3a Health Assessment

What are the three main functions of the respiratory system?

Bring oxygen into the body, remove carbon dioxide, and maintain acid-base (pH) balance.

What happens during inspiration and expiration?

Inspiration: diaphragm contracts and moves down, chest expands, air enters. Expiration: diaphragm relaxes and moves up, chest becomes smaller, air exits.

What are important respiratory health history questions?

Ask about shortness of breath, cough, sputum (color, amount, blood), wheezing, chest pain, asthma/COPD, pneumonia, smoking, environmental exposures, medications, and respiratory infections.

What are dyspnea, hemoptysis, and purulent sputum?

Dyspnea = difficulty breathing; hemoptysis = coughing up blood or blood-streaked sputum; purulent sputum = pus-containing sputum.

What happens in asthma and what would the nurse find?

Airways narrow from inflammation and bronchoconstriction; common findings are wheezing, cough, chest tightness, and shortness of breath.

What happens in COPD and what would the nurse find?

Chronic airflow limitation and air trapping; findings may include dyspnea, diminished breath sounds, prolonged expiration, barrel chest, and hyperresonance.

What happens in pneumonia and what would the nurse find?

Infection/inflammation fills alveoli with fluid or secretions; findings may include cough, fever, crackles, dull percussion, and increased transmitted voice sounds.

What happens in pleural effusion and what 4 would the nurse find?

Fluid collects between pleural layers; findings include reduced chest expansion, decreased breath sounds and tactile fremitus, and dull percussion.

What is a pneumothorax, what would the nurse expect to see?

Air in the pleural space that can collapse the lung; findings may include sudden dyspnea, chest pain, reduced breath sounds, and reduced expansion on one side.

What does pulse oximetry measure and what is normal, what can low values indicate?

SpO₂ estimates the percentage of hemoglobin saturated with oxygen. Lecture normal: above 95%. Low values may mean inadequate oxygenation; interpret with the patient's condition.

What is the difference between hypoxia and hypoxemia?

Hypoxia = insufficient oxygen in tissues; hypoxemia = insufficient oxygen in arterial blood.

What is the normal adult respiratory rate, what can tachypnea//bradypnea signal problems of?

12–20 breaths/minute. Tachypnea = abnormally fast; bradypnea = abnormally slow. Both may signal problems with ventilation or oxygenation.

What are abnormal breathing patterns?

Apnea =

hypoventilation =

hyperventilation =

Cheyne-Stokes =

Biot =

Apnea = no breathing;

hypoventilation = insufficient/shallow breathing;

hyperventilation = excessive rapid/deep breathing;

Cheyne-Stokes = breathing increases/decreases with periods of apnea;

Biot = irregular breaths with apnea.

What are signs of respiratory distress?

Accessory muscle use, nasal flaring, retractions, tripod position, cyanosis, abnormal respiratory rate, low SpO₂, and audible wheezing/grunting.

What is the order of a respiratory physical assessment?

Inspection → palpation → percussion → auscultation. Assess posterior then anterior chest.

Why do nurses use the ladder pattern?

To compare matching areas of both lungs side to side and identify uneven or abnormal findings.

What is normal chest expansion, what 3 does asymmetry suggest?

Both sides expand symmetrically when inhaling. Asymmetry may suggest pneumothorax, pleural effusion, or pain.

What is the normal chest AP-to-transverse diameter ratio?

1:2. Barrel chest may have a 1:1 ratio, commonly with COPD.

What do cyanosis and clubbing suggest?

Cyanosis = bluish skin from inadequate oxygenation; clubbing = enlarged/rounded fingertips associated with some chronic lung diseases.

What is tactile fremitus and how is it assessed, what does decreased fremitus occur with?

Vibrations felt through the chest while the patient says “ninety-nine.” Decreased fremitus may occur with pleural effusion or blocked transmission.

What is percussion used for?

Tapping the chest to estimate underlying air/fluid/tissue density and detect lung abnormalities.

What are the three main percussion sounds?

Resonance = normal air-filled lung;

dullness = increased density/fluid (e.g., pneumonia);

hyperresonance = excess air (e.g., COPD).

What are vesicular breath sounds?

Soft, low-pitched sounds heard over most peripheral lung fields; inspiration is longer than expiration.

What are bronchovesicular breath sounds?

Medium-pitched sounds over major bronchi (near sternum and between scapulae); inspiration and expiration are equal.

What are bronchial breath sounds?

Loud, high-pitched sounds over the trachea; expiration is longer than inspiration.

What are crackles and what causes them?

Popping or bubbling sounds usually during inspiration, often from fluid in small airways/alveoli; e.g., pneumonia.

What is wheezing and what causes it?

High-pitched musical whistling, usually during expiration, caused by narrowed airways; e.g., asthma.

What is stridor and why is it urgent?

Loud, harsh, high-pitched inspiratory sound from upper airway narrowing/obstruction. It can indicate threatened airway patency.

What is pleural friction rub?

Creaking/grating sound during breathing when inflamed pleural surfaces rub together; e.g., pleuritis.

What are diminished breath sounds, where can it be seen?

Quieter/absent sounds from reduced airflow or sound transmission, seen with conditions such as pleural effusion or pneumothorax.

What is egophony, what can it suggest?

Patient says “E” but nurse hears “A”; abnormal sound transmission suggests lung consolidation, such as pneumonia.

What is bronchophony, what does it suggest?

Patient says “ninety-nine” and words sound unusually loud and clear; may suggest consolidation.

What is whispered pectoriloquy, what can it suggest?

Patient whispers “ninety-nine” and nurse hears it clearly; may suggest lung consolidation.

How does aging affect 3 respiratory functions?

Decreased muscle strength, reduced lung elasticity, and decreased vital capacity.

What respiratory health promotion should nurses teach?

Smoking cessation, avoiding harmful exposures, and appropriate influenza, pneumococcal, pertussis, and COVID immunizations.