nr 302 health assessment lecture september 28th chapter 19 thorax and lungs

atelectasis

alveoli collapse or shrunken alveoli as a result of obstruction, compression on lung or lack of surfactant. patients will have cough, increased respiratory rate and low pulse, low oxygen saturation

trachea lies...

anterior to the esophagus and is 10 to 11 cm long in the adult

apgar score

appearance, pulse rate, grimace, activity, respiratory effort

abnormal findings common respiratory conditions

atelectasis, bronchitis, emphysema/COPD, asthma, pleural effusion, tuberculosis, pneumonia/lobar pneumonia, pulmonary embolism, pneumothorax, acute respiratory distress syndrome, lung cancer

paroxysmal nocturnal dyspnea

awakening from sleep with SOB and need to be upright

thorax abnormal

barrel chest, precuts excavatum, pectus carinatum, scoliosis, kyphosis

pulmonary chest pain

can tell us exactly where it hurts

lobes of the lung- anterior chest

crosses the 5th rib. contains upper middle and little of lower lobe.

abnormal findings adventitious lung sounds

discourteous sounds(crackles, friction rub), continuous sounds (wheezing)

pleural effusion

excess fluid and thickening in lung tissue

lubes of the lung- left lung

has no middle lobe

subjective data respiratory

have you had a cough, any shortness of breath, any history of respiratory infections, history of smoking, any mucous when you cough, what does the mucus look like, any environmental exposure

the nurse obtained a personal and family history from a client with neurological disorder. which factors in the clients history are associated with added risk for neurological problems

history of headaches, previous back injury, history of hypertension, history of diabetes mellitus

chronic bronchitis

increased production of mucous glands in airway. mucous is taking up the area where the lung needs to inhale and exhale "blue bloaters"

pneumonia

inflammatory process in lungs, causing alveoli to come swollen and porous

emphysema

loss of elasticity and hyperinflation of air sacs, decrease in oxygen "pink puffers"

lobes of the lung- lateral chest

lung tissue extends from apex of axilla down to seventh or eighth rib

rib cage protects the

lungs & heart

lung lobes

lungs are paired. right lung has 3 lobes left lung has 2 lobes.

control of respirations

major feedback loop, regulation or change of carbon dioxide and oxygen levels in blood. normal stimulus to breathe for most of uses an increase of carbon dioxide in blood(hypercapnia). decrease of oxygen in blood (hypoxemia) also increases respirations but is less effective.

mediastinum

middle section of the thoracic cavity

environmental exposure questions

occupational factors and exposure, protection from exposure, monitoring and follow up to exposure, awareness of symptoms that might signal breathing problems

the clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. which should the nurse include for this type of assessment

osculating lung sounds, obtaining the clients temperature, assessing the strength of peripheral pulses, obtaining information about the clients respirations

a client is admitted to the hospital for difficulty breathing. which is the best approach for the nurse to use obtaining the clients health history

our patient knows the best about their health. plan short sessions with the client to obtain data

asthma

reactive airway disease, shortness of breath, wheezing, labored breathing

a client is diagnosed with external otitis, which finding would the nurse expect to note on assessment of the client

redness and swelling in the ear canal

pleurae

slippery serous membrane that forms an envelope between lungs and chest wall. lungs are held tightly within the pleural cavity due to negative pressure. lubricating fluid allows for lungs to slide smoothly up and down during respiration

the nurse conducting a health screening is performing hearing assessments on clients. senior nursing students are assisting the nurse with the assessments. the nurse instructs the students to perform a voice test by taking which action

stand 2 to 3 ft away from the client and ask the client to block 1 external ear canal

the nurse is conducting a health screening clinic, and is preparing to test the visual acuity of a client using a snellen chart. the nurse educates the client about the procedure. which statement by the client indicates that the teaching has been effective.

stand 20ft from the chart and cover 1 eye

the nurse is testing the extra ocular movements in a filet to access for muscle weakness in the eyes. the nurse should implement which assessment technique to access for muscle weakness in the eye?

test the 6 cardinal position of gaze

trachea and bronchi transport gas between

the environment and lung parenchyma

floating ribs what happens easily

they break

the nurse is assessing for changes in skin color in a dark skinned client. the nurse finds which areas helpful in assessing for pallor or cyanosis

tough, nail beds, mucous membranes

a client with a diagnosis of asthma is admitted to the hospital with respiratory distress. which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client

wheezing

pulmonary embolism

when a substance (solid, liquid, air bubbles) enters venous circulation and causes obstruction to pulmonary vessels

pneumothorax

acute condition where free air enter pleural space causing lung collapse

major functions of respiratory system

1. supply oxygen to the body for energy production 2. remove carbon dioxide as a waste product of energy reactions 3. maintain homeostasis of arterial blood 4. maintain heat exchange

left lung has

2 lobes

right lung has

3 lobes

cardiac chest pain

all over pain, crushing/squeezing pain ex. elephant sitting on chest

lobes of the lungs- posterior chest

almost all lower lobes. posterior chest contains almost all lower lobes. most remarkable point about posterior

orthopnea

SOB when lying supine

changing chest size

air rushes into the lungs as chest size increases (inspiration) and is expelled from lungs as chest recoils (expiration)