Respiratory Assessment and Auscultation

Respiratory Assessment & Auscultation

• In a respiratory assessment, inspection of the chest should be done first.
• Comparing sounds bilaterally using a systematic ladder pattern ensures accurate auscultation results.
• Chronic hyperinflation of the lungs causes barrel chest in COPD patients.
• Wheezes indicate narrowed airways; they are high-pitched, musical sounds during expiration.
• Increased tactile fremitus is indicated by pneumonia due to lung consolidation.
• Hyperresonance upon chest percussion is associated with air trapping in emphysema.
• Stridor is most likely associated with airway obstruction.
• The correct order for auscultating posterior lung fields is side-to-side in a ladder-like pattern.
• Crepitus indicates air trapped under the skin.
• Crackles are an adventitious breath sound related to fluid in alveoli in pulmonary edema cases.
• Uneven chest expansion in a patient with a rib fracture suggests pneumothorax.
• Tripod positioning while sitting is most likely caused by severe respiratory distress.
• Dullness during percussion indicates fluid in the lungs.
• Rhonchi, low-pitched snoring sounds that clear with coughing should be documented.
• Cheyne-Stokes respiration may indicate heart failure or neurological injury.

Nursing Interventions

• Administer albuterol to a patient with an oxygen saturation of 88% and audible wheezing.
• Assess a 30-year-old asthma patient first reporting difficulty breathing and an O2 saturation of 88%.
• The diaphragm is best for detecting high-pitched breath sounds.
• Pleural inflammation is associated with a pleural friction rub.
• Kussmaul respirations may indicate metabolic acidosis.

Breath Sounds & Causes

• Stridor from upper airway obstruction is a high-pitched, crowing sound during inspiration.
• Wheezing is due to narrowing of airways in asthma from bronchospasm.
• Rhonchi, a snoring, low-pitched sound, clears after coughing.
• Fine crackles in the lung bases of a CHF patient are due to fluid accumulation in alveoli.
• Pleural effusion is most likely to cause diminished breath sounds in the right lower lung.
• Stridor is commonly associated with anaphylaxis.
• Crackles that do not clear with coughing in pneumonia indicate fluid-filled alveoli.
• Diminished breath sounds are expected in a post-operative patient with atelectasis.
• Provide supplemental oxygen and prepare for intubation since stridor indicates compromised airway caused by severe allergic reaction.
• Encouraging coughing and deep breathing is the priority intervention to treat coarse crackles in a pneumonia patient
• Administer albuterol first for high-pitched wheezing associated with asthma.
• Rhonchi is most likely caused by COPD with thick mucus secretions.
• Rhonchi clears with coughing, while crackles do not.

Respiratory Findings

• Excess body mass reducing air movement, which limits chest expansion causes diminished breath sounds in a patient with obesity.
• Pleural effusion causes absent breath sounds in the lower lung fields due to fluid compressing lung tissue.
• Wheezing on expiration is a concern in anaphylaxis, indicates airway obstruction.
• Crackles are pulmonary edema bases indicate fluid overload
• Stridor indicates life-threatening airway obstruction requiring immediate intervention.
• Rhonchi is expected in bronchitis because of mucus buildup.
• Pneumothroax results in absent or diminished breath sounds.

Answers & Explanations

• Stridor due to upper airway obstruction indicates an obstruction in the larynx or trachea.
• Wheezing occurs in asthma due to airway constriction because of narrowing airways due to bronchospasm.
• Rhonchi, iow-pitched sounds that clear with coughing indicates large airway mucus
• Crackles results in fine crackles are associated with fluid accumulation in alveoli in pulmoary edema
• Pleural effusion reduces sound transmission leading to diminished breath sounds.
• Stridor is common in anaphylaxis because of airway swelling.
• Crackles occur when fluid or inflammation pop open alveoli.
• Diminished breath sounds because atelectasis causes alveolar collapse, reducing airflow.
• Wheezing in asthma requires a Albuterol a bronchodilator treatment
• Rhonchi is common in COPD and is Mobilzes secretions in lung
• Obesity can limit chest expansion limiting reducing airway in body mass to move air.
• Airway obstruction in wheezing signals in anaphylaxis a impending collaspe of fluid.
• Pneumothorax collapses the lung, reducing air movement.

Prioritization Questions

• For respiration, always prioritize; Airway, Breathing, then Circulation (ABC).
• Assess the patient with suspected anaphylaxis and audible stridor, since this is an airway obstruction (Stridor = airway obstruction (ABC priority). Immediate intervention needed).
• The post-op patient requires immediate attention. Low BP + tachycardia = potential hypovolemia or hemorrhage. Requires immediate attention.
• Assess patient who has sudden-onset confusion and slurred speech. Look for FAST assessment to for any symptoms indicating a urgent sign of stroke.
• Hyperkalemia >5.5 is a cardiac emergency (risk of arrhythmias) with potassium intake
• The second most concern is for the patient with dehydration and a blood pressure of 88/58 mmHg since it addresses Malsow's physiologicals.
• Potential sepsis is of cosideration for a patient with pneumonia who has a fever, address the infection concern.
• Signiciant raise to 150 mL/hr indicates active bleeding or compication for Chest Tube patients
• Weight gain + orthopnea = worsening heart failure, due to fluid overload
• LPNs task is to can perform sterile procedures but not admission assessments or blood transfusions for stroke
• UAPs can collect specimens but cannot assess or administer medications for patient with urine problems

Case Study 1: Post-Operative Patient with Decreased Breath Sounds

• Diminished breath sounds after surgery from atelectasis, shallow breathing and immobility.
• Prevents and treats as a post-op is to Encourage use of the incentive spirometer
• Helps reopen alveoli by c) Instruct the patient to take deep breaths and cough post op
• e) Mobilizes secretions and improves early ambulation from surgery
• Apply oxygen by priority before ABC for ABC to call the provider if patient is in servere distress.

Patient with Wheezing and Dyspnea

• Treat is a nebuziled Albuterol if fir asthma exacerbations.
• Asthma indicates wheezing since airways are narrowed resulting in high-pitched musical sounds.
• Severe increases can cause tachycardia, but severe increases (>120 bpm) in rate requires monitoring of alveoli.

Case Study 3: Patint with Stridor

• Epneprhine is the prority if severe inaphylaxis.
• Swelling worst then needed because intubation is needed before the airway occurs.

NCLEX-Style Practice Questions

• Auscultates are Rhonchi with a low-pitched low sound.

Nursing Assess

• Sound should be persisnted due to friction rub
• Chronic is low long term in a a nail angle
• Patients may have carditis, with high blood pressue during deep breath

Nurse Question Case

• Sound is more indicated when pt hold ther breath
• Assess nurse on sound of lungs
• Assist pt when needed on oxygen when help breathe

Cardio Diagonistic

• ECG test should be taken if there is fluid issues
• Troponin show that the chest has been injured
• Elevrated in cardiac issue
• Find ECG that is elevated or has multiple

Emerancy

• First action is 12-ead ECG
• Reason why patient needs aspirin

Pt Assestent

• If needs more then more likely test.
• MI is diagnosed via elevation levels.
• Avoid caffeina and feel report

The nurse

• Pts that need a stent of a diaphoreis ECG
• Need more time

Nursing Explation

• Highist pioroty when needed
• Elevated that has PE
• Assitment

4. In distress

• Ask on where the nurse has to go
• When to work with them.

Question 16

• If O2 is need
• 4 L per cannla can
• Hypoxa or not breathing then it is not good

Assitent need with more air

• Assess them a little faster them they see
• High Flower is needed when over whelmed

More then

• Look if there is more cyanosis
• More needed a fast respone can be taken

Select (Sata)

• O2 needs more asssitance
• Respirtory or more high
• Nurse assessment and help there is a needed task.

Questions.

• There should be questions on which what.
• The test should be done in lung and breath is not there.
• Chest has to be in middle of the head to give better sound.

Q: Is oxygen

• Breath has to be done for any test.

Heart Sound

• Over laod is needed all the time.

In and OVer

• Long term for test hypoxia.

With P:E Patients

• Assistence
• Get them oxygen and help them start moving.
• Test is needed for what they need.

With asthma is

• Proventil
• Not do other options to improve lung health and test.

Select for all

• There more need assitance with more is needed.

Assess patient

• Assess and go over all test more frequently to assit new test as to needed.
• O2 improve to all new level to improve oxygen to heart