Final Exam Study Guide Modules 6-8 PDF

Final Exam Study Guide Modules 6-8 Module 6: Assessment of Lungs and Thorax Learning Objectives 1. Perform assessment of the lungs and thorax using inspection, palpation, and auscultation. a. Inspection i. Respiratory rate and rh...

Final Exam Study Guide Modules 6-8 Module 6: Assessment of Lungs and Thorax Learning Objectives 1. Perform assessment of the lungs and thorax using inspection, palpation, and auscultation. a. Inspection i. Respiratory rate and rhythm 1. Rate: 12-20 2. Rhythm: consistent, even, regular ii. Chest rise and fall symmetrical iii. No accessory muscle use or retractions 1. Accessory muscles of respiration are muscles other than the diaphragm and intercostal muscles that may be used for labored breathing iv. Comfortable positioning, not in tripod position 1. Tripod position may indicate hypoxia, COPD; they are taught to do pursed lip breathing v. Color appropriate for ethnicity, no cyanosis vi. Chest wall configuration 1. Normal: AP:T is 1:2 a. AP is less than transverse 2. Abnormal: AP:T 1:1 a. Barrel chest b. Irreversible c. Ex. COPD: lungs are hyperinflated i. Chronic hypoxia vii. Nails 1. Abnormal: Clubbing caused by chronic hypoxia viii. Posterior thorax 1. Abnormal: Asymmetry and dorsal curvature a. Ex. Asymmetry- scoliosis i. Can interfere with lung expansion b. Ex. Dorsal curvature- kyphosis, gibbus  i. Can impede on respirations; difficult to breathe b. Palpation i. What are we feeling for? 1. Abnormal findings: crepitus, friction, masses, temperature 2. Normal findings: warm, no masses or tenderness ii. Technique 1. Hands move with breathing starting at T9 vertebrae 2. Go from left to right to down and then right to left motions iii. Put hands in W shape on mid back 1. Symmetric chest expansion at T9 or T10 level 2. Should see a. Both hands move when pt is breathing in and out 3. Tells us a. Lungs are symmetric  iv. Tactile Fremitus: palpable vibration; sounds generated from larynx 1. Have pt say “99, 99” and “blue moon” a. Findings: vibrations are strong as examiner moves towards lung bases; symmetric 2. Technique a. Use palmar base of fingers c. Percussion i. Client position 1. Slightly bent forward ii. Compare bilaterally and note any symmetry iii. Avoid body prominences iv. Specific technique 1. Starting at apices (where the traps are) and going side-to-side, working way down v. Findings 1. Normal: resonance (low-pitch, clear, and hollow sound); indicates healthy lung tissue 2. Abnormal: dull; can indicate fluid in lungs, pneumonia, or tumor vi. Pattern 1. Why do we hear different sounds over bones than over lung tissue? a. Bones are denser giving it a dull flat sound b. We hear dullness over liver and visceral area  2. Compare bilaterally d. Auscultation i. Position 1. Sit upright, relaxed, hands on knees ii. How should we have pt breathe? 1. In and out of mouth every time stethoscope makes contact with skin iii. How far down should we listen? 1. To lateral part of back iv. Why is pattern important? 1. To ensure you cover all lung fields 2. Make sure to listen to the lateral portion of the lungs (side of body) v. What do we expect to hear? 1. Clear lung sounds 2. No adventitious lung sounds (crackles or wheezing)  3. Bronchovesicular over major bronchi 4. Vesicular over peripheral lung fields vi. Bronchial sound 1. On anterior chest over trachea 2. Loud, high-pitched vii. Bronchovesicular sound 1. Heard closest to bronchi 2. Louder than vesicular 3. Even on inspiration and expiration viii. Vesicular sound 1. On lateral part of body 2. Whisper-like sound 3. Louder on inspiration 4. Smaller airway 5. ix. Examples of adventitious sounds: 1. Fine crackles a. High-pitched crackling 2. Coarse crackles a. Fluid in the lungs b. Sounds like you’re drinking a drink and have reached the bottom and you keep drinking with your straw 3. Pleural friction fremitus a. Friction in pleural tissue due to inflammation 4. Wheeze-sibilant a. Obstruction, air escaping through small airway, narrowed 5. Wheeze-sonorous rhonchi a. Obstruction, air escaping through small airway, narrowed on exhale 6. Stridor a. Upper airway obstruction b. Something lodged in throat  c. Common in children e. Anterior chest i. Same technique as posterior 2. Assess respiratory rate, rhythm, and pulse oximetry. i. Respiratory rate and rhythm 1. Regular, even, effortless, symmetric, consistent a. Rate: 12-20 breaths per minute ii. Pulse oximetry 1. Noninvasive method to assess arterial oxygen saturation (SPO2) a. Normal values: 97%-99% 2. Place on foot (for babies), finger, or toe 3. Inaccurate readings can be caused by carbon monoxide binding to the Hgb instead of oxygen or anemia 3. Discuss the purpose and describe the procedure for percussion of the lungs. a. Purpose i. Aids in determining if lung tissue is healthy in an adult b. Procedure i. Find predominant note over the lung fields ii. Start at apices and percuss the band of normally resonant tissue across tops of both shoulders, iii. Percuss in interspaces, make side-to-side comparisons all the way down to lung region iv. Percuss at 5-cm intervals avoiding the damping effects of scapula and ribs c. Findings i. Resonance: low-pitched, clear, hollow sound that predominates in healthy lung tissues in the adult 1. Relative term with no constant standard  2. May be duller in athletes with heavily muscular chest wall and in heavily obese adults ii. Abnormal 1. Hyperresonance and dullness a. Hyperresonance is a lower-pitched, booming sound found when too much air is present (ex. emphysema, pneumothorax) b. Dull note signals abnormal density in lungs as with pneumonia, pleural effusion, atelectasis, or tumor 2. Asymmetry: one side with prominent dullness or marked hyperresonance indicates underlying disease 4. Distinguish between normal and abnormal findings of the lungs and thorax exam and use appropriate terminology to document findings. 5. Auscultate lung sounds in Nursing Anne. 6. Describe the appropriate nursing actions for any abnormal findings. Information on Slides Major functions of respiration: ○ Supplying O2 to the body for energy ○ Removing CO2 as waste ○ Maintaining homeostasis ○ Maintaining heat exchange to some extent ABC ○ Airway ○ Breathing ○ Circulation Landmarks ○  ○ When to assess lungs ○ When admitted ○ Pt has SOB ○ Every shift w/ every pt Sometimes more than once Position ○ Sitting in relaxed position ○ Shoulders drooping and slightly forward ○ Turn them to their side if they are unable to sit Module 7: Assessment of Neurological System Learning Objectives 1. Identify and demonstrate assessment of the major components of a neurologic examination including: 1. Mental status 1. LOC 2. Alert and oriented a. Person, place, and time 3. Glasgow Coma Scale (GCS) a. Used to quantify LOC b. Score: 3-15 i. Eye-opening ii. Motor response iii. Verbal response iv.