Respiratory and Cardiovascular assessment

normal respiratory rate

12-20 breaths per minute

adventitious lung sounds

abnormal lung sounds that can signal fluid, mucous, or inflammation

dyspnea

difficulty breathing and breathing and can be viewed as shortness of breath and is usually associated with exercise

apnea

absence of breathing

bradypnea

respirations are less than 12 breaths/min

clubbing

Bulbous enlargement of the distal phalanges of the fingers and toes that occurs with chronic cyanotic heart and lung conditions

-caused from lack of oxygen from heart or pulmonary disease

tachypnea

rapid breathing greater than 20 breaths/min

hypoxia

Low oxygen saturation of the body, not enough oxygen in the blood

-insufficient tissue oxygenation at the cellular level

pursed lip breathing

a technique used to prevent alveolar collapse through deep inspiration and prolonged expiration through pursed lips

incentive spirometer

A technique used to promote deep breathing by showing patients visual feedback about inspiratory volume

barrel chest

a rounded, bulging chest shape that looks like a person who is holding a deep breath

Cheyne-Stokes respiration

an irregular pattern of breathing characterized by alternating rapid or shallow respiration followed by slower respiration or apnea

-cycles of apnea and hyperventilation

kussmaul breaths

Very deep, laborious breaths; in an attempt to correct the metabolic acidosis, the respiratory system works hard to "blow off" excess carbon dioxide

-deep regular and increased speed

fremitus

palpable vibration

-sound waves from palpating the skin

vesicular breath

breath sounds are soft, breezy and low pitched caused by air moving through smaller airways

Bronchovesicular breath

sounds are heard over the right and left major bronchi

-they are medium pitch and intensity caused by air flowing through larger airways

bruit

blowing, swooshing sound heard through a stethoscope when an artery is partially occluded or narrow

thrill

a sensation that is continous and palpable over a blood vessel that resembles a cats purr

murmur

abnormal swishing or blowing sound during systolic or diastolic phase due to increased forward flow or backwards flow into a valve that wont close

bradycardia

slow heart rate (less than 60 bpm)

tachycardia

fast heart rate above 100 beats/min

Dysrthmia

interruption in normal pulse waves or sounds and effects the hearts cardiac output

perfusion

Process of sending oxygenated blood to the tissues and returning deoxygenated blood to the lungs, all carried out by cardiovascular system

angina pectoris

chest pain due to an imbalance between myocardial oxygen supply and demand

Location of the apices of the lungs

stethoscope slightly above the clavicle anteriorly or above the scapula posteriorly

left upper lobe (of lung)

place stethoscope on the front of chest between 2-4 intercostal spaces along the midclavicular line. For posterior use C7 to T3 just medial above scapula

right upper lobe

place stethoscope anteriorly in the second intercostal space along the midclavicular line or C7-T3 posterioly

left lower lobe

place stethoscope posteriorly on the lower back between T3 and T10 or laterally on the 6th to 8th intercostal space to assess the left lower lobe

right middle lobe

place stethoscope on the right anterior chest at the 4th intercostal space near right nipple and laterally in the 5th ot 6th intercostal space

right lower lobe

place stethoscope on the posterior back below T3 to T10 or laterally at the 6th intercostal space along the mid-axillary line

vesicular breath sounds

soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue

-inspiratory phase is three times longer than the expiratory phase

bronchovesicular breath sounds

medium-pitched and quieter sounds normally heard over the mainstem bronchi

-inspiratory phase is equal to the expiratory phase

bronchial breath sounds

loud, high-pitched, hollow sounds normally heard over the trachea and the large bronchi

crackles

fine, crackling sounds made as air moves through wet secretions in the lungs

-high-pitches, short heard during the end of inspiration and can result from pneumonia or chronic lung disease

rhonchi

Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.

-associated with fluid or mucous in larger airways along with external pressure causing turbulence CLEARS AFTER COUGHING

wheezing

A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways; occurs in asthma and bronchiolitis.

friction rub

dry, rubbing, grating sound that does not clear with coughing and is common in viral infection BEST HEARD WITH INSPIRATION

Stridor

strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx

what signs and symptoms are expected with a patient experiencing hypoxia

Apprehension, restlessness, inability to concentrate, decreased level of conciousness, dizziness and behavioral changes

location of apical pulse

5th intercostal space, midclavicular line

location of pulmonic pulse

left second intercostal space

location of second pulmonic area (Erb's point)

down the left sternal boarder to the third intercostal space

location of tricuspid valve

4th intercostal space, left sternal border

mitral valve location

5th ICS mid clavicular line

S1 heart sound

closure of AV valves (mitral and tricuspid)

-high pitched and dull in quality and occurs after a long diastolic pause and before a short systolic pause

S2 heart sound

Closure of the semilunar valves (pulmonary and aortic)

-follows the short systolic pause before the long diastolic pause

S3

an abnormal heart sound detected early in diastole as resistance is met to blood entering either ventricle; most often due to volume overload associated with heart failure

-abnormal in adults over 31 years old

S4

an abnormal heart sound detected late in diastole as resistance is met to blood entering either ventricle during atrial contraction; most often caused by hypertrophy of the ventricle

-commonly heard in healthy athletes, children and adults

if a persons peripheral pulse cannot be palpated what should the nurse first do

the nurse should use an ultrasound stethoscope to try and amplify the pulse wave

what is PMI and where is it located

Point of maximal impulse, a small pulsation at the 5th intercostal space midclavicular line