Oxygenation and Perfusion

Factors to Assess: Questions to ask about Medications.

* Are you taking any medications for your breathing, your heart, or for your blood pressure? * What other medications are you taking?

How do you teach a patient to use a incentive spirometer?

* Assist the patient to an upright or semi-Fowler's position if possible. * Remove dentures if they fit poorly. * Assess for pain. Administer pain medication, as prescribed, if needed. If the patient has recently undergone abdominal or chest surgery, place a pillow or folded blanket over a chest or abdominal incision for splinting. * Demonstrate how to steady the device with one hand and hold the mouthpiece with the other hand. * Instruct the patient to exhale normally and then place lips securely around the mouthpiece. * Instruct the patient not to breathe through the nose. Use a nose clip if necessary. Instruct the patient to inhale slowly and as deeply as possible through the mouthpiece without using the nose (a nose clip may be used). * Instruct the patient to remove the lips from the mouthpiece and exhale normally. If patient becomes light-headed during the process, tell him or her to stop and take a few normal breaths before resuming incentive spirometry. * Encourage the patient to complete breathing exercises about 5 to 10 times every 1 to 2 hours, if possible. Rest in between breaths as necessary.*

What is the procedure of CPR?

* Compressions: Check the pulse. If the victim has no pulse, initiate chest compressions to provide artificial circulation. * Airway: Tilt the head and lift the chin; check for breathing. The respiratory tract must be opened so that air can enter. * Breathing: If the victim does not start to breathe spontaneously after the airway is opened, give two breaths lasting 1 second each. * Defibrillation: Apply the AED as soon as it is available.

Factors to Assess: Questions to ask about Sputum.

* Do you ever cough up and spit out mucus? * How much do you spit out and do you associate it with anything (time of day, environment)? * What color is it? Is it ever blood tinged? * What is its odor?

Factors to Assess: Questions to ask about Pain.

* Do you have any chest pain? Do you have pain with breathing? Do you have pain in the arms or legs? * When did it start? * On a scale of 0 to 10 (10 being very painful), how severe is the pain? * Where is the pain? * Is the pain worse with inspiration? Expiration? Cough? Activity? * Does the pain radiate? * What measures are you using to relieve the pain?

Factors to Assess: Questions to ask about Health history.

* Do you have any heart, lung, or breathing conditions? * Does anyone in your family/home have any breathing conditions or respiratory infections?

Factors to Assess: Questions to ask about Lifestyle and environment

* Do you smoke? If so, how many years have you smoked? * How much do you smoke (i.e., how many packs per day or year)? * Do you live with a smoker or are there smokers in your workplace? * Are you exposed to respiratory irritants in your workplace? * Are there other pollutants in your workplace?

What are some common mistakes patient make when using a metered-dose inhaler (MDI)?

* Failing to shake the canister * Holding the inhaler upside down * Inhaling through the nose rather than the mouth * Inhaling too rapidly * Stopping the inhalation when the cold propellant is felt in the throat * Failing to hold their breath after inhalation * Inhaling two sprays with one breath

Factors to Assess: Questions to ask about Fever.

* Have you had pneumonia recently? * Do you have any contact with people who have tuberculosis? * Do you have night sweats? * Are others in your household well or ill? * Have you traveled anywhere recently?

Factors to Assess: Questions to ask about Recent changes.

* Have you noticed any changes in your breathing (out of breath, cough, wheezing)? * Have you noticed any changes in your ability to perform activities of daily living? * Do you have any swelling or redness in your arms or legs? * Do you have a respiratory infection? If so, what type? * What relief measures are you using?

Factors to Assess: Questions to ask about Fatigue.

* Have you noticed you feel more tired lately? * Are you getting your normal amount of sleep at night? * Has your sleep at night been affected by any difficulty breathing? * Do you become easily fatigued when you climb stairs?

Factors to Assess: Questions to ask about Cough.

* How much and how often do you cough? * What is it like (dry, bubbly, hoarse)? * Do you cough up mucus? If so, how much and what does it look like? * Do you have a history of allergies? * Do you ever wheeze? * Are you exposed to dust? Fumes?

Factors to Assess: Questions to ask about Usual patterns of respiration.

* How would you describe your breathing? * Do you have allergies? * What type(s) of allergies do you have? * What relief measures do you use?

Factors to Assess: Questions to ask about Dyspnea.

* Is it constant or remittent or related to any activity? * How do different positions affect it? * How does it affect your daily activities? * Can you sleep lying flat? How many pillows do you use?

What are some nursing interventions for ventilation assistance?

* Maintain a patent airway. * Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds. * Initiate and maintain supplemental oxygen, as prescribed. * Administer appropriate pain medication to prevent hypoventilation. * Ambulate three to four times per day, as appropriate. * Monitor respiratory and oxygenation status. * Administer medications (e.g., bronchodilators and inhalers) that promote airway patency and gas exchange. * Teach pursed-lip breathing techniques, as appropriate. * Initiate a program of respiratory muscle strength and/or endurance training, as appropriate.

The nurse is instructing the client with a pulmonary disorder on deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? a) "If you breathe through the mouth first, you will swallow germs into your stomach." b) "Breathing through your nose first will warm, filter, and humidify the air you are breathing." c) "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." d) "We are concerned about you developing a snoring habit, so we encourage nasal breathing first."

Answer: "Breathing through your nose first will warm, filter, and humidify the air you are breathing." Rationale: Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner? a) 12 L/min oxygen via nonrebreather mask b) 8 L/min oxygen via partial rebreather mask c) 10 L/min oxygen via Venturi mask d) 8 L/min oxygen via nasal cannula

Answer: 8 L/min oxygen via nasal cannula Rationale: The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease.

A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood. What range is considered a normal value for SpO2? a) 95% to 100% b) 85% to 90% c) 65% to 70% d) 75% to 80%

Answer: 95% to 100% Rationale: A range of 95% to 100% is considered normal SpO2; values less than 85% indicate that oxygenation to the tissues is inadequate.

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? a) Checking the amount of oxygen in the cylinder before using it b) Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c) Placing the oxygen cylinder on the stretcher next to the patient d) Discontinuing oxygen flow by turning cylinder key counterclockwise until tight

Answer: A Rationale: The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.

A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? a) Quickly position the patient on his or her side. b) Put on disposable gloves and remove the oral airway. c) Check that the airway is the appropriate size for the patient. d) Put on sterile gloves and suction the airway.

Answer: A Rationale: When a patient vomits upon insertion of an oropharyngeal airway, the nurse should immediately position the patient on his or her side to prevent aspiration, remove the oral airway, and suction the mouth if needed.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a) Closely assess the patient before, during, and after the procedure. b) Hyperoxygenate the patient before and after suctioning. c) Limit the application of suction to 20 to 30 seconds. d) Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e) Use an appropriate suction pressure (80-150 mm Hg). f) Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

Answer: A, B, D, E Rationale: Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80-150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis

A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. a) Dyspnea b) Hypotension c) Small pulse pressure d) Decreased respiratory rate e) Pallor f) Increased pulse rate

Answer: A, C, E, F Rationale: If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

The nurse is assessing the respiratory rates of clients in a community health care facility. Which client exhibits an abnormal value? a) A 12-year-old with a respiratory rate of 20 bpm b) A 70-year-old with a respiratory rate of 18 bpm c) A 4-year-old with a respiratory rate of 40 bpm d) An infant with a respiratory rate of 20 bpm

Answer: An infant with a respiratory rate of 20 bpm Rationale: The infant's normal respiratory rate is 30 to 55 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 40 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

The nurse is caring for a client receiving oxygen therapy via nasal cannula who suddenly becomes cyanotic with a pulse oximetry reading of 91%. Which is the next most appropriate action the nurse should take? a) Assess oxygen tubing connection b) Assess lung sounds c) Elevate head of the bed d) Reposition client

Answer: Assess oxygen tubing connection Rationale: If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.

When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a) The oxygen must be humidified. b) The rate will be no more than 2 to 3 L/min or less. c) Arterial blood gases will be drawn every 4 hours to assess flow rate. d) The rate will be 6 L/min or more.

Answer: B Rationale: A rate higher than 3 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rates does not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate.

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? a) High Fowler's position b) Left side with pillow under chest wall c) Lying position/half on abdomen and half on side d) Trendelenberg position

Answer: B Rationale: For postural drainage, the nurse should place the patient lying on the left side with a pillow under the chest wall to drain the right lobe of the lung, use high Fowler's position to drain the apical sections of the upper lobes of the lungs, place the patient in a lying position, half on the abdomen and half on the side, right and left, to drain the posterior sections of the upper lobes of the lungs, and place the patient in the Trendelenburg position to drain the lower lobes of the lungs.

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? a) The age of the patient b) The size of the endotracheal tube c) The type of secretions to be suctioned d) The height and weight of the patient

Answer: B Rationale: The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a) Tilt the patient's head forward. b) Hold the mask tightly over the patient's nose and mouth. c) Pull the patient's jaw backward. d) Compress the bag twice the normal respiratory rate for the patient.

Answer: B Rationale: With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16-20 breaths/min in adults).

A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply. a) Thoracentesis b) Spirometry c) Pulse oximetry d) Peak expiratory flow rate e) Diffusion capacity f) Maximal respiratory pressure

Answer: B, C, D Rationale: Spirometers are used to monitor the health status of patients with respiratory disorders, such as asthma. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma, along with PEFR to monitor airflow. These three tests may be administered by the nurse. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a) Refrain from exercise. b) Reduce anxiety. c) Eat meals 1 to 2 hours prior to breathing treatments. d) Eat a high-protein/high-calorie diet. e) Maintain a high-Fowler's position when possible. f) Drink 2 to 3 pints of clear fluids daily.

Answer: B, D, E Rationale: When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily is recommended.

A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? a) Decreased Cardiac Output related to difficulty breathing b) Impaired Gas Exchange related to use of bronchodilators c) Fatigue related to impaired oxygen transport system d) Ineffective Airway Clearance related to fatigue

Answer: C Rationale: Fatigue related to an impaired oxygen transport system is an example of a nursing diagnosis with alteration in oxygenation as the etiology or cause of other problems. Ineffective Airway Clearance, Decreased Cardiac Output and Impaired Gas Exchange are examples of nursing diagnoses indicating alterations in oxygenation as the problem.

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a) Instruct assistant to notify the primary care provider. b) Assess the patient's vital signs. c) Remove the tape, adjust the depth to ordered depth and reapply the tape. d) No action is required as depth will adjust automatically.

Answer: C Rationale: The tube depth should be maintained at the same level unless otherwise ordered by the physician. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape.

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a) Notify the physician. b) Apply an occlusive dressing on the site. c) Assess the patient for signs of respiratory distress. d) Put on gloves and insert the chest tube in a bottle of sterile saline.

Answer: D Rationale: When a chest tube becomes separated from the drainage device, the nurse should first put on gloves, open a sterile bottle of normal saline or water, and insert the chest tube into the bottle without contaminating the chest tube. This creates a water seal until a new drainage unit can be attached. Then the nurse should assess vital signs and notify the physician.

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a) The patient vomits during suctioning. b) The secretions appear to be stomach contents. c) The catheter touches an unsterile surface. d) Epistaxis is noted with continued suctioning.

Answer: D Rationale: When epistaxis is noted with continued suctioning, the nurse should notify the physician and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a) "I will be careful not to shake up the canister before using it." b) "I will hold the canister upside-down when using it." c) "I will inhale the medication through my nose." d) "I will continue to inhale when the cold propellant is in my throat." e) "I will only inhale one spray with one breath." f) "I will activate the device while continuing to inhale."

Answer: D, E, F Rationale: Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: a) blood pH. b) age. c) hemoglobin level d) sodium and potassium levels.

Answer: Hemoglobin levels Rationale: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

Which oxygen delivery system is most commonly used because it does not impede eating or speaking? a) Oxygen mask b) Oxygen tent c) Oxygen hood d) Nasal cannula

Answer: Nasal cannula Rationale: A nasal cannula is commonly used because it does not impede eating or speaking and is easily used in the home. A mask is used when a client requires a higher concentration of oxygen than a nasal cannula can deliver. Oxygen hoods and tents are generally used to deliver oxygen to infants and children.

Which is a sign of dyspnea specific to infants? a) Panting respirations b) Nasal flaring c) A forward-leaning position d) Increased respiratory rate

Answer: Nasal flaring Rationale: In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.

Which is a major organ of the upper respiratory tract? a) Trachea b) Lungs c) Bronchi d) Pharynx

Answer: Pharynx Rationale: The pharynx, mouth, and nose are major organs of the upper respiratory tract. The trachea, bronchi, and lungs are major organs of the lower respiratory tract.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. a) True b) False

Answer: True Rationale: This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? a) Vesicular b) Bronchial c) Crackles d) Bronchovesicular

Answer: Vesicular Rationale: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds, whereas bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? a) an older adult client who has COPD b) an adolescent who has asthma c) an adult who is receiving oxygen at home d) a child who has pneumonia

Answer: a child who has pneumonia Rationale: An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? a) side-lying position, half on the abdomen and half on the side b) left side with a pillow under the chest wall c) Trendelenburg position d) high-Fowler's position

Answer: high-Fowler's position Rationale: Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: a) croup. b) alcohol abuse. c) pneumonia. d) asthma.

Answer: pneumonia Rationale: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol abuse do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol abuse depresses the central respiratory center.

What are some nursing diagnoses in regards to oxygenation?

Examples: 1. ineffective airways r/t a 20-year history of COPD, aeb cannot sit quietly in chair or on bed. 2. impaired gas exchange r/t smokes one pack of cigarettes per day aeb reports shortness of breath, nausea, and ankle edema for 1 week. 3. ineffective breathing pattern r/t anxious about results of cardiac catheterization and possible cardiac surgery aeb hyperventilating, tachypneic (40 breaths/minute)

Physical Assessment:

Inspect: Observe the apperance of the patient. How do they look? Do they seem as though they are short of breath? Restless? Anxious? What about their skin color? Is it pallor (pale)? Or cyanosis (bluish)? Palpate: Note skin temperature and color when palpating. Assess symmetry of chest. Note presence or absence of edema, masses, tenderness. Percussion: Assess the position of the lungs, density of lung tissue, and identify changes in the tissue. *This assessment skill is not used frequently. * Auscultate: Listen for normal or abnormal sounds. Normal sounds includes; vesicular (soft, low-pitched sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard over the trachea and larynx), broncho-vesicular (medium-pitched sounds, heard over the major bronchi). Adventitious sounds are crackles (water present) and wheezes (musical sounds)

Respiratory Variations in the Life-Cycle:

Remember the norms for adults to understand the norms for children and older adults. Children will always be above the adult norms, and generally older adults will always be below the adult norms. Respiration rate: Adults: 12-20 bpm Children: 30-55 bpm Older adults: 16-24 pbm Respiratory pattern: Children: breathes with their stomach (abdomen) Older adults: breathes with their chest (thoracic) Breath sounds: Children: Loud, harsh crackles at end of deep inspiration Older adults: Clear