Health Assessment: Chapter 11 - Lungs, Respiratory System & abdomen

during inspiration what contracts & pushes the abdominal content down?

diaphragm

what are the primary muscles of inspiration?

diaphragm and intercostal muscles

low pitched, coarse, loud Rhonchi heard during expiration/inspiration maybe cleared by coughing is observed in?

disorder such as COPD or brochities

what kind of cough does viral pneumonia cause ?

dry cough

what is Hemoptysis ?

expectoration of sputum-containing blood. It may vary in severity from slight streaking of blood to frank bleeding

The manubrium & body of the sternum articulates with? & the manubrium does what?

first seven ribs & supports the clavicle

list the continuous lung sounds?

high pitched(polyphonic) wheeze(sibliant), low pitched(Rhonci-monophonic) wheeze, stridor,

list the types of lung sounds?

high pitched(polyphonic) wheeze, low pitched(monophonic) wheeze, stridor, coarse crackles, fine crackles, pleural friction rub,•Atelectatic crackles

when Sound is elicited by percussion; very loud intensity and very low pitch with a booming quality; heard over lungs when air is trapped in emphysema is known as?

hyperresonance

What is chronic bronchitis?

hypersecretion of mucus by the goblet cells of the trachea and bronchi leading to a productive cough for more than 3 months

what could be the cause of tracheal shift?

increase in lung volume of contralateral lung/pleural space caused by pneumothorax, large pleural effusion or consolidation, decrease in volume ipsilateral lung caused by atelectasis

What is pneumonia?

inflammation of the terminal bronchioles and alveoli

during inspiration what helps to push chest wall outward?

intercostal muscle

what is Orthopnea or orthopnoea ?

is shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair. commonly seen as manifestation of heart failure

Abnormal convexity of the posterior curve of the spine is known as?

kyphosis

acute cough last for how long

less than 3 weeks

Sputum production with a change in position suggests ?

lung abscess and bronchiectasis

name the structures within the thorax/chest ?

mediastinum, right & left pleural cavities.

chronic cough last for how long ?

more than 3 weeks

A pneumothorax that occurs following penetration of the chest by either injury or surgical procedure is called?

open

the chest wall and diaphragm are protected by the _______

parietal pleura

A patient has normal breath sounds, tactile fremitus & percussion throughout the entire left lung, lower 2/3 of right lungs has dullness to percussion & increased tactile fremitus?

pneumonia(consolidation -increased) pus in lungs

fine high pitched crackles(rales) can be heard in inspiration/expiration & is not cleared by coughing or change in body position can be heard in ?

pneumonia, heart failure, restrictive pulmonary disease

what are the common causes of chronic cough?

postnasal drip, gastroesophageal reflux disease (GERD), asthma, infections such as chronic bronchitis, and blood pressure drugs

what kind of cough does bacterial pneumonia causes ?

productive cough

frothy sputum with dyspnea is associated with ?

pulmonary edema

where is bronchial breath sounds expected?

trachea & area above manubrium

rust-colored sputum may occur with ?

tuberculosis or pneumococcal pneumonia

During the problem-based history, a patient reports coughing up sputum when lying on the right side, but not when lying on the back or left side. The nurse suspects this patient may have a lung abscess. What additional question does the nurse ask to gather more data?

"Does the sputum have an odor?"

Which question will give the nurse additional information about the nature of a patient's dyspnea?

"How has this condition affected your day-to-day activities?"

Which question gives the nurse further information about the patient's complaint of chest pain?

"How would you describe the chest pain?"

list the Accessory muscles that may contribute to respiratory effort?

( anteriorly) - sternocleidomastoid, scalenus, pectoralis minor, serratus anterior, and rectus abdominis muscles ( posteriorly ) serratus posterior superior, transverse thoracic, and serratus posterior inferior muscles

what are the common causes of acute cough?

viral infections, allergic rhinitis, acute asthma, acute bacterial sinusitis, or environmental irritants

white or clear sputum may occur with what kind of infections ?

viral, cold or bronchitis

the lungs are protected by the ?

visceral pleura

High-pitched, musical noise that sounds like a squeak; heard during auscultation of a narrowed airway is known as?

wheeze

when is Whispered pectoriloquy is performed ?

when there is a positive finding of bronchophony.

the respiratory system is protected by the thoracic cage consisting of?

11 thoracic vertebrae, 12 pairs of ribs, & sternum

A patient tells the nurse that he has smoked 1 1/2 packs of cigarettes a day for 14 years. The nurse records this as _____ pack-years?

21

list the subjective data of mechanics of respiration?

•Cough •Shortness of breath •Chest pain with breathing •History of respiratory infections •Smoking history •Environmental exposure •Self-care behaviors

The adult sternum is how long & has how many components?

7 inches (17 cm) & the manubrium, body, the xiphoid process

After taking a brief health history, a nurse needs to complete a focused assessment on which patient?

A male who works as a painter

Which finding does the nurse expect when performing tactile fremitis?

A vibration of sounds that are equal bilaterally

What are the functions of the upper airways? Select all that apply.

A,-Conduct air to lower airway C,-Prevent foreign matter from entering the respiratory system. D-Warm, humidify, and filter air entering lungs.

On examination, a nurse finds the patient has a productive cough with green sputum and inspiratory crackles(Rales). What other findings does this nurse expect during the examination? Select all that apply.

A-Dull tones to percussion B -Increased vibration on vocal fremitus C. Fever E-A sharp, abrupt pain reported when the patient breathes deeply

A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse expect to find? Select all that apply.

A-Thoracic expansion that is symmetric bilaterally D,-Breath sounds clear with vesicular breath sounds heard over most lung fields E,-Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to a lateral diameter F-Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine

what does egophony check for?

Abnormality in vocal resonance; when lungs are auscultated, the patient says "e-e-e," but the nurse hears "a-a-a"; suggests pleural effusion.

A nurse examines a patient with a pleural effusion and finds decreased fremitus. What additional abnormal finding should the nurse anticipate during further examination?

Absent breath sounds, sharp chest pain in the affected area

During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and maintains a tripod position. Based on these data, what abnormal findings should the nurse expect to find during the examination?

An increased anteroposterior diameter

A nurse auscultates (adventitious)low-pitched, coarse snoring sounds in a patient's lungs during inhalation. What is the most appropriate action for the nurse to take at this time?

Ask the patient to cough and repeat auscultation.

On inspection, the nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. What other findings does this nurse expect during the examination? Select all that apply.

B,- Hyper-resonance heard on percussion C- Decreased breath sounds heard on auscultation D,-Decreased diaphragmatic excursion on percussion F-Decreased to absent vibration on vocal fremitus

During a symptom analysis, a patient describes his productive cough and states his sputum is THICK and YELLOW. Based on these data, the nurse suspects which factor is the cause of these symptoms?

Bacteria

A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this patient's dyspnea is due to HEART disease rather than a RESPIRATORY disease?

Bilateral peripheral edema

A nurse palpating the chest of a patient finds increased fremitus bilaterally. What is the significance of this finding?

Bilateral pneumonia

A patient has right lower lobe pneumonia, creating a consolidation in that lung. In assessing for vocal fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation?

Bronchophony reveals the patient's spoken "99" as clear and loud.

The nurse is comparing pitch and duration of the various types of a patient's breath sounds and recognizes which one of these is an expected finding?

Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio.

an exam finding has bilateral decreased breath sounds, decreased tactile fremitus, & hyper-resonant to percussion what is this?

COPD-chronic obstructive pulmonary disease, it is hard to tell clinically

A nurse inspects a patient's hands and notices clubbing of the fingers. The nurse correlates this finding with what condition?

Chronic hypoxemia,( cystic fibrosis & COPD)

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color?

Clear

A nurse is assessing a patient who was diagnosed with EMPHYSEMA and chronic BRONCHITIS 5 years ago. During the assessment of this patient's integumentary system, what finding should the nurse correlate to this respiratory disease?

Clubbing of the fingers

In reviewing the patient's record, the nurse notes that the patient has air in the subcutaneous tissue. The nurse validates that this patient has crepitus with which finding?

Crackling sensation under the skin of the chest on palpation

hypoventilation causes a blue hue to the skin known as?

Cyanosis

On inspection, a nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data does the nurse anticipate?

Decreased breath sounds on auscultation

A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination?

Distant to absent breath sounds over the left chest

evaluating the intensity of the spoken voice by asking the patient to say "e-e-e" is known as?

Egophony

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected?

Fever and tachypnea with crackles(Rales) over the right lower lobe

A patient is admitted to the emergency department with a TRACHEAL obstruction. What sound does the nurse expect to hear as this patient breathes?

High-pitched sounds on inspiration and exhalation

A nurse is auscultating the lungs of a healthy male patient and hears crackles(rales) on inspiration. What action can the nurse take to ensure this is an accurate finding?

Hold stethoscope firmly to prevent movement when placed over chest hair.

A patient reports a productive cough with yellow sputum, fever, and sharp pain when taking a deep breath to cough. Based on these data, what abnormal findings will the nurse anticipate on examination?

Increased tactile fremitus and dull percussion tones

Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult?

Near the sternal border

A nurse notices a patient's chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately?

Palpate for tracheal deviation.

During an inspection of the respiratory system the nurse documents which finding as abnormal?

Patient leaning forward with arms braced against knees

A nurse suspects a patient has a chest wall injury and wants to collect more data about thoracic expansion. Which is the appropriate technique to use?

Place both thumbs on either side of the patient's T9 to T10 spinal processes, extend fingers laterally, ask the patient to take a deep breath, and observe lateral movement of the thumbs.

A nurse is assessing for vocal (tactile) fremitus on a patient with pulmonary edema. Which is the appropriate technique to use?

Place the palms of the hands-on the right and left thoraces, ask the patient to say "99," and feel for vibrations.

On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding?

Rhonchi

Which finding may indicate abnormal thoracic expansion?

S-shaped curvature of the spine

A pneumothorax that develops when air leaks into the pleura and cannot escape is called?

Tension

A patient is suspected of having a lung consolidation. A nurse uses the three techniques for assessing vocal resonance in this patient. What is the expected finding among the three procedures that will help eliminate consolidation as a problem?

The nurse documents hearing muffled sounds when the patient says "1-2-3."

Which patient should the nurse assess first?

The patient whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right.

Which breath sounds are expected over the posterior chest of an adult?

Vesicular

A nurse had previously heard crackles(rales) over both lungs of a patient. As the patient improves, what lung sounds do the nurse expect to hear in the patient's lungs?

Vesicular breath sounds heard in peripheral lung fields

Narrowing of the bronchi creates which adventitious sound?

Wheeze

-Transmission of whispered words through the chest wall, heard during auscultation is known as ?

Whispered pectoriloquy

How does the nurse palpate the chest for tenderness, bulges, and symmetry?

With the palmar surface of fingers of both hands, feel the consistency of the skin over the chest and the alignment of vertebrae

What is emphysema?

a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness.

how many types of cough ?

acute & chronic

. Increased sputum in the morning implies ?

an accumulation of sputum during the night and is common with bronchitis

where is vesicular breath sounds heard in a normal findings?

anterior thorax including apex of lungs

high pitched sibilant wheeze sound during expiration/inspiration occurs in small air way may be as a result of?

asthma-when thickness of airway increase

yellow or green sputum may occur with?

bacterial infections

Foul-smelling (fetid) sputum is typically associated with ?

bacterial pneumonia, lung abscess, or bronchiectasis.

what is the appearance of someone with Emphysema?

barrel chest, underweight, increased anteroposterior lateral diameter

An abnormality in vocal resonance. When lungs are auscultated, the patient says "ninety-nine" or "one, two, three" indicating lung consolidation is known as ?

bronchophony

A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack-years? a. 10 b. 20 c. 40 d. 60

c. 40

where is Broncho vesicular sound heard in normal findings?

central area of anterior thorax around sternal boarder

,A spontaneous, traumatic, or iatrogenic (caused by illness or medical treatment) pneumothorax is called?

closed

list the discontinuous lung sound?

coarse crackles, fine crackles, pleural friction rub

The abnormal respiratory sound heard during auscultation, characterized by discontinuous bubbling sounds; heard over distal bronchioles and alveoli that contain serous secretions; formerly called rales is known as?

crackles(Rales)

a Dry, crackling sound or sensation heard or felt as a joint is moved through its range of motion is called?

crepitus

Thick sputum is commonly associated with ?

cystic fibrosis