Maryville NURS 612 Exam 2 | STUDY GUIDE
without clothes on; 1st assess shape and size; 2nd check for
inspect the chest 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 midline trachea, costal angle, angle of ribs, intercostal spaces, suprasternal
notch
symmetry of chest thoracic expansion at costal angle, w/o use of accessory muscles
What is the nature of your cough?; Do you produce any
hx questions for cc of resp issue 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?
rate between 12 to 20/min; ratio of resp to heart beats= 1:4; pt
normal respirations
should breathe easily, regularly w/o apparent distress; pattern
should be even, not too shallow or too deep
hypopnea term for abnormally shallow respirations
term for resp rate greater than 20, but consistent and may occur
tachypnea
during hyperventilation; often a symptom of pain
, term for resp rate less than 12; may indicate neurologic or
bradypnea 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
term for fast and deep, heavy respirations, can be caused by
hyperventilation
exercise, anxiety, and CNS and metabolic diseases
hyperpnea term for abnormally deep respirations
kussmaul respirations deep and mostly rapid respirations, used to describe resp effort of metabolic
acidosis
regular breathing with intervals of apnea by crescendo
cheyne stokes respirations
decrescendo breathing; can be seen in sleeping pts, but mostly pts
who are very ill, esp with brain damage
irregular breathing that varies in depth and is interrupted
irregularly by intervals of apnea; associated with severe and
biot respirations persistent increased intracranial pressure, resp compromise from
drug poisoning, or brain damage at the medulla and generally
equals poor prognosis
peripheral areas related to observe the lips and nails for cyanosis or pallor; lips for pursing;
respiratory assessment fingers for clubbing; and alae nasi for flaring
dry, rubbing, or grating sound; palpable, coarse, grating
pleural friction rub vibration; usually on inspiration; caused by inflammation of
the pleural surfaces; think feel of leather rubbing on leather
stand behind patient and place thumbs along spinal process at
thoracic expansion 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.
crackly/crinkly sensation that can be palpated and heard, a gentle
crepitus bubbly feeling; indicates air in the subcutaneous tissue from a
rupture somewhere in the resp system, or infection with gas
producing organism
palpate the throracic muscles and skeleton; feeling for pulsations,
palpating the chest and trachea
areas of tenderness, bulges, depressions, masses, and unusual
movement
palpable vibration of the chest wall that results from speech or
other verbalizations. best felt posteriorly and laterally at the level
tactile fremitus of the bifurcation of the bronchi; have patient say "99" while you
palpate with palmer surface of fingers or ulner aspect of the hand;
use firm, light touch
decreased of absent fremitus may be caused by excess air in lungs
or may indicate emphysema, pleural thickening, or effusion,
without clothes on; 1st assess shape and size; 2nd check for
inspect the chest 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 midline trachea, costal angle, angle of ribs, intercostal spaces, suprasternal
notch
symmetry of chest thoracic expansion at costal angle, w/o use of accessory muscles
What is the nature of your cough?; Do you produce any
hx questions for cc of resp issue 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?
rate between 12 to 20/min; ratio of resp to heart beats= 1:4; pt
normal respirations
should breathe easily, regularly w/o apparent distress; pattern
should be even, not too shallow or too deep
hypopnea term for abnormally shallow respirations
term for resp rate greater than 20, but consistent and may occur
tachypnea
during hyperventilation; often a symptom of pain
, term for resp rate less than 12; may indicate neurologic or
bradypnea 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
term for fast and deep, heavy respirations, can be caused by
hyperventilation
exercise, anxiety, and CNS and metabolic diseases
hyperpnea term for abnormally deep respirations
kussmaul respirations deep and mostly rapid respirations, used to describe resp effort of metabolic
acidosis
regular breathing with intervals of apnea by crescendo
cheyne stokes respirations
decrescendo breathing; can be seen in sleeping pts, but mostly pts
who are very ill, esp with brain damage
irregular breathing that varies in depth and is interrupted
irregularly by intervals of apnea; associated with severe and
biot respirations persistent increased intracranial pressure, resp compromise from
drug poisoning, or brain damage at the medulla and generally
equals poor prognosis
peripheral areas related to observe the lips and nails for cyanosis or pallor; lips for pursing;
respiratory assessment fingers for clubbing; and alae nasi for flaring
dry, rubbing, or grating sound; palpable, coarse, grating
pleural friction rub vibration; usually on inspiration; caused by inflammation of
the pleural surfaces; think feel of leather rubbing on leather
stand behind patient and place thumbs along spinal process at
thoracic expansion 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.
crackly/crinkly sensation that can be palpated and heard, a gentle
crepitus bubbly feeling; indicates air in the subcutaneous tissue from a
rupture somewhere in the resp system, or infection with gas
producing organism
palpate the throracic muscles and skeleton; feeling for pulsations,
palpating the chest and trachea
areas of tenderness, bulges, depressions, masses, and unusual
movement
palpable vibration of the chest wall that results from speech or
other verbalizations. best felt posteriorly and laterally at the level
tactile fremitus of the bifurcation of the bronchi; have patient say "99" while you
palpate with palmer surface of fingers or ulner aspect of the hand;
use firm, light touch
decreased of absent fremitus may be caused by excess air in lungs
or may indicate emphysema, pleural thickening, or effusion,
