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Nursing Chs 29-33
Important info.
| Question |
|---|
| Assessment of Resp. Hx |
| -Smoking Hx |
| -Childhood illnesses (asthma, pneumonia, comm. diseases, hay fever, allergies, eczema, frequent colds, croup, and cystic fibrosis) |
| -Adult Illnesses (Pneumonia, sinusitis, TB, HIV/AIDS, Lung disease emphysema and sarcoidosis, diabetes, hypertension, and heart disease |
| -Influenza, pneumococcal, and BCG vaccines |
| -Surgeries of U or L resp system |
| -Injuries to U or L resp system |
| -Hospitalizations |
| -Date of chest x-ray, pulmonary function test, TB test, other diagnostic tests |
| -Recent weight loss |
| -Night sweats |
| -Sleep disturbances |
| -Lung disease/condition of fam. |
| -Geographical areas of recent travel |
| -Occupation/leisure activities |
| Percussion |
| -Resonance: Low pitch, moderate-loud, hollow, long duration, characteristic of normal lung tissue. |
| -Hyperresonance:Higher pitch than resonance, very loud, booming, longer than res., indicates presence of trapped air, commonly heard over emphysematous or asthmatic lung, occasionally over pneumothorax |
| -Flatness:High pitch, soft, extreme dullness, , short, example is sternum. Over lung fields may indicate massive pleural effusion |
| -Dullness:Medium pitch, medium, thudlike, medium duration, example is over liver and kidneys. Can be percussed over atelectatic lung or consolidated lung |
| -Tympany:High pitch, loud, musical/drumlike, short, examples are chest filled w/ air and abdomen distended w/ air. Over lung, usually indicates a large pneumothorax |
| Features of Adventitious Breath Sounds |
| -Discontinuous |
| *Fine crackles, fine rales, and high-pitched rales: In early or late inspiration. Popping, discontinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near the ear. "Velcro" sounds late in in i |
| *Coarse crackles and low-pitched crackles: Common on expiration, may be present early in inspiration. Lower-pitched, coarse, discontinuous rattling sounds caused by fluid/secretions in large airways; likely to change w/ coughing or suctioning. Associated |
| -Continuous |
| *Wheeze: Audible during either inspiration, expiration, or both. Squeaky, musical continuous sounds associated w/ air rushing through narrowed airways; may be heard w/out stethoscope. Arise from small airways. Usually do not clear w/ coughing. Associated |
| *Rhonchus (rhonchi):Audible during both inspiration and expiration, commonly more prominent on expiration. Lower-pitched, coarse, continuous snoring sounds. Arise from large airways. Associated w/: Thick and tenacious secretions, sputum production, obstru |
| -Pleural Friction Rub: Heard during inspiration and expiration, generally at end of inspiration and beginning of expiration. Loud, rough, grating, scratching sounds caused by inflamed surfaces of pleura rubbing together; often associated w/ pain on deep |
| inspirations. Heard in lateral lung fields. Associated w/: Pleurisy, TB, pulmonary infarction, pneumonia, and lung cancer |
| -O2 therapy intervention for pt w/ resp. problems *Clear oral, nasal and tracheal secretions *Maintain airway patency *Set up O2 equipment and administer through a heated, humidified system *Monitor O2 liter flow *Monitor position of O2 delivery devi |
| *Periodically check O2 delivery device to ensure prescribed concentration is being delivered *Monitor effectiveness of O2 therapy (pulse ox, ABGs) *Ensure replacement of mask or cannula when device is removed *Observe for signs of O2-induced |
| hypoventilation *Monitor for signs of O2 toxicity and absorption atelectasis *Monitor O2 equipment to make sure it does not interfere w/ pt's attempts to breathe *Monitor pt's anxiety r/t need for O2 therapy *Monitor for skin breakdown from friction o |
| device *Provide for O2 when pt is transported *Instruct pt/fam about O2 use at home *Arrange for use of O2 devices that facilitates mobility, teach pt |
| -Safety for pt receiving O2 therapy *Check Dr.'s prescription w/ type of delivery system and liter flow or % of O2 actually in use *Obtain prescription for humidification if O2 is delivered at 4L/min or more *Be sure |
Created by:
evangelineh86
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