Respiratory Assessment (NUR 310)

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Questions and Answers

Which type of breath sound is characterized as loud and high-pitched, found specifically over the trachea and major bronchi?

  • Vesicular
  • Bronchovesicular
  • Bronchial/Tracheal (correct)
  • Rhonchi

What type of adventitious breath sound is described as intermittent, rattling, and heard during inspiration due to increased moisture?

  • Crackles (correct)
  • Pleural friction rub
  • Wheezes
  • Stridor

Which percussion sound would you expect to elicit over the precordium?

  • Dullness (correct)
  • Resonance
  • Tympany
  • Hyper-resonance

What is the normal AP-to-lateral chest ratio in adults?

<p>1:2 (D)</p> Signup and view all the answers

Which respiratory pattern is characterized by alternating periods of hyperventilation and apnea?

<p>Cheyne-Stokes respiration (B)</p> Signup and view all the answers

Which type of breath sound is described as a high-pitched, whistling sound associated with narrowed small airways?

<p>Wheezes (A)</p> Signup and view all the answers

Which assessment technique involves feeling for abnormalities such as tenderness and crepitus?

<p>Palpation (C)</p> Signup and view all the answers

What is considered a medical emergency when assessing breath sounds?

<p>Stridor (B)</p> Signup and view all the answers

Which anatomical landmark is used to assess symmetric respiratory excursion during palpation?

<p>T9-T10 (A)</p> Signup and view all the answers

What does 'crepitus' during palpation of the chest indicate?

<p>Air escaped from the lung entering subcutaneous tissues (B)</p> Signup and view all the answers

What finding during percussion indicates a solid or fluid-filled area in the lung?

<p>Dullness (A)</p> Signup and view all the answers

What does an increased vocal fremitus suggest?

<p>Compression or consolidation of lung tissue (B)</p> Signup and view all the answers

A patient is sitting forward, supporting themselves with their arms. What is this position called, and what does it suggest?

<p>Tripod position, indicating respiratory distress (C)</p> Signup and view all the answers

What does a barrel chest typically indicate?

<p>Chronic lung disease such as emphysema (C)</p> Signup and view all the answers

During the preliminary assessment, which of the following respiratory rates would be considered normal for a relaxed adult?

<p>16 breaths per minute (B)</p> Signup and view all the answers

What does the term 'pectus excavatum' refer to when inspecting the anterior chest?

<p>Markedly sunken sternum (D)</p> Signup and view all the answers

Flashcards

Suprasternal notch

A prominent indentation at the top of the sternum.

Tripod position

A stance where a patient leans forward, supporting themselves with their arms.

Kyphosis

An exaggerated backward curve of the thoracic spine.

Pectus excavatum

A condition where the sternum is significantly sunken in.

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Vocal fremitus

Vibrations felt on the chest when a patient speaks.

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Resonance

A normal percussion sound indicating air-filled spaces in the lungs.

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Auscultation

Listening to sounds within the body, especially the lungs.

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Pulse oximetry

A non-invasive method to measure blood oxygen levels.

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Bronchial/Tracheal Sounds

Loud, high-pitched sounds heard over the trachea and major bronchi.

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Bronchovesicular Sounds

Moderate pitch sounds located between scapulae and around the sternum in the 1st and 2nd ICS.

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Vesicular Sounds

Soft, low-pitched rustling sounds heard in the periphery of the lungs.

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Crackles (Rales)

Intermittent rattling sounds caused by air traveling through moist areas of the lungs.

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Wheezes

High-pitched, whistling sounds heard when air passes through narrowed airways.

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Rhonchi

Continuous, coarse sounds resulting from narrowed larger airways.

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Pleural Friction Rub

Crackling or grating sound created when pleura rub together, heard on inspiration and expiration.

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Stridor

High-pitched, loud sound indicating upper airway obstruction, a medical emergency.

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Study Notes

Respiratory Assessment (NUR 310)

  • Anterior Anatomy Landmarks: Suprasternal notch/clavicle, 5th rib, xiphoid process

  • Posterior Anatomy Landmarks: Cervicothoracic junction, T9-T10

  • Preliminary Assessment: Assess for distress (sweating, strained look, noisy breathing), position/work of breathing (tripod, retractions, accessory muscles), level of consciousness (anxious/agitated/confused), signs of hypoxia (skin color, pallor, cyanosis), respiratory rate (even, smooth, silent, 12-20), pulse oximetry (greater than or equal to 95%)

  • Inspection: Assess slope of ribs (downward 45° may indicate emphysema), bilateral chest wall expansion (uneven may indicate trauma), barrel chest (rounded), kyphosis (exaggerated posterior curve of the thoracic spine), lordosis (inward curvature of the lumbar spine), pectus excavatum ("funnel chest"), pectus carinatum ("pigeon breast"), scoliosis (lateral S-shaped curvature of the thoracic & lumbar spine)

  • Palpation: Assess for tenderness, masses, sinus tracts (passages under skin filled with fluid or air), crepitus (air escaped from lung to SQ tissue), symmetric respiratory excursion, vocal or tactile fremitus (palmar surface of hand, best between scapulae, increased with compression/consolidation of lung tissue, decreased with obstructions).

  • Percussion: Assess for sounds; resonance (air-filled space, loud, low pitch), dull (solid/fluid filled, tumor/pneumonia/effusion/atelectasis), hyperresonance (over-inflated alveoli, high-pitched). Technique: Don't hold percussion hammer like a hammer! Use a slight wrist movement.

  • Auscultation Sequence: Let patient breathe at their own rate, assess side-to-side, moving down ICS.

  • Types of Breath Sounds: Bronchial/Tracheal (loud, high-pitched, anterior only), Bronchovesicular (moderate pitch, between scapulae and one side of the sternum in 1st & 2nd ICS), Vesicular (soft, low-pitched, periphery), decreased/absent (bronchial tree obstructed)

  • Adventitious Breath Sounds: Crackles (rales): intermittent rattling, popping, bubbling, usually on inspiration(fine-soft, high-pitched, coarse-louder, lower pitch); wheezes (high-pitched, whistling, narrowed small airway, inspiration or expiration); rhonchi (continuous, coarse, snoring, louder/lower than crackles, narrowed larger airways, inspiration, expiration, may clear with coughing); pleural friction rub (crackling/grating, inspiration & expiration), stridor (MEDICAL EMERGENCY, high-pitched, loud, caused by obstruction of upper airway, heard on inspiration)

  • Anterior Assessment: (Page 13) Inspect respiratory rate & rhythm (tachypnea, bradypnea, apnea, hypernea, hyperventilation, Cheyne-Stokes, ataxic, Kussmaul's), costal angle (less than or equal to 90 degrees), AP-to-lateral ratio (about 1:2, increased in older adult, increased in barrel chest, increased in pectus carinatum)

  • Additional: Palpation (page 14) areas to check for tenderness, masses, sinus tracts, crepitus, Percussion (page 15) technique, sound characteristics for the precordium (dullness), Auscultation (page 16) displacing breast tissue to listen directly to the chest wall, anterior areas to listen for bronchial/tracheal, bronchovesicular, & vesicular sounds

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