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Nursing Skills LP4
Respiratory Assessment
36
Nursing
Undergraduate 1
03/30/2014

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Cards

Term
adventitious breath sounds
Definition
abnormal breath sounds
Term
Normal breath sounds
Definition
Vesicular
Bronch-vesicular
Bronchial
Term
Vesicular breath sounds
Definition
soft-intensity, low-pitched "gentle sighing"
-air moving through smaller airways (bronchioles and alveoli)
-over peripheral lung, best heard at base of lungs
-best heard on inspiration
Term
Broncho-vesicular breath sounds
Definition
moderate intensity and moderate pitched "blowing" sounds created by air moving through the larger airway (bronchi)
-between the scapulae and lateral to the sternum at the first and second intercostal spaces
-equal inspiration and expiration
Term
Bronchial
Definition
high pitched, loud, "harsh", sounds created by air moving through the trachea
-anteriorly over the trachea, not normally heard over lung tissue
-louder than vesicular sounds, have short inspiratory phase and long expiratory (1:2 ratio)
Term
Crackles
Definition
fine, short interrupted crackling sounds,(like a lock of hair being rolled near the ear)
-may not be cleared by coughing

-air passing through fluid or mucus in any air passage
-most common in bases of lower lung lobes
Term
Rhonchi (gurgles)
Definition
continuous, low-pitched, coarse, gurgling, harsh, louder sounds with a snoring quality
-best heard on expiration
-may be altered by cough
-air passing through narrowed air passages as a result of secretions, swelling, tumors
-predominantly over trachea and bronchi
Term
Friction rub
Definition
superficial grating or creaking sounds heard during inspiration and expiration
-not relieved by coughing
-rubbing together of inflamed pleural surfaces
-heard most often in areas of greatest thoracic expansion (lower anterior and lateral chest) heard over all lung fields
Term
Wheeze
Definition
continuous, high-pitched squeaky musical sounds
-best heard on expiration.
-not usually altered by coughing
-
Term
Stridor
Definition
high-pitched musical breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree
Term
fremitus
Definition
the faintly perceptible vibration felt through the chest wall when the client speaks
Term
Respirations Averages (and ranges) by age

Newborn
Definition
35 (30-60)
Term
Respirations Averages (and ranges) by age

1 Year
Definition
30 (20-40)
Term
Respirations Averages (and ranges) by age

5-8 years
Definition
20 (15-25)
Term
Respirations Averages (and ranges) by age

10 years
Definition
19 (15-25)
Term
Respirations Averages (and ranges) by age

Teen
Definition
18 (15-20)
Term
Respirations Averages (and ranges) by age

Adult
Definition
16 (12-20)
Term
Respirations Averages (and ranges) by age

Older Adult
Definition
16 (15-20)
Term
Tachypnea
Definition
quick, shallow breaths
Term
Bradypnea
Definition
abnormally slow breathing
Term
apnea
Definition
cessation of breathing
Term
hyperventilation
Definition
overexpansion of the lungs characterized by rapid and deep breaths
Term
hypoventilation
Definition
underexpansion of the lungs, characterized by shallow respirations
Term
Cheyne-Stokes breathing
Definition
rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea
Term
dyspnea
Definition
difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed
Term
orthopnea
Definition
ability to breathe onl in upright sitting or standing position
Term
intercostal retraction
Definition
indrawing between the ribs
Term
substernal retraction
Definition
indrawing beneath the breastbone
Term
suprasternal retraction
Definition
indrawing above the clavicles
Term
hemoptysis
Definition
the presence of blood in the sputum
Term
productive cough
Definition
a cough accompanied by expectorated secretions
Term
nonproductive cough
Definition
a dry, harsh cough without secretions
Term
RRED
Definition
rate: 10-20 normal for adults
rhythm: regular or irregular
effort: labored or nonlabored or a specific difficulty
depth: shallow, moderate, or deep
Term
pursed lip breathing
Definition
Relax your neck and shoulder muscles.
Breathe in for two seconds through your nose, keeping your mouth closed.
Breathe out for four seconds through pursed lips. If this is too long for you, simply breathe out twice as long as you breathe in.
Term
cyanosis
Definition
bluish tinge most evident in the nail beds, lips, and buccal mucosa.
In dark skinned clients close inspection of the palpebral conjunctiva (lining of eyelids) and palms and soles may show evidence
Term
oxygen saturation
Definition
95-100%

below 70% life threatenin
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