Health Assessment Ch.14
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- What are signs of normal breathing?
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*No use of shoulder muscles
*Use of diaphragm as the major muscle at work; lower chest expansion during inspiration. - When are trapezius or shoulder muscles used during inspiration? Is it normal?
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*Acute and chronic airway obstruction or atelectasis.
*Abnormal - Which ethnicity generally has a larger thorax and greater lung capacity?
- Adult Caucasians
- Is kyphosis a normal finding? Why or why not?
- Normal; it resultsl from a loss of lung resiliency and a loss of skeletal muscle.
- What causes barrel chest?
- Emphysema due to hyperinflation of the lungs.
- A diameter of the anterior posterior thorax that equals the diameter of the transverse thorax is called what?
- Barrel chest
- What is kyphosis?
- A deformity that is a pronounced forward curvature of the thoracic spine.
- What condition is commonly the result of emphysema?
- Barrel chest
- At what angle should the ribs slope downward from the spine?
- 45 degrees
- What is the ratio for the dimensions of a normal thorax?
- 1:2
- What ethnicity and gender have a greater risk for lung cancer?
- African American males
- What is indicative of a non-productive cough?
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*Upper respiratory irritation
*Early congestive heart failure - What is indicative of late-evening coughing?
- Exposure to irritants during the day.
- What is indicative of coughs during the night?
- Post-nasal drip; sinusitis
- What is indicative of pink, frothy sputum?
- Pulmonary edema
- What is indicative of a continuous cough?
- Acute infections
- What is indicative of early morning coughing?
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*Chronic bronchial inflammation
*Smoking - What is indicative of rust-colored sputum?
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*Tuberculosis
*Pneumococcal pneumonia - What is hemoptysis?
- Blood in the sputum.
- What is indicative of hemoptysis?
- Serious respiratory conditions.
- What is indicative of yellow or green sputum?
- Bacterial infections
- What is indicative of white or mucoid sputum?
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*Common colds
*Viral infections
*Bronchitis - What iconditions are associated with wheezing?
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*CHF
*Asthma
*Excessive secretions - What are some s/s of CHF?
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*Orthopnea
*paroxysmal nocturnal dyspnea
*Non-productive coughs (early sign)
*Wheezing - What is paroxysmal nocturnal dyspnea?
- Severe dyspnea that awakens the person from sleep.
- What is orthopnea?
- Difficulty breathing while lying supine.
- What is the strongest stimulus to breathe?
- Carbon dioxide
- Why might a normal aging adult experience dyspnea?
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*Loss of elasticity in lungs.
*Fewer functional capillaries.
*Loss of lung resiliency. - Gradual onset of dyspnea is indicative of what?
- Emphysema
- Acute onset of dyspnea is indicative of what?
- Viral or bacterial infection.
- What position does an individual assume when COPD is present?
- Client leans forward and uses arms to support weight and lift chest to increase breathing capacity; AKA tripod position.
- What are you palpating for when assessing the thorax?
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*tenderness, pain or other sensation
*crepitus
*fremitus
*chest expansion
*surface characteristics
*warmth - What is crepitus?
- A crackling sensation that occurs when air posses through fluid or exudate.
- What is another name for crepitus?
- Subcutaneous emphysema
- When can crepitus be palpated?
- When air escapes the lung or other airways into the subcutaneous tissue. Eg. thoracic injury, around a chest tube or tracheostomy.
- What is fremitus?
- Vibrations of air in the bronchial tubes transmitted to the chest wall and felt by the examiner when client says "99".
- How do you palpate for fremitus?
- Use the ball or ulnar edge of one hand.
- What is a normal finding for fremitus?
- Sounds are the same bilaterally. A decrease in intesity is heard as the examiner moves from the apex to the base.
- What causes unequal fremitus?
- Consolidation due to obstruction, air trapping in ephysema, pleural effusion.
- What causes diminished fremitus?
- Pneumothorax or obstruction of the tracheobronchial tree.
- Why is the ball of the hand best for assessing tactile fremitus?
- It is sensitive to vibratory sensation.
- How do you palpate for chest expansion?
- Place hands on the posterior chest wall with thumbs at the level of T( or T10. As the client takes a deep breath, observe the movement of your thumbs.
- What is a normal observation when palpating chest expansion?
- When client takes a breath, examiner's thumbs should move apart by 5-10 cm symmetrically.
- What is atelectasis?
- Collapse or incomplete expansion of the lungs.
- What may be normal findings of palpating chest expansion in an older adult?
- Decreased expansion due to calcification of the costal cartilages and loss of the accessory musculature. However, it should be symmetric.
- What are some conditions that cause unequal chest expansion?
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Atelectasis
Pneumonia
Chest trauma
Pneumothorax - What is pneumothorax?
- Air in the pleural space.
- What can cause a decreased lung excursion?
- COPD due to decreased diaphragmatic function.
- How do you percuss for tone on the thorax?
- Right to left and top to bottom starting at the apices above the scapulae, comparing sides.
- What is the normal percussion tone elicited over normal lung tissue?
- Resonance
- Why might the examiner hear hyperresonance upon percussion?
- Trapped air as in emphysema or pneumothorax
- Why might the examiner hear dullness upon percussion?
- Fluid or solid tissue replaces air in the lungs or occupies the pleural space.
- What are some examples of dullness heard upon percussion?
- Lobar pneumonia, pleural effusion or tumor.
- What are normal measurements for diaphragmatic excursion?
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3-5 cm bilaterally in adults.
7-8 cm bilaterally in well-conditioned clients. - What is a normal position for the diaphragm?
- the level of the diaphragm may be higher onthe right because of the postition of the liver.
- What is the procedure for percussing diaphragmatic excursion?
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Client exhales forcefully and holds breath. At T7, percuss intercostal spaces of the right posterior chest wall. Percuss downward unti the tone changes from resonance to dullness.-Mark.
Client inhales deeply and holds. Percuss intercostal spaces from mark downward until resonance changes to dullness.-Mark. Measure and repeat on left posterior thorax. - What are some causes of uneven excursion?
- Unilateral pneumonia, damage to the phrenic nerve or splenomegaly.
- An abnormal finding of diaphragmatic descent may be due to what?
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Atelectasis of the lower lobes or by emphysema, in which diaphragmatic movement and air trapping are minimal. The diaphragm remains in a low position upon expiration and inspiration.
Other possible causes are pain or abdominal changes such as extreme ascites, tumors or pregnancy. - What are the three normal breath sounds that can be auscultated?
- Bronchial, bronchovesicular and vesicular.
- What could diminished or absent breath sounds indicate?
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Obstruction as a result of secretions, mucus plug or a foreign object.
Abnormalities of the pleural space. - What are some examples of abnormalities of the pleural space?
- Pleural thickening, pleural effusion or pheumothorax.
- When might you hear louder than normal breath sounds?
- Consolidation or compression that results from a denser lung.
- What can cause diminished inspiratory breath sounds?
- Emphysema with a loss of elasticity of lung tissue.
- What are normal respiratory patterns?
- 12-20/min and regular
- What is tachypnea?
- Respiration greater than 24/min and shallow.
- Tachypnea is a normal response to what?
- Fever, anxiety, exercise
- What is bradypnea?
- Respirations of less than 10/min and regular.
- With what conditions can tachypnea occur?
- Alkalosis, pneumonia or pleurisy
- When does normal bradypnea occur?
- Well-conditioned athletes
- When does abnormal bradypnea occur?
- Medication-induced depression of the respiratory center, diabetic coma, neurologic damage.
- What is hyperventilation?
- Increased rate and increased depth.
- What are Kussmal's repirations?
- A type of hyperventilation associated with diabetic ketoacidosis.
- What are some causes of hyperventilation?
- Extreme exercie, fear or anxiety. Other causes include disorders of the CNS, an overdose ofthe drug salicylate or severe anxiety.
- What is hypoventilation?
- Decreased rate, descreased depth, irregular pattern.
- What is associated with hypoventilation?
- Overdose of narcotics or anesthetics.
- What is Cheyne-Stokes respiration?
- Regular pattern characterize by alternating periods of deep, rapid breathing followed by periods of apnea.
- Cheyne-Stokes respiration may be a result of what?
- Severe CHF, drug overdose, increased intracranial pressure or renal failure.
- When might Cheyne-Stokes respiration be a normal value?
- Elderly during sleep
- What is Biot's respiration?
- Irregular pattern characterized by varying depth and rate of respiration followed by periods of apnea.
- When might Biot's respiration be seen?
- Meningitis or severe brain damage.
- Name some abnormal adventitious breath sounds.
- fine crackles, coarse crackles, pleural friction rub, sibilant wheeze, sonorous wheeze.
- What is a sonorous wheeze?
- Low-pitched snoring or moaning sounds heard primarily during expiration but may be heard throught the respiratory cycle. Wheezes may clear with coughing.
- What is a sibilant wheeze?
- High-pitched musical sounds heard primarily during expiration but may also be head on inspiration.
- What is the source of a sibilant or sonorous wheeze?
- Air passing through constricted passages caused by swelling, secretions or tumor.
- When are sibilant wheezes heard?
- Acute asthma or chronic emphysema.
- When are sonorous wheezes heard?
- Bronchitis or single obstructions and snoring before an episode of sleep apnea.
- What is stridor?
- Harsh honking wheeze with severe broncholarynospasm, such as occurs with croup.
- What is a sign of croup?
- Stridor
- Name some discontinuous sounds.
- Fine and coarse crackles.
- Name some continuous sounds.
- Pleural friction rub, sibilant and sonorous wheezes.
- What is a pleural friction rub?
- Low-pitched, dry, grating sound. Sound is like crackles, only more superficial and occurs during both inspiration and expiration.
- What is the source of a pleural friction rub?
- Sound is the result of rubbing of two inflamed pleural surfaces.
- Name a condition of a pleural friction rub.
- Pleuritis
- What are the chracteristics of coarse crackles?
- Low-pitched, bubbling, moist sounds that may persist from early inspiration to early expiration. Like softly separating Velcro.
- What are the characteristics of fine crackles?
- High-pitched, short, popping sounds heard during inspiraton and not cleared with coughing. Sounds are discontinuous.
- What is the source of coarse crackles?
- Inhaled air comes into contact wth secretions in the large bronchi and trachea.
- What is the source of fine crackles?
- Inhaled air suddenly opens the small deflated air passages that are coated and sticky with exudate.
- Fine crackles occuring late in inspiration are indicative of what?
- Restrictive diseases such as pneumonia and CHF.
- Fine crackles occuring early in inspiration are indicative of what?
- Obstructive disorders such as bronchitis, asthma, or emphysema.
- Coarse crackles may indicate what?
- Pneumonia, pulmonary edema and pulmonary fibrosis. Velcro rales of pulmonary fibrosis are heard louder and closer to stethoscope, usually do not change location, and are more common in clients with long-term COPD.
- What is the normal pitch of bronchial breath sounds?
- High
- What is the normal quality of bronchial breath sounds?
- Harsh or hollow
- what is the normal amplitude of bronchial breath sounds?
- Loud
- What is the duration of normal bronchial breath sounds?
- Short during inspiratio, long in expiration.
- What is the location of bronchial breath sounds?
- Trachea and larynx
- What is the normal pitch of bronchovesicular breath sounds?
- Moderate
- what is the normal quality of bronchovesicular breath sounds?
- Mixed
- What is the normal amplitude of bronchovesicular breath sounds?
- Moderate
- What is the duration of normal bronchovesicular breath sounds?
- Same in inspiraton and expiration.
- What is the location of normal bronchovesicular breath sounds?
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Over the major bronchi-posterior; between the scapulae; anterior:
around the upper sternum in the first and second intercostal spaces. - What is the pitch of normal vesicular breath sounds?
- Low
- what is the quality of normal vesicular breath sounds?
- Breezy
- What is the normal amplitude of vesicular breath sounds?
- Soft
- What is the normal duration of vesicular breath sounds?
- Long in inspiration, short in expiration.
- What is the normal location of vesicular breath sounds?
- Peripheral lung fields
- How should you perform auscultation the thorax?
- Begin from the apices of the lungs at C7 and continue to the bases at T10 and laterally from the axilla down to the seventh or eight rib; making a backwards, continuous 's' from top left to bottom left.
- How long should you listen at each posterior thorax?
- One complete cycle
- When would it be advantageous for the client to wear a thin t-shirt upon thoracic ausculatation?
- When the chest is extremely hairy as to not hear friction.
- How should you ausculatate the anterior thorax?
- Ausculatate from the apices of the lungs slights above the calvicles to the bases of the lungs at the sixth rib.
- How should the client breathe during ausculatation of the thorax?
- Deeply through the mouth
- How should you perform palpation of the posterior thorax?
- From neck(left scapulae) to just above the waist(base of the lungs); top to bottom and left to right, comparing bilaterally.
- Upon palpation of the posterior thorax, fingers are best for assessing what?
- Sensation, lumps, lesions
- Tactile fremitus is best felt with what?
- Palm of hand
- What can you assess best using anterior thoracic palpation?
- Lung's right middle lobe.
- What is scoliosis?
- A deformity that imparts an 'S' to the spine.
- Scoliosis is primarily found in what gender/age group?
- Young females
- In what group is kyphosis common?
- Elderly
- What is another name for pectus carinatum?
- Pigeon chest
- What is pectus carinatum?
- A minor deformity in which the sternum protrudes but requires no treatment; depressed costal cartilages.
- What is another name for pectus excavatum?
- Funnel chest
- What is pectus excavatum?
- A congenital malformation characterized by a sunken sternum and seldom causing symptoms other than self-consciousness.
- What sounds should you ausculatate for?
- Breath, adventitious and voice sounds.
- Where is flatness detected upon percussion?
- Over the muscles and bones.
- Where is dulness detected upon percussion?
- Breast tissue, the heart and liver.
- Where is tympany detected?
- Over the stomach.
- What is a normal costal angle?
- No more than 90 degrees
- Pain or tenderness at the costachondral junction of the ribs is indicative of what?
- Fractures, especially in older clients with osteoporosis.
- Labored and noisy breathing occurs during what conditions?
- Severe asthma and chronic bronchitis.
- What is indicative of bulging of the intercostal spaces?
- Trapped air seen in emphysema or asthma.
- What is indicative of retraction of intercostal spaces?
- Increased inspiratory effort due to obstruction of the respiratory tract or atelectasis.
- What group of people may use nasal flaring and why?
- Small children in labored respiration.
- Nasal flaring could indicate what?
- Hypoxia
- When might you see pursed lip breathing?
- Asthma, emphysema or CHF as a physiologic response to help slow down expiration and keep alveoli open longer.
- When might neck muscles be abnormally used during breathing?
- Facilitates inspiration in acute or chronic airway obstruction or atelectasis.
- What muscles are typically used for breathing when experience COPD?
- Abdominal and intercostal muscles.
- Abdominal and intercostal muscles are used for breathing during what condition?
- COPD
- What is a normal color for the face, lips, chest during breathing?
- Ambient skin color with pik undertones.
- When might cyanosis be seen?
- Client is cold, hypoxic.
- What color is seen in clients with COPD or CHF as a result of polycythemia?
- Ruddy to purple complexion.
- How do you auscultate for bronchophony?
- Ask the client to repeat the phrase "99" when you listen to the chest wall.
- How do you auscultate for egophony?
- Ask the client to repeat the letter "E" while you listen to the chest wall.
- How do you aucultate for whispered pectoriloquy?
- Ask the client to whisper the phrase "1-2-3" while you listen to the chest wall.
- What are adventitious breath sounds?
- Added or superimposed breath sounds over the normal breath sounds.
- What are normal bronchophony findings?
- voice transmission is soft, muffled, and indistinct. The sound of the voice may be heard, but the actual phrase cannot be distinguished.
- What are normal egophony findings?
- Voice transmission will be soft and muffled, but the letter "E" should be distinguishable.
- What are normal whispered pectoriloquy findings?
- Transmission of sound is very faint and muffled. It may be inaudible.
- What are abnormal bronchophony findings?
- The words will be easily understood and louder over areas of increased denisyt. This may indicate consolidation from pneumonia, atelectasis or tumor.
- What are abnormal egophony findings?
- Over area of consolidation or compession, the sound will be louder and change to "A".
- What are abnormal whispered pectoriloquy findings?
- Over areas of consolidation or compression, the sound will be transmitted clearly and distinctly. In such areas, it will sound as if the client is whispering directly into the stethoscope.
- Why might the sternum and ribs be more prominent in the older client?
- Loss of subcutaneous fat.
- When are sternal retractions observed?
- During labored breathing.
- Pain in the chest is usually associated with what?
- Pleura, thoracic muscles and tracheobronchial tree, but not in the lungs due to lack of nerve endings.