Term
| Subjective Data Question: 1 |
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Definition
| Do you ever experience difficulty breathing (dyspnea)? |
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Term
| Subjective Data Question: 1 - rational |
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Definition
| Sudden onset is usuallly associated with viral or bacterial infection. |
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Term
| Subjective Data Question: 2 |
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Definition
| Do you wheeze when you cough or are active? |
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Term
| Subjective Data Question: 3 |
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Definition
| Have you ever or do you currently smoke cigarettes or use other tobacco products? How much and when did you start? |
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Term
| Subjective Data Question: 4 |
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Definition
| Are you currently taking or have you used any medications (prescription or OTC), herbal medicines, dietary supplements, or alternative therapies for breathing problems or to manage colds or other respiratory problems? |
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Term
| Respiratory Function Assessment: |
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Definition
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Term
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Definition
| Position client in semi- to high-Fowler's position. |
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Term
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Definition
| Expose chest while providing privacy. |
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Term
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Definition
| Inspect color of face, lips, and chest: "The client has evenly colored skin tone without unusual or prominent discoloration. Ruddy to purple complexion may be seen with COPD or CHF as a result of polycythemia (an abnormally increased concentration of hemoglobin in the blood). Cyanosis may be seen if the client is cold or hypoxic." |
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Term
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Definition
| Inspect color and shape of nails: "The nails are tones of pink and the nail base are at about a 160-degree angle to the skin. Clubbing (180-degrees or more) can occur from hypoxia." |
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Term
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Definition
| "The ratio is 1 to 2. The shoulders and scapulae are symmetric and nonprotruding." |
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Term
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Definition
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Term
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Definition
| "I'm palpating the anterior and posterior chest with my fingertips for tenderness, crepitus (a crackling sensation when air escapes from the lungs into the subcutaneous tissue), and retraction." |
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Term
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Definition
| "Now I'm going to palpate for respiratory excursion by placing my hands on the posterior thorax with my thumbs at the level of T9 or T10 and feeling if it is moving equally with deep breaths." |
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Term
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Definition
| "Now I'm going to palpate for tactile fremitus by asking the client to repeat the phrase 99 while I move my hands to each area assessing for vibrations of air in the bronchial tubes transmitted to the chest wall. Normally fremitus is symmetric and easily identified in the upper region of the lungs. Consolidation increases fremitus. Bronchial obstruction and air trapping in emphasema decrease fremitus." |
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Term
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Definition
| "I'm going to check for bronchophony by asking the client to repeat the phrase '99' as I ascultate the chest wall. It sounds soft, muffled, and indistinct. The sound is heard but the phrase is indistinguishable. If it was distinguishable and louder it might indicate consolidation from pneumonia, atelectasis (lung collapse), or tumor." |
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Term
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Definition
| "I'm going to check for egophony by asking the client to repeat the letter 'E' while I listen over the chest wall. It sounds soft, muffled, and the letter 'E' is not distinguishable. If it sounded louder and like 'A' it might indicate consolidation or compression." |
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Term
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Definition
| "I'm listening around the trachea where I hear bronchial sounds; they are loud, high-pitched, and harsh or hollow sounding." |
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Term
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Definition
| "Posteriorly I am listening no lower than C7 (the vertebral prominence) where I hear bronchovesicular sounds; they are moderate in amplitude and pitch." |
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Term
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Definition
| "Working my way down the peripheral lung fields where I hear vesicular sounds; they are soft, low-pitched, and breezy sounding." |
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Term
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Definition
| Assess for respiratory rate accurately. |
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