N125- Respiratory Assessment

Review of Structure of the Lungs and Thorax
Click the card to flip 👆
1 / 32
Terms in this set (32)
Review of Structure of the Lungs and Thorax
- thoraxic cage: borders
Anterior thoracic landmarks: suprasternal notch, sternum, sternal angle, cotal angle
- posterior thoracic landmarks: vertebra prominens, spinous processes, inferior border of scapula, twelfth rib
Mediastinum
contains esophagus, trachea, heart, great vessels
Lobes of the lungs
-anterior
- posterior
- lateral
Trachea and bronchial tree
- location of the trachea and bronchi
- dead space
-function of acinus
Four functions of the respiratory system
- control respiration
- changing chest size during respiration
- inspiration & expiration
- gas exchange
Developmental considerations for infants and children
- surfactant
- vulnerability related to small size and immaturity of pulmonary system
- flexibility in sequence of the exam
- crying enhances palpation of tactile fremitus
- thoracic cage is soft and flexible
- Apgar scoring system
- sternal or intercostal retractions indicate distress
- respiratory rate and pattern
- on auscultation, localization of breath sounds are more difficult
- percussion of limited use in newborns
Developmental Considerations of Pregnant Women
- enlarging uterus elevates diaphragm; decreases vertical diameter of thoracic cage, compensated by increase in horizontal diameter
Developmental considerations of older adults
- lungs more rigid and harder to inflate
- decrease in vital capacity
- increase in residual volume
- decrease in number of alveoli
- increased shortness of breath on exertion
- increased risk for post-op. complications
- round, barrel-shaped thoracic cage and kyphosis
- chest expansion somewhat decreased
- less mobile thorax
Developmental consideration of acutely ill patients
second examiner needed to support patient in upright position for exam
Cultural and Social Considerations
- new and re-emerging cases of TB in Canada (2010) at unprecedented national low
- asthma rates down, but contributing factor in 10% of hospital admissions of children age less than 5 years
- preventable risk factors for resp. distress: tobacco smoke, poor air quality
- lung cancer is leading cause of cancer death in Canada
- Women incur greater lung damage from exposure to environmental tobacco compared with men
Health history- cough - shortness of breath - chest pain with breathing - history of respiratory infections - smoking history - environmental exposure - self-care behavioursHealth history for children- illness: frequent colds - allergy - chronic resp. illness - safety: childproofing, inhalation of toxic substances - environmental smokeHealth history for older adults- activity intolerance - level of activity - lung disease - painRespiratory assessment equipment- stethoscope - small ruler marked in cm - marking pen - alcohol wipeRespiratory assessment: inspection- shape and configuration of chest wall - facial expression - level of consciousness - skin color and condition - quality and number of respirations - rib interspaces - accessory muscles - position patient takes to breatheRespiratory assessment: palpation- symmetrical expansion - tactile fremitus: technique; factors that affect normal intensity of tactile fremitus - palpate the entire chest wallRespiratory assessment: percussion- predominant note over lung fields - resonance - border of cardiac dullness (anterior)Respiratory assessment: auscultation- breath sounds - adventitious soundsAbnormal findings: abnormal breath soundsadventitious sounds** - pleural friction rub: coarse and low pitched with a grating quality - crackles: fine vs coarse - wheezes: high vs low pitched - atelectatic crackles: sounds like fine crackles however do not last, are not pathological, and disappear after a few breathsAbnormal findings: configurations of the thorax- barrel chest - scoliosis - kyphosisAbnormal findings: respiratory patterns- tachypnea - bradypnea - hyperventilation - hypoventilationAssessment of common respiratory conditions- atelectasis (collapse) - lobar pneumonia - bronchitis - emphysema - asthma (reactive airway disease) - pleural effusion (fluid) - pleural thickening - heart failure - pneumothorax - tuberculosis - pulmonary embolism - acute respiratory distress syndrome (ARDS)Tactile fremitus would be increased when: A: the patient has a blocked bronchus B: the patient has a mild case of pneumonia C: the patient has an advanced case of pneumonia D: the patient has pleural effusionCThe nurse knows that the proper technique for assessing lungs in an adult patient is performing auscultation: A. from right to left, using a "z" pattern B. from top to bottom, using landmarks for accuracy C. using the bell of the stethoscope to hear vascular sounds D. on the anterior chest wall and abdomen to determine diaphragm functionAAirway management goalto maintain adequate tissue oxygenation and protect the airwayAirway management- maintains patency of patient's nose, upper airway, trachea, and lower airway - noninvasive techniques of managing airway include: hydration, positioning, nutrition, chest physiotherapy, deep breathing, coughing, humidity, incentive spirometry, and aerosol therapy - Invasive techniques are needed when patients are unable to protect or clear their own airwayAirway management: oral suction- Yankauer suction catheter - rigid, minimally flexible plastic - used when secretions are copious and thickOxygen therapy- administration of supplemental oxygen - prevents or treats hypoxia- routes of administration: nasal cannula, face masksOxygen therapy: nasal cannula- simple, effective, and comfortable - inexpensive and disposableOxygen therapy: face masks- simple face mask - plastic face mask with reservoir bag - Venturi mask - face tentIncentive spirometry- helps a patient deep-breathe - two types: flow-oriented, volume-orientedConsiderations for oxygen therapy- explain oxygen therapy, safety precautions, and signs of oxygen toxicity and carbon dioxide retention - older adults with chronic illnesses or arthritis require additional time to demonstrate the procedure - give the client time to learn, it takes an older adult longer to achieve target volume - because of the fragility of older adults' skin and mucous membranes, offer oral hygiene and skin care more frequently