Respiratory 2a Web

8/13/2019 Respiratory 2a Web

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Physical Assessment of the

Respiratory System

Day 2A


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History

Physical problems

Function problems

Life style

Smoking

Family Hx

Occupation hx

Allergens en!ironment Recreational exposure

Anxiety

S"S


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#he nurse is teaching a group of prenatal clientsabout the effects of cigarette smoke on fetal$e!elopment% &hich characteristic is associate$

'ith babies born to mothers 'ho smoke$ $uringpregnancy(

A%Lo' birth 'eight

)%Large for gestational age

*%Preterm birth+ but appropriate si,e for gestation

D%-ro'th retar$ation in 'eight an$ length


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.nspection

/ormal chest

Slight retraction of

intercostal spaces 2x as 'i$e as $eep

Anteriorposterior

$iameter

012


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.nspection

)arrel chest

Dt o!er inflation of

lungs

anteriorposterior

$iameter

212


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.nspection

Funnel chest

Depression of the

lo'er portion of thesternum

*omplications

Heart $amage

*ar$iac output

/rs management

3urmurs


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.nspection

Pigeon chest

Sternum protru$es

out'ar$ anteriorposterior

$iameter


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.nspection

Scoliosis

Lateral cur!ature of

thoracic spine Assessment

Shoul$ers ele!ate$(

*omplications

Lung " heart $amage )ack problems

)o$y image


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4ui,(

Ho' many hours a $ay shoul$ a chil$'ear a brace for treating scoliosis(

A% 5 hr

)% 02 hr

*% 26 hr

D% 27 hr


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.nspection

8yphosis

A8A

Hunchback Abnormal cur!ature

of the thoracic spine


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.nspection

Lor$osis

A8A

S'ayback Abnormal cur!ature

of the lumbar spine


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.nspection

9niform expansion

of the chest

Pneumonia

Pleural effusion

Pneumothorax

)ulging intercostal

spaces

Obstruction

:mphysema


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.nspection

3arke$ retraction of

intercostal spaces

)lockage

Shoul$er rise

Accessory muscles

Posture


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.nspection1 )reathing patterns

Rate

:upnea /ormal

022; min #achypnea

rate

Pnuemonia+ pulm e$ema+ aci$osis+ septicemia+ pain

)ra$ypnea rate

.*P+ $rug OD


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Depth

8ussmaul


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Rhythm

Apnea

/ot breathing

*heynestokes

=arying $epth fb apnea

Death rattles

Death rales


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Rhythm

)iots

rate " $epth ' abrupt pauses

Assoc ' .*P


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.nspection1

#rachea

( De!iation

Pleural effusion #ension pneumothorax

Atelectasis

*olor

LO* :motional state


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Palpation

#3L #en$erness >#?

3asses >3?

Lesions >L?

Sinuses Palpate belo' eyebro' "

*heekbone

*repitus Subcutaneous emphysema

Air leaks into the sub@tissue


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Percussion

Rational

#o $etermine if

un$erlying tissue is

fille$ 'ith air or soli$

material

Proce$ure

Pt sitting

#ap starting at shoul$er

compare rt to lf


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Percussion1 results

Resonance $rum like

/ormal

Hyperresonance

#oo much air

:mphysema

Flatness $ull

Flui$ or soli$

Pleural effusion

Pneumonia

#umor


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Auscultation

Purpose

Asses air flo'

through bronchialtree

Proce$ure

Diaphragm of

stethoscope Superior inferior

*ompare rt to lf


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Auscultation1 Results

/ormal =esicular

Lung fiel$

Soft an$ lo' )ronchial

#rachea " bronchi Hollo'

)roncho!esicular 3ixe$ )et'een scapulae Si$e of sternum 0st" 2n$intercostal space


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A$!entitious

*rackles

Rales

air bronchi 'ithsecretions

Fine crackles

Air su$$enly

reinflate$ *ourse *rackles

3oist


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&hee,es

Sonorous 'hee,es

Deep lo' pitche$

Snoring

:

*ause$ by air

narro'e$ passages

Dt secretions

Sibilant &hee,es

High pitche$

&histlelike

. " :

*ause$ by air narro'e$ passages

Dt constriction

Asthma


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Pleural friction rub

Dt inflammation of

pleural membranes -rating+ creaking

. " :

)est hear$

Anterior+ Lo'er+lateral area


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Stri$or

*ro'ing

Partial obstruction ofthe larynx or trachea


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4ui,(

A chil$ 'ith $ifficulty breathing an$ a

barkingcough i$ $isplaying signs

associate$ 'ith 'hich con$ition(

A% Asthma

)% *roup

*% *ystic fibrosisD% :piglottitis


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4ui,(

&hen assessing the lung soun$s of achil$ 'ith asthma+ 'hich soun$ are youmost likely to hear(

A% 3urmurs)% Sonorous &hee,ing

*% Sibilant &hee,ing

D% *rackles:% Pleural friction rub


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:arly " latesigns of hypoxia

Anxiety

)ra$ycar$ia

*yanosis

Depresse$

respirations

Diaphoresis

Disorientation Dyspnea

Restlessness

Hea$ache

Agitation

Poor Bu$gment

Retraction

#achycar$ia

#achypnea


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#he nurse recogni,es 'hich of the

follo'ing as an early sign of hypoxia(A% Restlessness+ ya'ning " tachycar$ia

)% Dyspnea+ confusion " bra$ycar$ia

*% )ra$ycar$ia+ hypotension $yspnea

D% Dyspnea+ restlessness+ hypotension


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Dyspnea

Definition

SO)

SOB, flat affect, BS x 4


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Dyspnea

Significance

*ommon 'ith car$iac " resp% $isease

Su$$en onset C healthy person

Pneumothorax

Su$$en onset ill+ postop or inBury

Pulmonary emboli


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Dyspnea

Orthopnea

Sit up to breath

*OPD

*HF


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Dyspnea

Right !entricle

.f chronic air'ay resistance

pressure

Rt !entricle 'ork

Rt% =ent $amage


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Dyspnea

/rs 3anagement

Fin$ cause

-i!e O2

HO)

*ommunication

8.SS


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*ough

Definition

#o expel air from the lungs su$$enly

.rritation of mucous membrane


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*ough

Significance

.nfection

.rritants

Protecti!e mechanism

Dry+ irritating

9R#

*ough chest pain Pleural or musculoskeletal


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*ough

/rs management

Assess

Describe

Directe$

Pain control

Splinting

.nfection control

Suppressants Antitussi!es


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Sputum Pro$uction

Definition

3atter $ischarge$

from resp% track thatcontains mucus an$

pus+ bloo$+ fibrin+ or

bacteria


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Sputum Pro$uction

Significance

Purulent

#hick+ yello'green )acteria

Rusty

Strep or staph

#hin+ mucous

=iral


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Sputum Pro$uction

Pinktinge$

Lung *A

#) Pink tinge$+ profuse+

frothy

Pulmonary e$ema

3alo$orous

Lung abscess


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Sputum Pro$uction

/rs 3anagement

#hick

Hy$rate 'ater

/ebuli,er

Humi$ifier

#*D)

/o smoking

Oral care

Appetite


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Do Eou 8no'(((((

&hat breath soun$ 'oul$ you expect to

hear on a patient 'ith increase$ sputum

pro$uction(

A% =esicular

)% *rackles

*% Sonorous 'hee,es

D% Sibilant 'hee,es


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Obtaining a sputum specimen

:xplain From lungs

Sterile cup Deep breath x 6

*ough $eeply

:xpectorate

)est time forspecimencollection( A3


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A nurse is to collect a sputum specimen for aci$

fast bacillus >AF)? from a client% &hich

action shoul$ the nurse take first(

A%Ask client to cough sputum into container)%Ha!e the client take se!eral $eep breaths

*%Pro!i$e a appropriate specimen container

D%Assist 'ith oral hygiene


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*hest pain

Definition

*ar$iac or

pulmonary


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*hest pain

Significance

*A >late stage?

Pneumonia Pulmonary

embolism

Pleurisy


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*hest pain

Pleurisy

.nflammation of

pleura

Sharp 'ith breath

breath soun$s


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&hat(((((

&hat breath soun$ 'oul$ you expect to

hear on a patient suffering from pleurisy(

A% *rackles

)% Sonorous 'hee,es

*% Sibilant 'hee,es

D% Pleural Friction Rub


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*hest pain

/rs 3anagement

Assess

Analgesics O8+but

Position for pain

Affecte$ si$e

Splint


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*lubbe$ fingers

Definition

Sponginess of the

nail be$ Loss of the nail be$

angle

Finger tip is roun$

an$ bulbous


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*lubbe$ Finger

Significance

chronic hypoxia

/rs 3anagement 3arker


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3r% *a!eman1

3r% *a!eman enters the :R unconscious follo'ingan Automobile acci$ent% #he parame$ics report

that his O2 sats are 5G% Eou note that 3r%

*a!eman has clubbe$ fingers% &hat $oes this

tell you(


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Hemoptysis

Definition

:xpectoration of

bloo$ from therespiratory tract


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Hemoptysis

Significance

Pulm or car$iac

*ommon causes Pulm infection

*A of lungs

Pulm% :mboli

Pulm% .nfarction

#)


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Hemoptysis

Hemoptysis

Definition(

*oughe$ up bloo$

From( Pulm hemorrhage

Description

Pink+ re$+ mixe$ 'ith

sputum

)loo$ pH

Alkaline bloo$

Hematemesis

Definition(

=omite$ bloo$

From( Stomach -.

Description

*offee groun$

)loo$ ph Aci$ic bloo$


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Hemoptysis

/rs 3anagement

Determine source

Serious


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*yanosis

Definition

)luish coloring of

skin


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*yanosis

Significance

=ery late in$icator of

hypoxia Appears 'hen O2

sats 5IG

/O# a reliable sign

of hypoxia

:sp% 'ith anemia


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*yanosis

/ormal

)reath 0;; O2 molecules K5 cross into bloo$

)loo$1 0;; Hgb

O2 SA#S

K5G

/o cyanosis


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*yanosis

Hypoxia

)reath 0;; O2 molecules I cross into bloo$

)loo$1 0;; Hgb

O2 SA#S

IG

*yanosis


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*yanosis

Anemic an$ hypoxic

)reath 0;; O2 molecules I cross into bloo$

)loo$1 I Hgb

O2 SA#S

0;;G

/o *yanosis


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*yanosis

/rs% 3anagement

8no' color of Pt% skin

Assess color of tongue

" lips

Fingernail polish

AfricanAmerican

=asoconstriction >col$'eather? peripheral

cyanosis

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