 1-2 liters per minute (not enough) = 24-28% 3-5 LPM = 32-40% 6 LPM = 44% |
| high flow NC | 10 LPM = 65% 15 LPM = 90% |
| simple face mask | 5-8 LPM = 40-60% |
| what is the minimum setting for simple face mask | 5 LPM |
| non-rebreather used if | still hypoxemic on NC |
| non-rebreather LPM | 10-15 LPM = 80-95% |
| NRB maintain | flow rate so reservoir bag collapses only slightly with inspiration |
| NRB check that | valves and rubber flaps are functioning properly (open during expiration and closed during inhalation) |
| are NRB long term | NO, should not be on longer than a day and are for emergency use until respiratory distress is treated |
| expectorations | color, consistency, odor, amount, dry hacking, bloody, rusty, smells, purulent |
| pulmonary toilet | C&DB, IS, teach effective coughing, splint abd with pillow, postural drainage/chest physiotherapy, maintain hydration (breaks up secretions), bronchodilators (works instantly), environmental/lifestyle changes (get them to think about not smoking |
Created by:
leh195