Case NR 302 FINAL EXAM NR 302 FINAL EXAM STUDY GUIDE

NR 302 FINAL EXAM STUDY GUIDE Thorax and Lungs -What data can be gathered on a patient in respiratory distress from general survey only? -Do they use accessory muscles when breathing? Position-tripod, Barrel chest, Nasal flaring, color -Structure and Function: The thorax -Thoracic cage -Sternum, 12 pairs of ribs -12 thoracic vertebrae -Muscles and cartilage -Thoracic Cavity -Mediastinium -Pleural cavity -Lung (Apex and base) Structure and Function: Pleural Membranes -Parietal pleura-lines the whole cavity -Visceral pleura-lines the organs -Pleural space/cavity-both above total Structure and Function: The respiratory system -Trachea -Bronchi -Bronchioles -Alveolar Sacs -Alveoli Landmarks-Visualize what you cannot see! -Anterior chest -Suprasternal notch “U shaped” -Sternum -Sternal angle (Angle of Louis) continuous with 2nd rib -Ribs & intercostals -Costal angle (at xiphoid) 90 degrees -Posterior chest -Vertebra prominence C7 -Spinous processes T1 is 1st rib -T3 separates upper and lower lobes -Inferior border of the scapula 8th rib -12th rib Subjective Data -Difficulty breathing, sleeping, chest pain, cough and sputum (Rusty-TB), smoking history, environmental exposure TO calculate smoking pack-years 1. Multiple the number of cigarettes smoked per day by number of years smoked 2. Divide by 20 i.e 10 cigarettes smoked per day x 10 years / 20 = 5 pack years Objective Data -Inspection of patient: Resp. rate & effort to breathe (Nasal flaring, accessory muscles, positioning) skin color, nails, configuration of chest (Chest deformities) -Palpation of anterior and posterior chest: Tenderness, lumps, crepitus (Subcutaneous air-rice krispis under skin), tactile fremitus (99), respiratory expansion -Percussion of lung fields: Resonance, hyper-resonance, dull, diaphragmatic excursion -Auscultation of chest: Normal, adventitious, voice sounds, measurements of pulmonary function: For screening**Begin at the moment of contact Normal breath sounds -Bronchial (Tracheal) –Over trachea & larynx E1 -Bronchovesicular—Over major bronchi I=E -Vesicular—over peripheral lung fields IE Normal Assessment Findings -Inspection: RR 14 reg,even & unlabored (eupnea), skin & nails pink, no cyanosis noted, relaxed posture, shape symmetric AP: Transverse 1:2, costal angle 90 degrees -Palpation: Chest expansion symmetric, tactile fremitus symmetric, no tenderness, no crepitus, no lumps or masses -Percussion: Resonance throughout, diaphragmatic excursion equal bilaterally -Auscultation: Normal breath sounds Adventitious Breath sounds -Crackles/rales -Pleural friction rub -wheeze -Rhonchi Voice Sounds -Bronchophony “99” -Egophony “EEEEEE” -Whispered Pectoriloquy “one-two-three” Abnormal breathing patterns -Tachypnea -Bradypnea -Hyperventilation -Hypoventilation -Cheyne-strokes—fast breathing with apnea (People who are dying) Time to THINK as a NURSE… -Discuss dyspnea and orthopnea -What causes pleuritic pain (pleurisy) -Differentiate Crepitus vs Fremitus -Is abnormal posture or chest shape a concern? Why? Yes -Connect nasal flaring & accessory muscle use -Atelectasis-collapsed lung -Differentiate various colors of sputum -What would cause dense of consolidated lung tissue?—Fluid, tumor, mucous, food Case Study Mr. JS is a 70 year- old male with progressive COPD. Reason for seeking care, “I am not getting air.” He reports smoking 1.5 packs of cigarettes per day since age 16 . He presents to the emergency department with complaints of worsening dyspnea, productive cough, chest tightness, chills & fatigue Vital Signs: temp. 101.2 oral, apical heart rate 108, RR 24 labored, B/P 124/78, pulse ox 88% on room air (RA) -Subjective -Chest tightness -Dyspnea -chills -fatigue -Objective -Vitals -Labored -productive cough -Accessary muscles -Tripod -Purse lipped breathing -Pants unbuttoned -malnourished -Barrel chest -Clubbing/stained nails -Anxious Assessment Reveals Inspection: -Pt. is leaning forward in TRIPOD position -RR 24 labored and shallow, lips appear cyanotic -Using accessory muscles of the neck & shoulders (hypertrophied) -“Barrel-shaped” chest with costal angle 90 degrees -Clubbing of the nails with yellow staining from nicotine -Productive cough: thick yellow – green sputum Palpation: -Decreased chest expansion on right side -Decreased fremitus throughout with Increased tactile fremitus over right lower lobe (RLL) Percussion: -Hyper resonance over lung fields -Dull over RLL Auscultation: -Decreased breath sounds throughout -Crackles over RLL -Bronchophony, egophony-bleeding goat, whispered pectoriloquy-loud RLL CALCULATE THIS PATIENT’S PACK YEAR HISTORY 81 years!!!!! Nursing Diagnoses -Self-care deficit: Bathing and hygiene -Impaired gas exchange -Ineffective tissue perfusion -Activity intolerance -Ineffective health maintenance -Anxiety -Nutrition: less than body requirements Test your knowledge The nurse is performing the respiratory assessment on a pt. with pneumonia. The pt. is asked to say “ninety-nine” & through the stethoscope the nurse hears the words clearly over the LLL. How will the nurse document the findings? 1. Bronchophony 2. Tactile fremitus 3. Crepitus 4. Egophony A pt. has developed a deep vein thrombosis (DVT) and the nurse is alert for the potential development of a pulmonary embolism (PE). Which findings would suggest s/s of PE? 1. Non-productive cough & abdominal pain 2. HTN & afebrile 3. Bradypnea & bradycardia 4. Chest pain & dyspnea Which of the following patient’s is at greatest risk to develop atelectasis and pneumonia? 1. Pt. w/ a hx of smoking 2 PPD that quit 2 yrs. ago 2. Pt. who is ambulatory q 4 hrs. 3. Pt. who is post- operative requiring “splinting(hold together)-hug pilow” secondary to pain