Podcast
Questions and Answers
What is the primary purpose of performing a physical assessment?
What is the primary purpose of performing a physical assessment?
Which method is primarily used to assess the density of underlying lung structures?
Which method is primarily used to assess the density of underlying lung structures?
What should a nurse look for during palpation of the thorax?
What should a nurse look for during palpation of the thorax?
In auscultation, what is crucial for comparing lung sounds?
In auscultation, what is crucial for comparing lung sounds?
Signup and view all the answers
What should a nurse observe for during the inspection phase of a physical assessment?
What should a nurse observe for during the inspection phase of a physical assessment?
Signup and view all the answers
Which condition is a potential cause of increased vibration during examination?
Which condition is a potential cause of increased vibration during examination?
Signup and view all the answers
Which of the following is a known cause of decreased vibrations during palpation?
Which of the following is a known cause of decreased vibrations during palpation?
Signup and view all the answers
Which of these options is NOT a reason for abnormal vibrations noted during palpation?
Which of these options is NOT a reason for abnormal vibrations noted during palpation?
Signup and view all the answers
What might respiratory effort indicate when assessing lung conditions?
What might respiratory effort indicate when assessing lung conditions?
Signup and view all the answers
Which of the following could cause an increase in vibrations upon palpation?
Which of the following could cause an increase in vibrations upon palpation?
Signup and view all the answers
In which scenario would you expect to see increased vibration due to respiratory conditions?
In which scenario would you expect to see increased vibration due to respiratory conditions?
Signup and view all the answers
Which respiratory condition is least likely to contribute to increased vibrations?
Which respiratory condition is least likely to contribute to increased vibrations?
Signup and view all the answers
What is a common physical finding associated with atelectasis?
What is a common physical finding associated with atelectasis?
Signup and view all the answers
Which breath sound is characterized by a high-pitched, audible noise caused by airflow through partially obstructed airways?
Which breath sound is characterized by a high-pitched, audible noise caused by airflow through partially obstructed airways?
Signup and view all the answers
What is the cause of rales during a respiratory assessment?
What is the cause of rales during a respiratory assessment?
Signup and view all the answers
Which abnormal breath sound is typically associated with inflammation and secretions in the large airways?
Which abnormal breath sound is typically associated with inflammation and secretions in the large airways?
Signup and view all the answers
Which breathing sound is produced by air passing through narrowed airways?
Which breathing sound is produced by air passing through narrowed airways?
Signup and view all the answers
Which of the following describes the sound of pleural friction rub?
Which of the following describes the sound of pleural friction rub?
Signup and view all the answers
What characterizes normal vesicular breath sounds?
What characterizes normal vesicular breath sounds?
Signup and view all the answers
Which abnormal sound is typically described as a high-pitched stridor often related to inflammation of the airways?
Which abnormal sound is typically described as a high-pitched stridor often related to inflammation of the airways?
Signup and view all the answers
During a respiratory assessment, which breath sound would you expect to hear in large airways affected by obstruction?
During a respiratory assessment, which breath sound would you expect to hear in large airways affected by obstruction?
Signup and view all the answers
What is Tactile Fremitus primarily assessed for?
What is Tactile Fremitus primarily assessed for?
Signup and view all the answers
Which area of the chest is likely to have the greatest vibrations during Tactile Fremitus?
Which area of the chest is likely to have the greatest vibrations during Tactile Fremitus?
Signup and view all the answers
Why might clinical history taking be ineffective in some patients?
Why might clinical history taking be ineffective in some patients?
Signup and view all the answers
Which of the following is NOT a component of the inspection process in respiratory assessment?
Which of the following is NOT a component of the inspection process in respiratory assessment?
Signup and view all the answers
How are normal vibrations distributed on the chest wall during Tactile Fremitus assessment?
How are normal vibrations distributed on the chest wall during Tactile Fremitus assessment?
Signup and view all the answers
Which of the following words is mentioned in the context of Tactile Fremitus assessment?
Which of the following words is mentioned in the context of Tactile Fremitus assessment?
Signup and view all the answers
What is a common barrier to effective clinical history taking?
What is a common barrier to effective clinical history taking?
Signup and view all the answers
Which two sites are particularly involved in the inspection process during respiratory assessment?
Which two sites are particularly involved in the inspection process during respiratory assessment?
Signup and view all the answers
Which of the following best describes normal Tactile Fremitus vibrations?
Which of the following best describes normal Tactile Fremitus vibrations?
Signup and view all the answers
Which type of oxygen delivery system is characterized by accurate oxygen concentration delivery regardless of the patient's inspiratory pattern?
Which type of oxygen delivery system is characterized by accurate oxygen concentration delivery regardless of the patient's inspiratory pattern?
Signup and view all the answers
What is one of the primary advantages of using Humidified High Flow Nasal Cannula (HHFNC) in emergency departments?
What is one of the primary advantages of using Humidified High Flow Nasal Cannula (HHFNC) in emergency departments?
Signup and view all the answers
Which of the following devices is classified as a reservoir system?
Which of the following devices is classified as a reservoir system?
Signup and view all the answers
When selecting an oxygen delivery system, which factor should not be considered?
When selecting an oxygen delivery system, which factor should not be considered?
Signup and view all the answers
Which statement about high flow oxygen devices is true?
Which statement about high flow oxygen devices is true?
Signup and view all the answers
What is a potential consequence of using a High Flow Nasal Cannula (HHFNC)?
What is a potential consequence of using a High Flow Nasal Cannula (HHFNC)?
Signup and view all the answers
Which of the following is NOT a characteristic of low flow oxygen systems?
Which of the following is NOT a characteristic of low flow oxygen systems?
Signup and view all the answers
Arterial blood gas analysis (ABG) is primarily used for which purpose?
Arterial blood gas analysis (ABG) is primarily used for which purpose?
Signup and view all the answers
What is the normal pH range in arterial blood?
What is the normal pH range in arterial blood?
Signup and view all the answers
What does a low PaCO2 indicate in arterial blood gas analysis?
What does a low PaCO2 indicate in arterial blood gas analysis?
Signup and view all the answers
Which of the following conditions results from low bicarbonate (HCO3) levels?
Which of the following conditions results from low bicarbonate (HCO3) levels?
Signup and view all the answers
When analyzing ABGs, what does it indicate if PaCO2 and HCO3 move in opposite directions?
When analyzing ABGs, what does it indicate if PaCO2 and HCO3 move in opposite directions?
Signup and view all the answers
What is the normal range for partial pressure of oxygen (PaO2) in arterial blood?
What is the normal range for partial pressure of oxygen (PaO2) in arterial blood?
Signup and view all the answers
How does age affect the normal value of PaO2?
How does age affect the normal value of PaO2?
Signup and view all the answers
What should be immediately assessed in an ABG analysis for signs of hypoxaemia?
What should be immediately assessed in an ABG analysis for signs of hypoxaemia?
Signup and view all the answers
What could a low pH along with high PaCO2 indicate?
What could a low pH along with high PaCO2 indicate?
Signup and view all the answers
Study Notes
Respiratory Monitoring
- Respiratory assessment is crucial in emergency nursing, requiring practice
- It's part of a complete assessment, highlighting deficits in airway, ventilation, and gas exchange.
- Assessment guides nursing and medical interventions for optimal respiratory function.
Learning Objectives
- Demonstrate respiratory assessment competency in the emergency department.
- Document findings and initiate appropriate nursing interventions post-assessment.
- Analyze assessment findings to select suitable oxygen therapy devices.
- Analyze and interpret arterial blood gas (ABG) results.
Key Concepts
- Respiratory health assessment
- Pulse oximetry
- Oxygen therapy
- Maintaining an artificial airway
- Arterial blood gas analysis
Respiratory Health Assessment
- Identifying gas-exchange adequacy (tissue oxygenation and carbon dioxide excretion) is vital.
- Identifying recent signs of respiratory dysfunction is paramount.
Physical Assessment
- Effective physical examination provides baseline data for efficient interventions
- Includes inspection, palpation, percussion, and auscultation
- Using a systematic format minimizes missed assessment aspects.
Inspection
- Direct observation of the chest, focusing on excursion, symmetry, skin colour, and lesions.
Palpation
- Examining the neck and thorax, looking for trachea position, subcutaneous emphysema, chest wall tenderness, crepitus, pulsations, and bulges.
Percussion
- Assessing underlying lung density based on sounds (resonance, hyperresonance, tympany, dullness, or flatness)
Auscultation
- Listening to and interpreting lung sounds using a stethoscope (anterior, posterior, and lateral aspects of the chest).
- Listening during both inspiration and expiration, comparing both sides of the chest.
Reading
- Review current critical care texts, highlighting effective clinical history taking, including barriers to effective history gathering, chest-wall configuration (inspection), respiratory effort (inspection), general observations, tactile fremitus assessment (palpation), respiratory expansion (palpation), and resonance, hyperresonance, tympany, dullness, and flatness (percussion)
- Auscultation findings (crackles, wheezes) should be noted
Activity 1
- Find a YouTube video describing and demonstrating normal and abnormal breath sounds (bronchial, bronchovesicular, vesicular; crackles, pleural friction rub, stridor, wheeze)
Activity 2
- Complete a respiratory assessment on a patient in the ED. Document and discuss findings including:
- Patient history
- General observations (inspection and palpation)
- Auscultation findings
Diagnostic Data
- Pulse oximetry
- ABGs (arterial blood gases)
- Chest X-ray
- Pulmonary function tests
- Capnography
Pulse Oximetry
- A non-invasive method to measure arterial oxygen saturation (SpO2).
- Indications: general monitoring, transport, procedures, oxygen therapy, sleep disorders, limb injury monitoring.
- Application sites: finger, toe, earlobe, bridge of nose.
- Limitations: nail polish, poor peripheral perfusion, peripheral vasoconstriction, anaemia.
Oxygen Therapy
- Oxygen therapy uses various devices (low and high flow).
- Consideration must be given before choosing a system/device.
- The use, dosage and method should be based on true hypoxia and pulse oximetry.
Activity 3
- Locate oxygen delivery devices in the facility.
- Discuss advantages and disadvantages of each device with a clinical support person.
Arterial Blood Gas Analysis
- ABGs are a valuable diagnostic tool in critical care and emergencies.
- Used to analyze oxygenation (PaO2, SaO2), acid-base status (pH, PaCO2, HCO3), and respiratory components.
Activity 4
- Accessing procedures and guidelines.
- Demostarting and discussing collection, labelling, and transport procedures for Arterial Blood Gas (ABG) samples
- Discussing the processing for arterial blood gas samples
6 Step Analysis
- Determining if the pH is normal (7.35-7.45), acidic (<7.35), or alkaline (>7.45).
- Analyzing PaCO2 (35-45 mmHg) to determine respiratory acidosis OR alkalosis.
- Analyzing HCO3 (22-26 mmol/L) to determine metabolic acidosis or alkalosis.
- Matching PaCO2 or HCO3 with the pH to identify a specific acid-base disorder (respiratory acidosis, respiratory alkalosis, metabolic acidosis, or metabolic alkalosis).
- Addressing any compensation (if present) from PaCO2 OR HCO3 moving in opposite directions
- Analyzing PaO2 and SaO2 for oxygenation (e.g., hypoxaemia).
Activity 5
- Analyze provided ABG results and determine if they are normal, acidic or alkaline. Determine the oxygenation and acid-base status.
Chest X-Ray
- Chest X-rays are critical diagnostic tools for evaluating the lungs.
- Common abnormalities include atelectasis, barotrauma, pleural effusion, pulmonary edema, pulmonary embolism, pneumonia, pneumothorax, and rib fractures.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
Test your knowledge on the primary methods and observations necessary for performing an effective physical assessment in nursing. This quiz covers key topics such as lung sound assessment, palpation techniques, and inspection criteria. Perfect for nursing students or professionals looking to refresh their skills.
