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2011-03-08 00:17:15
Health Assessment

Chapter 12
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  1. _____is the process of moving gases in and out of the lungs by inspiration and expiration
  2. ________is the process by which oxygen and carbon dioxide move from areas of high concentration to areas of lower concentration
  3. The mediastinum is positioned in the middle of the chest and within it lie:
    • the heart,
    • the arch of aorta
    • the seperior vena cava
    • the lower esophagus
    • lower part of the trachea
  4. The lungs are contained withing the pleural cavities which are lined with what two types of serous membranes:
    the parietal and visceral pleurae
  5. The chest wall and diaphram are protected by the ________ pleura and the lungs are protected by the ______ pleura
    • chest wall & diaphram = parietal pleura
    • lungs=visceral pleura
  6. Each lung extends anteriorly about _______ above the first rib into the base of the neck in adults
    1.5" (4cm)
  7. Posteriorly, the lungs' apices rise to about the level of _______ whereas the lower borders, on deep inspiration, expand down to about _______ and, on expiration, rise to about ______.
    • -apices rise to T1
    • -lower boarders expand down to T12
    • -expiration rise to T9
  8. The adult sternum is about _____" long and has three components:
    • 7"
    • -manubrium, body, xiphoid process
  9. The intercostal space is named according to what?
    The rib immediately above it. The 1st ICS is located between the 1st & 2nd ribs
  10. The ______ and _______ are the PRiMARY muscles of inspiration
    Diaphragm and intercostal muscles
  11. During inspiration the diaphragm contracts and pushes the abdominal contents _______ while the ICM help to push the chest wall _______
    • up
    • outward
  12. The effort of inspiration ________the intrathoracic pressure, which creates a negative pressure w/in the lungs compared w/the pressure outside the lungs, hence causing the lungs to fill with air.
  13. Name the accessory muscles that may contibute to respiratory effort:
    • (anteriorly) sternocleidomastoid, scalenus, pectoralis minor, serratus anterior, rectus abdominis
    • (posteriorly) serratus posterior superior, transverse thoracic & serratus posterior inferior muscles
  14. Nose, pharynx, larynx & intrathoracic trachea much up the upper airway which has three functions which are:
    • -conduct air to the lower airway
    • -warm, filter & humidify inspired air
    • -protect lower airway from foreign matter
  15. The trachea splits into a left and right main stem bronchus at about teh level of T? and T?
    T4 & T5
  16. The depression at the ventral aspect of the neck, just above the manubrium
    Suprasternal notch
  17. The junction between the manubrium and sternum: useful for rib identification
    Manubriosternal junction (angle of Louis)
  18. Imaginary verticle line throught he middle of the sternum
    midsternal line
  19. intersection of the costal margins, usually no more than 90 degrees
    costal angle
  20. these bones cover the first ribs and extend out both sides of the nanubrium to the shoulder
  21. imaginary vertical lines on the right & left sides fo the chest that are "drawn" through the clavicle midpoints, parallel to the midsternal line
    midclavicular lines
  22. imaginary verticle lines on the right and left sides of the chest "drawn" from anterior axillary folds through the anterolateral chest, parallel to the midsternal line
    Anterior axillary lines
  23. imaginary vertical lines on the right & left sides of the chest "drawn" from the posterior axillary folds along the posterolateral thoracic wall w/abducted lateral arm
    Posterior axillary lines
  24. imaginary vertical lines on the right and left sides of the chest "drawn" from axillary apices; midway between and parallel to the anterior and posterior axillary lines
    midaxillary lines
  25. Spinous process of C7; visible and palpable with the head bent forward
    Vertbra promines
  26. imaginary vertical line "drawn" along the posterior vertebral spinous processes
    vertebral line
  27. imaginary vertical lines on the right and left sides of the chest "drawn" parallel to the midspinal line; they pass through inferior angles of the scapulae in the upright client with arms at sides
    scapular lines
  28. Risk factors for lung cancer:
    • Tobacco smoking:most important facto
    • secondhand smoke
    • asbestos-7x's >likely to die of L. cance
    • environmental exposure in the workplace
    • marijuana:inhaled deeper&held longer
    • personal & family history
    • Gender: F >genetic predisposition
    • Air pollution
  29. White or clear sputum may occur with:
    colds, viral infections or bronchitis
  30. A bacterial infection may procuduce what color sputum?
    yellow or green
  31. Patient is producing black sputum. This color sputum may be associated with:
    smoke or coal dust inhalation
  32. This color sputum may occur with tuberculosis or pneumococcal pneumonia
  33. ________ is the expectoration of sputum containing blood
  34. Describe different variations of the consistency of putum:
    thin, thick, a gelatin consistency, sticky or frothy
  35. Pink, frothy sputum with dyspnea is associated with __________________

    Thick sputum is commonly associated with _____________
    • pulmonary edema
    • Cystic fibrosis
  36. Foul-smelling sputum called ________ is typically associated with what issues?
    • Fetid - foul-smelling sputum
    • associated with: bacterial pneumonia, lung abscess or bronchiectasis
  37. a cough associated with a fever, shortness of breath, and noisy reath sounds may be indicative of:
    a lung infection
  38. tightness of the chest associated with shortness of breath and a nonproductive cough is more likely to be associated with a problem such as:
  39. normally, a person can say ____ to ____ words before taking a breath
  40. A pt who has severe dyspnea may take a breath after ______________
    • After every third word.
    • This is documented as "three-word dyspenea"
  41. ___________ is difficulty breathing when the individual is lying down
  42. What does the term three-pillow orthopnea mean?
    The client needs to prop up with three pillows to relieve the dyspnea
  43. This is shortness of breath that awakens the individual in the middle of the night, usually in a panic with the feeling of suffocation
    Paroxysmal nocturnal dyspnea
  44. Name some signs of respiratory distress:
    • appearance of apprehension
    • restlessness, nasal flaring, supraclavicular or intercostal retractions or bulging with expiration
    • use of accessory muscles
  45. This may occur after chest trauma when the chest wall moves IN on inspiration and OUT on expiration.
    Paradoxical chest wall movement
  46. What is the tripod position and what does it suggest?
    • Leaning forward with the arms braced against the knees, against a chair or against a bed.
    • This also suggests respiratory distress
  47. A normal adult rate of breathing is ____to_____ breaths per minute and is called __________.
    • 12-20 breaths/minute
    • eupnea
  48. Men tend to use _________breathing
    Women tend to use ______breathing
    • men: abdominal
    • women: thoracic
  49. Chest retraction appears then intercostal muscles are drawn inward between ribs and indicates:
    airway obstruction that may occur during an asthma attack or pneumonia
  50. A sigh is a normal variation observed with breathing but FREQUENT sighing is considered an ABNORMAL finding and may indicate:
    fatigue or anxiety
  51. This is a respiratory rate <12 breaths per minute. The rate and depth remains smooth and even
  52. This is a respiratory rate >20 breaths per minute. The rate and depth remains smooth and even
    • Tachypnea
    • can be caused by a number of factors, including fever, fear or activity
  53. _______ breathing pattern is characterized by increased rate and depth of respiration and when occuring with ketoacidosis, it is very deep and laborious and is termed: _______
    • hyperventilation
    • Kussmaul breathing
  54. This breathing pattern is characterized by irregularly interspersed periods of apnea in a disorganized and irregular pattern, rate or depth
    • Biot breathing pattern
    • may be associated with persistnt intracranial pressure, respiratory distress, or damage to the medulla
  55. ________is characterized by intervals of apnea interspersed with a deep and rapid breathing pattern which may be seen in clients w/severe illness, brain damage or drug overdose
  56. ______is an abnormal respiratory pattern characterized by rapid inspiration with prolonged, forced expirations. Air is not fully exhaled; thus it becomes trapped in the lungs, which eventually leads to a __________.And is frequently seen in clients w/________________
    • Air trapping
    • barrel chest
    • chronic obtructive pulmonary disease
  57. Inadequate oxygen tension at the cellular level
  58. Clubbing of the nails is associated with _____ ________ observed in clients w/CF or chronic obstructive pulmonary disease
    chronic hypoxia
  59. This breath sound should be heard over main bronchi:
    1st & 2nd intercostal spaces at sternal border anteriorly and should be heard in the posterior thorax over the upper center area of the back on either side of the spine between the scapulae
    • Bronchovesicular
    • pitch: moderate
    • intensity: medium
  60. This breath sound should be heard over lesser bronchi, bronchioles and lobes:
    Peripheral lung fields
    • Vesicular
    • pitch: low
    • intensity: soft
  61. This breath sound should be heard over trachea
    • Bronchial
    • pitch: high
    • intensity: loud
  62. a breath sound that is not normally heard, such as a crackle, gurgle, rhonchus, or wheeze that are superimposed on the breath sound
    adventitious sound
  63. The term _________ is used to describe a harsh, high-pitched sound associated with breathing that is often associated with breathing that is often caused by laryngeal or tracheal obstruction.
    respiratory stridor
  64. Diminished breath sounds may be heard in patients whose ________have been destroyed
  65. This adventitious sound is heard as high-pitched, musical sound similar to a sqeak and occurs in small airways
    • wheeze
    • *heard in narrowed airway diseases such as asthma
  66. This adventitious sound is low-pitched, coarse, loud, low snoring or moaning tone
    • Rhonchi (sonorous wheeze)
    • coughing may clear
    • heard in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis
  67. This adventitious sound is a superficial, low-pitched, coarse rubbing or grating sound which sounds like 2 surfaces rubbing together.
    • Pleural friction rub
    • *heard throughout inspiration & expiration
    • *heard in individuals w/inflammation of the pleural surfaces
  68. Fine, high pitched crackling & popping adventitious sounds heard during the end of inspiration.
    • Fine crackles
    • may be heard in pneumonia, heart failure, asthma, and restrictive pulmonary disease
  69. Medium-pitched, moist sound heard about halfway through inspiration
    • Medium crackles
    • may be heard in pneumonia, heart failure, asthma, and restrictive pulmonary disease
  70. Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration
    • Coarse crackles
    • May be heard in pneumonia, heart failure, asthma and restrictive pulmonary diseases. Condition is worse or in terminally ill clients w/diminished gag reflex. Also heard in pulonary edema & pulmonary fibrosis
  71. The anteroposterior diameter of the chest shoulc be approximately _______ the lateral diameter
  72. Anteriorly the constal angle should be ___________ degrees
    less than 90 degrees
  73. The ribs should slope down _______ degrees relative to the spine
    45 degrees
  74. In patients with a ____________ the ribs are more horizontal in relation to the spine and there is an increase >90 degrees in AP diameter
    • barrel chest
    • The lungs are hyperinflated and the chest changes shape to accomodate
  75. this condition is noted by the prominent sternum
    pectus carinatum (pigeon chest)
  76. This condition is noted that sternum is indented above xiphoid
    Pectus excavatum (funnel chest)
  77. Assessing for Vocal (tactile) Fremitus should be performed when:
    only if abnormal sounds are heard during auscultation
  78. This is a vibration resulting from verbalizations felt by palpating the posterior thoracic wall:
    • Vocal (tactile) fremitus
    • Pt w/emphysema, pleural effusuion, pulmonary edema or bronchial obstruction will have decreased or absent vocal fremitus (because the vibration are blocked from being felt)
    • Pt w/congested or consolidated lung tissue/pneumonia or a tumor may have enhanced vocal fremitus
  79. Sounds that should be heard while percussing the thorax:
    -heavy muscles
    • flat over heavy muscles
    • dullness over liver
    • resonance over lungs
    • dullness over cardiac
    • tympany over stomach
  80. When there is an indication of consolidation of the lung or if there was an abnormal finding when tactile fremitus was performed, you would evaluate for vocal resonancy using these three techniques:
    • bronchophony-having pt to say ninety-nine, should be muffled
    • whispered pectoriloquy-have pt to whisper, "one-two-three", should be muffled
    • egophony-have pt to say "eeee" should be muffled "eeee" not "a-a-a"
  81. An inflammation of the mucous membranes of the bronchial tree. Initial cough is unproductive but may become productive after a few days. May experience substernal chest pain aggrivated by coughing. May have fever, malaise & tachypnea. Rhonchi are heard on ausculation w/wheezing heard after coughing
    Acute Bronchitis
  82. Infection of terminal bronchioles & alveoli. Fever, malaise & pleuritic chest pain. Inspiratory crackles, increased tactile fremitus, egophony & whispered pectoriloquy may be noted:
    • Pneumonia
    • Viral pneumonia=nonproductive cough w/clear sputum
    • Bacterial pneumonia=productive cough w/white, yellow or green sputum
  83. Infection primarily in lungs where pt is usually asymptomatic during early stages. Initial manifestations consist of fatigue, anorexia, weight loss, night sweats & fever. Later in the disease, is a cough tht becomes > frequnt, producing a mucopurulent sputum
  84. An accumulation of serous fluid in the pleural space between the visceral & parietal pleurae
    • Pleural effusion
    • manifestations depend on amount of fluid accumulation & position of client. There may be dyspenea, intercostal bulging or decreased chest wall movement
  85. This hyperreactive airway disease is characterized by bronchoconstriction, airway obstruction & inflammation in response to inhalation of allergens or pollutants, infection, cold air, vigorous exercise or emotional stress
    • Asthma
    • >res rate w/prolonged expiration
    • audible wheeze
    • dyspnea
    • tachycardia
    • anxious appearance
  86. The following is indicative of what chronic pulmonary disease?
    underweight/barrel chest who becomes short of breath, possible wheezing/crackles
    • emphysema
    • destruction of the alveolar walls causes permanent abnormal enlargement of the air spaces
  87. This disorder is characterized by hypersecretion of mucus by the goblet cells of the trachea & bronchi resulting in a productive cough for 3 months in each of 2 successive years
    • chronic bronchitis
    • caused by irritants such as cigarette smoke & air pollution
  88. Air in the pleural spaces results in a:
  89. Name the 3 types of pneumothorax along w/brief description:
    • 1. closed: spontaneous, traumatic or iatrogenic
    • 2. open: occurs following penetration of chest
    • 3. tension: develops when air leaks into the pleura & cannot escape
  90. Blood in the pleural space caused by injury to the chest results in
  91. This disorder refers to collapsed alveoli caused by external pressure from a tumor, fluid or air in the pleural space or by removal of air from hypoventialtion or obstruction by secretions
  92. An uncontrolled growth of anaplastic cells in the lung describes:
    • lung cancer
    • sypmtoms reported is persistent cough, wt loss, congestion, wheezing, hemoptysis, labored breathing or dyspnea
  93. No difficulty breathing until activity may have:
    pulmonary or heart disease that limits the availability of oxygen needed during excertion
  94. Viral pneumonia produces a ____cough
    Bacterial pneumonia produces a ___cough
    • dry
    • productive
  95. Increased sputum in the morning implies an accumulation of sputum during the night and is common w/____
  96. Sputum prodcution w/a change in position is suggestive of ________ & ______
    • lung abscess
    • bronchiectasis