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inspect the chest - (Answer)without clothes on; 1st assess shape and size; 2nd check for symmetry;
3rd thoracic landmarks; 4th color of skin; 5th check for supernumerary nipples; 6th superficial
venous patterns; and 7th observe for rib prominence
thoracic landmarks - (Answer)midline trachea, costal angle, angle of ribs, intercostal spaces,
suprasternal notch
symmetry of chest - (Answer)thoracic expansion at costal angle, w/o use of accessory muscles
hx questions for cc of resp issue - (Answer)What is the nature of your cough?; Do you produce any
sputum?; Is your cough related to activity?; What position are you most comfortable in?; How many
pillows do you sleep with at night?; Is your SOB related to activity?
normal respirations - (Answer)rate between 12 to 20/min; ratio of resp to heart beats= 1:4; pt should
breathe easily, regularly w/o apparent distress; pattern should be even, not too shallow or too deep
hypopnea - (Answer)term for abnormally shallow respirations
,tachypnea - (Answer)term for resp rate greater than 20, but consistent and may occur during
hyperventilation; often a symptom of pain
bradypnea - (Answer)term for resp rate less than 12; may indicate neurologic or electrolyte
disturbances, infection, or conscious response to protect against the pain of pleurisy or other irritative
pneumonia. Can also be 2/2 level of cardio fitness
hyperventilation - (Answer)term for fast and deep, heavy respirations, can be caused by exercise,
anxiety, and CNS and metabolic diseases
hyperpnea - (Answer)term for abnormally deep respirations
kussmaul respirations - (Answer)deep and mostly rapid respirations, used to describe resp effort of
metabolic acidosis
cheyne stokes respirations - (Answer)regular breathing with intervals of apnea by crescendo
decrescendo breathing; can be seen in sleeping pts, but mostly pts who are very ill, esp with brain
damage
, biot respirations - (Answer)irregular breathing that varies in depth and is interrupted irregularly by
intervals of apnea; associated with severe and persistent increased intracranial pressure, resp
compromise from drug poisoning, or brain damage at the medulla and generally equals poor
prognosis
peripheral areas related to respiratory assessment - (Answer)observe the lips and nails for cyanosis or
pallor; lips for pursing; fingers for clubbing; and alae nasi for flaring
pleural friction rub - (Answer)dry, rubbing, or grating sound; palpable, coarse, grating vibration;
usually on inspiration; caused by inflammation of the pleural surfaces; think feel of leather rubbing
on leather
thoracic expansion - (Answer)stand behind patient and place thumbs along spinal process at level of
10th rib, with palms lightly in contact with the posterolateral surfaces; watch the thumbs during quiet
and deep breathing; loss of symmetry = problem on either 1 or both sides.