NURS3801 Module 4: Lung and Respiratory Assessment

What are adventitious breath sounds?

abnormal breath sounds

What is dyspnea?

difficulty breathing

What are common respiratory conditions?

1. acute respiratory distress syndrome

2. COVID-19 viral pneumonia

3. tuberculosis

4. asthma

5. lung cancer

Where is the horizontal fissure located?

at the 4th rib on the right side

Where are the oblique fissures located?

from the 5th rib midaxillary line to the 6th rib midclavicular line

How are respirations controlled?

- response to cellular demands

- involuntary control from the medulla oblongata of the brain stem

- feedback of blood level of CO2 and O2

What is the normal stimulus to breathe?

hypercapnia: increased level of CO2

What is the stimulus to breathe in COPD patients?

hypoxemia: low oxygen in the blood

What oxygen saturation range indicates healthy levels?

95-100%

What oxygen saturation percentage indicates hypoxemia?

< 90%

What oxygen saturation percentage indicates severe hypoxemia?

80%

What are common symptoms of hypoxemia?

- anxiety

- restlessness

- confusion

- drowsiness

- headaches

- dyspnea or SOB

- elevated BP

- tachycardia

- tachypnea

- pallor and/or cyanosis

What questions should the nurse ask during a respiratory assessment?

- Any shortness of breath (SOB)?

- Does SOB occur on exertion or at rest?

- Do certain positions bring on SOB?

- Do you have pain when you breathe? If yes, where is the pain?

- What environmental exposures are present?

- Have you had a TB test, chest x-ray, vaccines?

- What medications are you currently taking?

- Have you had any changes to smell or taste?

- Have you been experiencing a cough?

- What are characteristics of the cough?

- Describe your pain.

- What is your smoking history?

What does white or clear sputum indicate?

colds, bronchitis, viral infections

What does yellow/green sputum indicate?

bacterial infection

What does rust colored sputum indicate?

tuberculosis, pneumococcal pneumonia

What does pink, frothy sputum indicate?

pulmonary edema

What signs indicate respiratory distress?

- increased respiratory rate

- increased effort to breathe

- nasal flaring

- pursed lip breathing

- pallor and/or cyanosis

- tripod position

- use of accessory muscles

- sternal retractions or retractions in intercostal spaces

What can clubbing indicate?

long standing hypoxemia

What is eupnea?

normal breathing:

- quiet

- unlabored

- even chest

What is apnea?

absence of breathing

What is tachypnea?

rapid breathing (>24 bpm in adults)

What is bradypnea?

slow breathing (

What is the normal respiratory rate for a neonate?

30-40 bpm

What is the normal respiratory rate for a 1 yo?

20-40 bpm

What is the normal respiratory rate for a 2 yo?

25-32 bpm

What is the normal respiratory rate for a 8-10 yo?

20-26 bpm

What is the normal respiratory rate for a 12-14 yo?

18-22 bpm

What is the normal respiratory rate for a 16 yo?

12-20 bpm

What is the normal respiratory rate for an adult?

10-20 bpm

Why are respiratory rates higher in newborns?

they have smaller lungs and weaker chest muscles

When is barrel chest seen?

aging, asthma, lung disease, infants

What is scoliosis?

s-shaped curvature of the thoracic and lumbar spine

What is kyphosis?

humpback in the thoracic area

Where should the trachea be located?

in the midline without any deviation

What is crepitus and what does it indicate?

- a crackly or crinkly sensation

- indicates air in the subcutaneous tissue

- rupture in the respiratory system

- following an injury or surgery

What is fremitus?

palpable vibration on the chest wall when talking

What increases fremitus?

fluid or a solid mass such as pneumonia or a tumor

What decreases fremitus?

air trapping which is seen in emphysema and pulmonary edema

When assessing fremitus, what should you instruct the patient to say?

"ninety nine" or "blue moon"

What is the purpose of percussing over the lungs?

- to distinguish lung position

- size and presence of air

- liquids or solids in the lungs

What should be used to percuss over the lungs?

hands or a reflex hammer

When percussing over the posterior lungs, what should the nurse avoid doing?

percussing over the scapulae

Which part of the stethoscope should be used for auscultating the lungs?

diaphragm

What should the nurse instruct the patient to do when listening to the lungs?

- sit and lean forward

- breathe slowly and deeply through the mouth

What are characteristics of normal bronchial breath sounds?

- high pitched

- loud

- expiratory phase is longer than inspiratory phase

Where are bronchial breath sounds heard?

over trachea

What are characteristics of vesicular breath sounds?

- soft

- low pitched

- inspiratory phase is 3x longer than expiratory phase

Where are vesicular breath sounds heard?

over most lung fields

What are characteristics of bronchovesicular breath sounds?

- moderate pitch

- moderate amplitude

- inspiration phase is equal to expiratory phase

Where are bronchovesicular breath sounds heard?

upper anterior chest and intercostal area

If adventitious sounds are heard when auscultating the lungs, what should the nurse document?

- what it sounds like: crackles, wheezes, rhonchi, rub

- where it is heard: which lung and which lobe

- when it is heard: inspiration, expiration, or both

What do course crackles (rales) sound like?

- loud

- low pitch

- gurgling

- like opening velcro

When are course crackles (rales) heard?

during inspiratory and expiratory phases

What do course crackles (rales) indicate?

secretions or fluid in small airways

What do fine crackles (rales) sound like?

- intermittent

- high pitched

- soft

- popping

- like rolling a strand of hair between the fingers

When are fine crackles (rales) heard?

inspiration

What do atelectatic crackles (rales) sound like?

- moistening your thumb and index finger and separating them near your ear

- popping sound

What causes atelectatic crackles (rales)?

previously deflated airways popping open

Can fine crackles (rales) be cleared by coughing?

no

Can atelectatic crackles (rales) be cleared by coughing?

yes

What patients may have atelectatic crackles (rales)?

- ones on bedrest

- after sleeping

- aging adults

What does pleural friction rub sound like?

- loud

- grating

- low pitch

When is pleural friction rub heard?

inspiration and/or expiration

What causes pleural friction rub?

inflamed pleural surfaces rubbing together

A patient is experiencing pain with breathing. What breath sounds would the nurse expect to hear?

pleural friction rub

What do wheezes sound like?

- can be high or low pitched

- continuous

- musical

When are wheezes heard?

mainly expiration

What can cause wheezes?

- narrowed airways due to swelling or tumor

- obstructive disease

What does stridor sound like?

- high pitched

- crowing

Where is stridor heard?

- larynx

- trachea

- upper airway

What can cause stridor?

- swelling

- inflammation

- spasm

- foreign body

- croup or epiglottitis in children

- allergies

- airway obstruction

What are characteristics of normal voice sounds?

- muffled

- indistinct

When assessing bronchophony, what should the patient say?

99

When assessing egophony, what should the patient say?

eeeeeeee

When assessing whispered pectoriloquy, what should the patient say?

1-2-3

When is barrel chest normal?

in infants and children below 6 years old

How do infants and children breathe?

- abdominal breathers

- nose breathers

What are differences between adult breath sounds and infant/children breath sounds?

infant/children:

- sounds are harsher and louder

- change in position or cough often clears crackles

What are common respiratory findings in older adults?

- kyphosis

- decreased gas exchange

- increased work of breathing

- loss of elasticity

- calcification of lung cartilage

- falls can fracture ribs

Compare acute and chronic bronchitis.

bronchitis: inflamed bronchial passages

acute:

- lasts up to 3 weeks

- cough produces thick sputum

- can be due to a virus or a bacteria

chronic:

- lasts at least 3 months

- s&s include dyspnea, cyanosis, fatigue, and clubbing

What are the assessment findings in a patient with pneumothorax?

- inspection: unequal chest expansion, tachypnea

- palpation: decreased or absent fremitus, tracheal shift, tachycardia, decreased BP

- percussion: hyper resonant

- auscultation: decreased or absent breath sounds and voice sounds

What causes a pulmonary embolism and what are signs and symptoms?

- caused by a blood clot that becomes trapped in a blood vessel in the lungs

- s&s: chest pain, dyspnea, tachypnea, diaphoresis, anxiety

What is hypoxia?

deficiency in the amount of oxygen reaching the tissues

What is hypoxemia?

low levels of oxygen in the blood

What is cyanosis?

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood

What is hypoventilation?

slow, shallow breathing that does not expel enough CO2

What is the biggest risk factor for lung disease and complications?

smoking

Which part of the lungs are you mostly listening to when auscultating the posterior chest?

the lower lobes

What happens if a COPD patient is given large amounts of oxygen?

they will stop breathing because low oxygen is their primary stimulus to breathe

How is oxygen saturation level measured?

- arterial blood gas (ABG)

- pulse oximeter

What is orthopnea?

difficulty breathing while lying down

What is DOE?

dyspnea on exertion: difficulty breathing when exercising

What is the proper ratio for anterior-posterior diameter: transverse diameter?

1:2

How does kyphosis affect lung capacity?

it decreases the ability of the lungs to inflate

What motion is used to listen to the lungs and why?

side to side to compare the 2 lungs

How many areas do we listen to when auscultating the posterior lungs?

9 on each lung

How many areas do we listen to when auscultating the anterior lungs?

5 on each lung

When is stridor heard?

inspiration

What positions indicate abnormal breathing?

- tripod

- head elevated: fowler's