Module F King 103- Assessment of the Respiratory System
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| Eupnea | Normal breathing 12-20
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| Bradypnea | Abnormally slow breathing pattern (Drug overdose)
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| Tachypnea | Abnormally fast breathing pattern (COPD)
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| Apnea | Temporary absence of breathing
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| Accessory muscles | Use of muscles other than diaphragm & intercostals to breath
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| Hyperpnea | Increased rte of breathing, deeper than during normal activity. (Electrolyte imbalance)
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| Dyspnea | "Air Hunger" labored/difficulty breathing
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| Orthopnea | Discomfort breathing in any position other than erect sitting/standing position
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| Excursion | Movement/depth of the chest wall
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| Hypoventilation | Decreased rate & depth of breathing (<12 adult; <20 child (12 & under))
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| hyperventilation | Increased rate & depth of breathing (>20 adult; >30 child (12 & under))
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| Atelectasis | collapse of alveoli, no air movement in small airways
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| Pneumon | Lung
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| Thorax | Chest
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| Pleural Cavity | Space within the thorax containing the lungs
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| Pneumothorax | Collection of air or gas in the pleural space
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| Pleural Space | Space betweenn visceral (organ) & parietal layers of the pleurae. (10 to 20 ML) of fluid
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| Pleural Effusion | Abnormal accumulation of fluid(blood or other body fluids) in intrapleural spaces of lungs.
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| Brochial | Loud, high pitched with hollow quality-best heard over trachea
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| Bronchovesicular | Blowing sound, medium pitch & intensity- heard over upper thorax
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| Vesicular | Soft, breezy, low pitch- heard over lower thorax
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| Mucus Membrane Beings at Mouth & ends... | At rectum
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| Which side has 2 lobes? | Left side
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| Which side has 3 lobes? | Right side
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| Ventilation | Exchange of oxygen/carbon dioxide gases in & out of lungs
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| Diffusion | Movement of oxygen & carbon dioxide between alveoli & red blood cells
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| Purfusion | Distribution of red blood cells to & from pulmonary capillaries (smallest structures)
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| Respiratory system plays important role in maintaining... | Acid-base balance
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| Resonance | Sound created by air- heard over posterior thorax (Heard more in children than adults)
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| Dull/Flat | Sound created by bone/mass- heard over scapula, ribs, spine, muscle, liver, & heart
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| Hyperresonant | Sound created by hyperinflation (too much air or emptiness)COPD
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| Tympany | Clear, hollow, drum-like, heard over (organs) cavity
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| Systematic Pattern | Posterior, Lateral, Anterior
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| Auscultate what at each position of the stethoscope? | The entire Inspiration & Expiration
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| Bronchophony | Speak "ninety-nine" fluid compressing lung causes vibrations to be transmitted clearly to chest wall (not muffled) Abnormal finding
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| Sputum- If client has cough must Note: | Amount- minimum, moderate, large
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| Color of Respiratory discharge.. | Clear, White, Yellow, Green, Gray, Any hemoptysis- bright red, dark red,or brown
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| Oder | Yes or No
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| Consistency | Watery, thin, thick, Frothy, copious(thick large amounts)
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| Difficulty breathing | Do you have a history of difficulty breathing?
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| Dyspnea (difficulty breathing) | When? At rest or upon exertion. Minimal exertion or strenuous exercise. (Any Pain?)
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| Any O2 therapy | What LPN & Route (NC or mask)
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| Ask about Chest X-ray's | Last one, for what reason, results
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| Ask about Regular Medications... | Prescribed, OTC, or herbal/home remedies
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| Rate | Eupnea, Bradypnea, Or Tachypnea,document actual findings.
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| Rhythm | Regular, Irregular, Apnea, Prolonged Inspration/Expiration
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| Depth | Shallow, or Deep
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| Breathing Pattern | Easy rise/fall of chest or pursed lip, nasal flaring
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| Chest Wall movement | Symmetrical Or Asymmetrical
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| Nasal Discharge | Color, odor, consistency
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| Lung Sounds | Where ausultated, What area(posterior, lateral, or anterior), Which side, ICS, Lobe, What Sound
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| Skin Color | Pink, Pallor (Pale), Cyanosis, Ashen, Motten, Or Yellow
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| Frequent colds... | Treated or Untreated
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| Cough | Productive or Non-Productive
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| Adventitous Sounds... | Describe Sound, Location & When heard
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| Measure Infants circumference where? | Under the arms at nipple line
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| Infants commonly breath from where? | Nose & Abdominal areas
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| 1st Respiratory Inspection | Shape, Symmetry (compare anterior/posterior diameter with lateral is 1:2) Infants will be 1:1 & round Observe posture!!!
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| 2nd Respiratory Palpation | Palpate for lumps, masses, pulsations, or uneven movements. Measure vocal/tactile fremitus (siting or lying position)
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| 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
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| 4th Respiratory Auscultation | Assess movement of air through the tracheobronchial tree. Detects mucous or accumulation of mucus or obstructed airflow
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| Recognition of normal sounds allows detection of... | Sounds caused by obstruction
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| Anatomical Landmarks of the Chest are.. | Left/Right scapular line, Vertebral line, Posterior/Anterior axillary line, Midaxillary line, Midsternal line, Midclavicular line
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| Use these terms when assessing the Thorax... | Manubrium, Xiphoid process, Body, Costal Cartilage
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| If abnormalities are assessed in tactile fremitus, percussion,ausculation what would be done next? | Test for whispered words (Bronchophony or Whispered Pectoriloquy)
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| What may be high pitched, fine, medium or course sounds, random/sudden reinflation of alveoli? | Rales/Crackles
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| What is whistling sounds, high pitched squeak, airflow in severely narrowed bronchus sometimes called musical? | Wheezing
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| What is vibrations felt through the chest wall when client is speaking? | Tactie or Vocal fremitus
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| What is a sonorous wheeze loud low pitched muscular spasm fluid mucous in trachae bronchi? | Rhonchi
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