Chapter 11: Lungs and Respiratory System Assessment

Respiratory system

supplies oxygen to cells and removes carbon dioxide using processes of ventilation and diffusion

Ventilation

the process of moving gases in and out of lungs by inspiration and expiration

Diffusion

the process by which oxygen and carbon dioxide move from areas of high concentration to areas of lower concentration

After inspiration, concentration of oxygen is _________ in alveoli than in pulmonary capillaries.

higher

Mediastinum

space between the lungs

Three main structures within thorax or chest:

-Mediastinum

-right pleural cavities

-left pleural cavities

Pleural cavities contain _______.

lungs

parietal pleura

outer layer of pleura lying closer to the ribs and chest wall

visceral pleura

inner layer of pleura lying closer to the lung tissue

Chest wall and diaphragm are protected by __________, and lungs are protected by ____________.

-parietal pleura

-visceral pleura

Right lung has _______ lobes and left has _______ lobes.

three; two

Thoracic cage protects most of respiratory system and consists of:

-12 thoracic vertebrae

-12 pair of ribs

-Sternum

________ are primary muscles of inspiration.

Diaphragm and intercostal muscles

During inspiration, diaphragm __________, while intercostal muscles ____________.

-contracts and pushes abdominal contents down

-push chest wall outward

During expiration, muscles ___________, expelling air as intrathoracic pressure ________.

relax; rises

During inspiration, air is drawn through ____________ and passes through _______________ to reach _____________.

mouth or nose; pharynx and larynx; trachea

_____________ make up upper airway.

Nose, pharynx, larynx, and intrathoracic trachea

Three functions of upper airway:

• Conducts air to lower airway

• Protects lower airway from foreign matter

• Warms, filters, and humidifies inspired air

Lower airway consists of:

-Trachea

-Right and left main stem bronchi

-Segmental and subsegmental bronchi

-Terminal bronchioles

Bronchioles open into __________, where gas exchanges occur.

alveolar ducts and terminate in multiple alveoli

Topographic markers

surface landmarks helpful in locating underlying structures and in describing exact location of physical finding

pneumothroax

air in the pleural cavity

hemothorax

blood in the pleural cavity

Present Health Status

Ø Do you have any chronic illnesses?

Ø Do you have allergies?

Ø Do you have difficulty breathing during daily activities?

Ø Do you have difficulty breathing when you sleep?

Ø Are you currently taking any oral medications for a respiratory disorder?

Ø Do you use an inhaler?

Ø Do you use oxygen at home?

Past Medical History

Ø Have you ever had problems with your lungs?

Ø Have you been diagnosed with respiratory diseases?

Ø Have you ever had an injury to your chest?

Productive cough

getting stuff up with cough

Non-productive cough

not getting stuff up with cough

sputum

material expelled from the lungs by coughing

Infants must be _________ for exam.

undressed to diaper

Conduct exam while infant is _________, as an exam of a __________ infant is difficult.

calm; crying

Acute bronchitis

inflammation of mucous membranes of bronchial tree caused by viruses or bacteria

Acute bronchitis clinical findings

-Cough initially nonproductive but may become productive after few days.

-Patients may complain of substernal chest pain aggravated by coughing.

-Fever, malaise, and tachypnea.

-Rhonchi and crackles frequently heard on auscultation.

-Wheezing heard after coughing.

substernal

behind the sternum

Rhonchi

Rattling noise of mucous in the lungs

Pneumonia

inflammation of terminal bronchioles and alveoli; may be caused by bacteria, fungi, viruses, mycoplasma, or aspiration of gastric secretions

Pneumonia Clinical Findings

-Viral pneumonia tends to produce a nonproductive cough.

-Bacterial pneumonia causes productive cough.

-Fever, tachypnea, and dyspnea.

-Crackles and wheezes heard on auscultation of the lungs.

Viral pneumonia

pneumonia caused by a virus

Bacterial pneumonia

pneumonia caused by a bacterial infection

Tuberculosis

a contagious, bacterial infection caused by Mycobacterium tuberculosis

Tuberculosis Clinical Findings

-Initial clinical manifestations consist of fatigue, anorexia, weight loss, fever.

-Characteristic finding later in disease is cough that becomes increasingly frequent, producing a mucopurulent sputum.

mucopurulent sputum

sputum containing white blood cells

Pleural effusion

accumulation of serous fluid in pleural space between visceral and parietal pleurae

Pleural effusion Clinical findings:

-Degree of manifestation depends on amount of fluid accumulation and position of patient.

-If effusion occurs rapidly and if it is large, there may be dyspnea, intercostal bulging, or decreased chest wall movement.

Asthma

hyperactive airway disease characterized by bronchoconstriction

Asthma occurs in response to:

-Allergens or pollutants

-Infection

-Cold air

-Vigorous exercise

-Emotional stress

Asthma Clinical Findings

-Increased respiratory rate with prolonged expiration

-Audible wheeze

-Dyspnea

-Tachycardia

-Anxious appearance

-Possible use of accessory muscles

-Cough

__________ are common findings with auscultation of a patient with asthma.

Prolonged expiration, expiratory and occasionally inspiratory wheeze, and diminished breath sounds

Emphysema

destruction of alveolar walls that causes permanent abnormal enlargement of air spaces

Emphysema Clinical findings:

-Underweight with barrel chest and short of breath with minimal exertion.

-Diminished breath and voice sounds.

-Wheezing or crackles on auscultation.

-Decreased diaphragmatic excursion on percussion.

Chronic bronchitis

inflammation of the bronchi persisting over a long time

Chronic bronchitis Clinical findings:

-Productive cough

-Increased mucus production

-Dyspnea.

-Findings on auscultation are rhonchi, sometimes cleared by coughing.

-When sufficient mucus occludes alveoli, crackles may be heard.

Three types of pneumothorax:

-closed

-open

-tension

Closed Pneumothorax

May be spontaneous, traumatic, or iatrogenic

Open Pneumothorax

Occurs following penetration of chest by either injury or surgical procedure

Tension Pneumothorax

Develops when air leaks into pleura and cannot escape

Pneumothorax Clinical Findings

-With minor collapse, patient may be slightly short of breath, anxious, and have chest pain.

-With large collapse, patient may be in severe respiratory distress, including dyspnea, tachypnea, and cyanosis.

-Decreased chest wall movement on affected side.

Hemothorax Clinical findings:

distant muffled breath sounds and dullness with percussion over affected area

Atelectasis

collapsed alveoli caused by external pressure from tumor, fluid, or air in pleural space or by removal of air from hypoventilation or obstruction by secretions

Atelectasis Clinical findings:

-Affected lobe has diminished or absent breath sounds.

-Oxygen saturation may decrease to less than 90%.

Lung cancer

uncontrolled growth of anaplastic cells in lung

Lung Cancer Clinical findings:

-Persistent cough

-Weight loss, congestion, wheezing, hemoptysis, labored breathing, or dyspnea are other manifestations that occur with advanced disease.

-Lung sounds may be normal or diminished over affected area; if there is a partial obstruction of airways from tumor, wheezes may be heard.

Before caring for the patient, the nurse reviews the test results. A chest radiographic report shows that there is atelectasis in the right base. During lung auscultation, what would the nurse expect to find?

a. Increased fremitus in the right base.

b. Diminished breath sounds.

c. Wheezing throughout.

d. Symmetrical chest expansion.

Diminished breath sounds.

1) The nurse is caring for a patient who is suffering from chronic obstructive pulmonary disease. He coughs frequently and produces a thick white sputum. During auscultation, the stethoscope should be placed:

a. Over the scapula to enhance adventitious lung sounds.

b. So that it is barely touching the skin to avoid auditory artifact.

c. Over the left lung fields first.

d. In one position long enough to hear an entire inhalation-exhalation set.

In one position long enough to hear an entire inhalation-exhalation set.

assess respirations for:

-rate

-rhythm

-chest expansion

-chest depth

-effort

auscultate breath sounds

8-10 ladder on front and back

What to do if you hear something that doesn't sound right?

ask them to shallow or cough first, listen again, then document if still abnormal

Nine-year-old Brian has a difficult time making friends at school and being chosen to play on the team. He also has trouble completing his homework and, as a result, receives little positive feedback from his parents or teacher. According to Erikson's theory, what does failure at this stage of development result in?

1) A sense of guilt

2) A poor sense of self

3) Feelings of inferiority

4) Mistrust

Feelings of inferiority

A parent informs the nurse that her 5-year-old child treats a doll like a real baby. The mother is very worried about this behavior. Which explanation given by the nurse is most appropriate?

1) The child's behavior is normal.

2) The child has a cognitive disorder.

3) The mother should keep the child away from the doll.

4) The child is likely to have a psychiatric problem in the future.

The child's behavior is normal.

The nurse is assessing an 8-year-old patient. According to Erikson's theory of psychosocial development, what would be the characteristics of this patient? Select all that apply.

1) The child searches for meaningful friendships.

2) The child learns to work and play with peers.

3) The child thrives on accomplishments and praise.

4) The child searches for an intimate relationship with another person.

5) The child is preoccupied with appearance and body image.

-The child learns to work and play with peers.

-The child thrives on accomplishments and praise.

The nurse is aware that preschoolers often display a developmental characteristic that makes them treat dolls or stuffed animals as if they have thoughts and feelings. Of what is this an example?

1) Logical reasoning

2) Egocentrism

3) Concrete thinking

4) Animism

Animism

A 17-year-old juvenile offender has sustained a fracture of the arm while fighting with his colleagues. The adolescent misbehaved with the nurse during dressing of the postsurgical wound. What does the behavior of the adolescent indicate according to the different theories of development?

1) Developmental crisis

2) Immature moral development

3) Immature cognitive development

4) Immature psychosexual development

Immature moral development

The nurse finds that a patient is in the integrity-versus-despair stage of Erikson's eight stages. Which patient response indicates the patient has not mastered this stage? Select all that apply.

1) The patient states she is a failure in her life.

2) The patient states she regrets her life because she did not achieve her goals.

3) The patient states she feels unable to play a role in the development of her kids.

4) The patient feels the need for an intimate relationship with another person.

5) The patient states she is preoccupied with thoughts of her appearance and body image.

-The patient states she is a failure in her life.

-The patient states she regrets her life because she did not achieve her goals.

The nurse is assessing a 10-year-old child for developmental abilities. According to Jean Piaget's theory of cognitive development, what are the usual abilities of such a child? Select all that apply.

1) The child is able to think about an action performed previously.

2) The child is able to describe an action without doing it.

3) The child understands that he or she is separate from the environment.

4) The child has magical thinking influenced by fantasy.

5) The child learns about the environment through reflex actions.

-The child is able to think about an action performed previously.

-The child is able to describe an action without doing it.

A mother approaches a primary health care provider with a 5-year-old child suffering from pneumonia. The girl is continuously crying and is demanding to see her father. The girl has a short stature. She is pretending to play and not allowing the nurse to administer medication. According to Erik Erikson's theory of psychosocial development, in which stage is the child?

1) Trust versus mistrust

2) Initiative versus guilt

3) Intimacy versus isolation

4) Autonomy versus sense of shame and doubt

Initiative versus guilt

A 17-year-old juvenile offender has sustained a fracture of the arm while fighting with his colleagues. The adolescent misbehaved with the nurse who was dressing the postsurgical wound. How is the adolescent's behavior explained, according to Piaget's theory of cognitive development? Select all that apply.

1) Adolescents exhibit risk-taking behaviors.

2) Adolescents are egocentric.

3) Pain becomes unbearable during this age.

4) Hormonal changes cause behavioral problems.

5) Adolescents feel that they are invulnerable.

-Adolescents exhibit risk-taking behaviors.

-Adolescents are egocentric.

-Adolescents feel that they are invulnerable.

According to Stella Chess and Alexander Thomas, what characteristics does the nurse find in a slow-to-warm-up child? Select all that apply.

1) The child has irregular habits.

2) The child reacts negatively to new stimuli.

3) The child is highly active and irritable.

4) The child does not adapt to new routines or people.

5) The child adapts slowly to new routines with repeated contact.

-The child reacts negatively to new stimuli.

-The child adapts slowly to new routines with repeated contact.

A head nurse is conducting a class on moral development stages in children. Which theory should the nurse include in the session?

1) Piaget's theory

2) Freud's theory

3) Kohlberg's theory

4) Erikson's theory

Kohlberg's theory

A student nurse claims to be a genius and smart enough to invent a vaccine for AIDS. According to Piaget's theory, of which kind of thought is the nursing student's behavior indicative?

1) Personal fable

2) Egocentrism

3) Imaginary audience

4) Postformal thought

Personal fable

A child between the ages of 3 and 6 years old fantasizes about the parent of the opposite sex. Whose developmental theory explains this behavior?

1) Sigmund Freud

2) Arnold Gesell

3) Erik Erikson

4) Jean Piaget

Sigmund Freud

An adolescent has successfully mastered the stage of identity versus role confusion of Erik Erikson's theory of psychosocial development. According to Erikson, what is the most accurate statement about how a person at this stage would behave?

1) The person is loyal only towards others.

2) The person is loyal only to his or her own ideals.

3) The person shows no loyalty to others or his or her own ideals.

4) The person is loyal towards others and his or her own ideals.

The person is loyal towards others and his or her own ideals.

When preparing a 4-year-old child for a procedure, which method is developmentally most appropriate for the nurse to use?

1) Allowing the child to watch another child undergoing the same procedure

2) Showing the child pictures of what he or she will experience

3) Talking to the child in simple terms about what will happen

4) Preparing the child through play with a doll and toy medical equipment

Preparing the child through play with a doll and toy medical equipment

A mother approaches a primary health care provider with a 5-year-old child suffering from pneumonia. The girl has a short stature, pretends to play, does not listen to the nurse's instructions. She does not allow the nurse to give nursing care and medications. The girl demands to see her father. According to Freud's theory of psychosexual development, in which stage of development is the child?

1) Oral stage

2) Anal stage

3) Oedipal stage

4) Genital stage

Oedipal stage

Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, "Did you hear about Kathy? You know, she fools around so much; I heard she was pregnant. That would never happen to me!" Of which adolescent belief is this an example?

1) Imaginary audience

2) False-belief syndrome

3) Personal fable

4) Sense of invulnerability

Sense of invulnerability

A small business owner has decided not to employ anyone belonging to a race other than his own. In which stage of Kohlberg's theory of moral development is the person?

Stage 1

Stage 2

Stage 5

Stage 6

Stage 5

You are working in a clinic that provides services for homeless people. The current local regulations prohibit providing a service that you believe is needed by your patients. You adhere to the regulations but at the same time are involved in influencing authorities to change the regulation. This action represents which stage of Kohlberg's theory of moral development?

1) Instrumental relativist orientation

2) Social contract orientation

3) Society-maintaining orientation

4) Universal ethical principle orientation

Social contract orientation