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NUR 121 Final Respiratory
Respiratory assessment
40
Nursing
Undergraduate 1
04/28/2012

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Term
The respiratory system
Definition
Supplies the body with oxygen
eliminates carbon dioxide
Term
The actual transfer of oxygen and carbon dioxide occurs in the ______
Definition
alveoli
Term
Lungs
Definition
The lungs start above the clavicle
Term
The right lung is _________ than the left
Definition
WIDER
Term
Landmarks for the Thoracic cage
ANTERIOR
Definition
Angle of Louis
Midsternal lines
Midclavicular lines
Anterior axillary lines
Term
Landmarks for the Thoracic cage
POSTERIOR
Definition
Seventh cervical vertebra
Midspinal line (vertebral line)
Midscapular lines
Posterior axillary lines
Term
Landmarks for the Thoracic cage
LATERAL
Definition
Midaxillary lines
Term
Lung Health History always include
Definition
Onset (date, sudden or gradual)
Duration
Frequency
Precipitating factors
Aggravating or alleviating Factors
Treatment/self-care
Outcome
Term
Present Health Status
Definition
Allergies
Tobacco use
Medications including aerosols or inhalants
Screening tests i.e. Pulmonary Functions Test (PFT)
Nutritional data
Exercise patterns
How many pillows they sleep with
Term
Present Illness
Definition
Cough
Sputum production
Shortness of Breath
Chest Pain
Term
Past History
Definition
Respiratory Infections or Disease
Trauma - airbag, seatbelts
Surgery
Chronic Conditions - malignancy
Term
Family History and other
Definition
TB
COPD
Lung Cancer
Asthma

Employment history
Recent Travels
Hobbies

IMMUNIZATIONS (pneumovac
Term
Respiratory Process
Definition
Diaphragm descends during inspiration causing negative pressure
Negative pressure draws air from atmosphere
Term
Air passes into alveoli to __________ body tissue
Definition
Oxygenate
Term
End of inspiration: Muscles relax, lungs _______
Definition
recoil
Term
Lung pressure is ______ than atmospheric pressure, "Dirty" air leaves lungs into the atmosphere
Definition
greater
Term
Expiration is a ________ process
Definition
Passive
Term
Assessment of Respiratory system
Definition
Requires stethoscope
pt. is sitting during the posterior and lateral assessment
Supine for Anterior assessment
Term
Order of assessment
Definition
Inspection
Palpation
Percussion (Advanced)
Auscultation
Term
Inspection
Definition
Measure and assess pattern of respirations, specifically, RATE, RHYTHM, EFFORT, and DEPTH
Assess skin, color, condition, lessons, including nail beds and lips
Thoracic Configuration, AP diameter, abnormalities i.e. barrel chest
Anterior Posterior : Lateral - 1:2
Term
Normal breathing
Definition
12-20
Term
Tachypenea vs. bradypenea
Definition
24 vs. 10
Term
Hyperventilation or Kussmaul
Definition
deep gasping
Term
Periodic or Cheyne- Stokes respirations
Definition
regular breathing with deep fast respirations followed by apnea
Term
Biot's respirations
Definition
all over the place
Term
Orthopenea
Definition
Can not breath while laying down
Term
Palpation
Definition
Assess for tenderness, pulsations, masses or skin lesions
Assess thoracic expansion
Asses tactile freitus- feel it stronger between the scapula
Assess tracheal position
Term
Percussion
Definition
Purpose: to determine lung position and size
Detect the presence of air, liquids, or solids within the lungs
Percussion tone is RESONANCE
flat- percuss over bone
tympany- air
hyperresonance- lung with excessive air, COPD lung
dullness- Lung with fluid or tumor
Assessment by percussion is completed in a systemic pattern over the anterior and posterior thorax noting:
Intensity
Pitch
Duration
Quality
Term
Auscultation
Definition
Bronchial
Bronchialvesicular
Vesicular
Term
Auscultation
Definition
Sternal angle or Angle of Louis 2nd ribs
Have pt. breath slowly through mouth
listen for one COMPLETE respiratory cycle
Term
Adventitious breath sounds
CRACKLES
Definition
Discontinuous breath sounds
Course: LOW PITCH, bubbly, moist sounding, early inspiration to early expiration

Fine: HIGH PITCH, pop, generally only heard during inspiration
Term
Adventitious Breath Sounds
WHEEZES
Definition
Continuous sounds.
Whistle like
EXPIRATION
Term
Adventitious Breath Sounds
PLEURAL FRICTION RUB
Definition
Continuous sounds
Sounds like a crackle, but during INSPIRATION and EXPIRATION
can be caused by dehydration
Term
ABG
Definition
pH: 7.35-7.45
PCO2: 35-45
HCO2: 22-27
PO2: 80-100
O2: 95-100%
Term
Physiologic changes with aging
Definition
Elderly have decreased mobility of the thorax
Decrease ability to cough and expectorate, less vigorous cough
Increase risk of pneumonia
Term
A ___________ provides information regarding the anatomic location and appearance of the lungs
Definition
Chest Xray
Term
a __________ removes fluid or air from the pleural space via a transthoracic aspiration
Definition
Thoracentesis
Term
Post Thoracentesis
Definition
Monitor vitals
Monitor respiratory status
apply pressure dressing and assess puncture site for bleeding and crepitus
monitor for signs of pneumothorax
Term
A ______________ is a direct visual examination of the larynx trachea, and bronchi with a fiber optic bronchoscope. Pt. is sedated during procedure
Definition
Bronchoscopy
Term
PFT
Definition
Include a number of different tests used to evaluate lung mechanics, gas exchange, and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gasses.
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