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Respiratory Assessment & Diagnostics
(NSC 386)
Name the structures of the upper respiratory tract. - ANS - nose
- mouth
- pharynx
- epiglottis
- larynx
- trachea Name the structures of the lower respiratory tract. - ANS - lungs (5 total lobes)
- bronchi
- bronchioles
- alveoli Which lung has 3 lobes? - ANS right The lungs are surrounded by a ____ ____. - ANS pleural sac What is the major muscle of respiration? - ANS diaphragm When air is inhaled, the diaphragm is moved [up/down]. - ANS down When air is exhaled, the diaphragm is moved [up/down]. - ANS up What is oxygenation? - ANS the process of obtaining O2 from the atmospheric air and making it available to the body organs and tissues
What is ventilation? - ANS inspiration and expiration What is minute ventilation? - ANS how much air moves in and out of the body in 1 minute How is ventilation calculated? - ANS tidal volume (avg: 500) x breathing rate (avg: 16) What is compliance? - ANS ability of the lungs to expand What is resistance? - ANS any obstacle to airflow during inspiration and/or expiration What is the main driving force of ventilation? - ANS the brain How does the brain control ventilation? - ANS - pH and CO2 changes in spinal fluid โ brain
- O2 changes received by heart or arteries โ brain What is a normal adult respiratory rate? - ANS 12- What is oxygen saturation? - ANS the % of Hgb saturated with O What is a normal O2 sat? - ANS above 95% What O2 sat requires immediate intervention? - ANS <90% How does the body compensate (as indicated by VS) for a low O2 sat? - ANS - โ RR
If the patient presents with pursed lip breathing, what may be the cause? - ANS breathlessness r/t asthma or COPD If the patient presents tachypneic, what may be the cause? - ANS - hypoxemia
- anxiety If the patient presents in the tripod position, what may be the cause? - ANS severe respiratory distress What should be inspected on the neck and chest during a respiratory assessment? - ANS - symmetry and use of accessory muscles
- deformities
- trachea (midline)
- respiratory excursion How is respiratory excursion measured? - ANS place hands on pt's back with thumbs each 1 in from either side of spine โ ask pt to breathe โ assess symmetry and proper diaphragm mvt If the patient has altered chest movement, what may be the cause? - ANS - atelectasis
- pneumothorax
- pleural effusion
- splinting If the patient presents with tracheal deviation, what may be the cause? - ANS pneumothorax Where on the body are bronchovesicular lung sounds heard? - ANS over main bronchi
Where on the body are vesicular lung sounds heard? - ANS over lesser bronchi, bronchioles, and lobes Where on the body are bronchial lung sounds heard? - ANS over the trachea What do fine crackles sound like? - ANS - soft
- high pitched
- brief (5-10 sec) What do coarse crackles sound like? - ANS - loud
- low pitched
- brief (20-30 sec) What do wheezes sound like? - ANS - relatively high pitched
- musical
- hissing/shrill What do rhonchi sound like? - ANS - low pitch wheeze
- snore-like What does stridor sound like? - ANS - high pitched
- in neck What is a common cause of stridor? - ANS edema in neck What are the 3 ways in which specimens may be collected for a sputum study? - ANS - expectoration
How is a bronchoscopy used as a treatment? - ANS mucus plug or foreign body removal What is the purpose of a lung biopsy? - ANS to obtain tissue, cells, and/or fluid for to be cultured and evaluated for cancer cells What nursing care is provided to the patient before a bronchoscopy? - ANS - NPO 6-12 hrs before
- conscious sedation
- topical anesthetic for throat What nursing care is provided to the patient after a bronchoscopy? - ANS - NPO until gag reflex returns
- monitor sedation
- monitor bleeding T/F: Blood-tinged mucus is an abnormal finding post-bronchoscopy. - ANS false, it is normal What nursing care is provided to the patient who underwent a lung biopsy via bronchoscopy? - ANS - monitor bleeding (hemorrhage)
- monitor respiratory status (pneumothorax) What nursing care is provided to the patient who underwent a percutaneous lung biopsy? - ANS - monitor dressing for drainage (hemorrhage)
- chest xray (pneumothorax)
- monitory respiratory status (pneumothorax) How is a thoracentesis performed? - ANS large bore needle is placed through the chest wall into the pleural space and fluid is removed manually by syringe or drained into bag
Why might a thoracentesis be performed? - ANS pleural effusion What teaching should be provided to the patient prior to a thoracentesis? - ANS - sit upright
- lean on bedside table with feet supported
- no talking
- no coughing What should be monitored constantly if undergoing a thoracentesis? - ANS O2 sats What nursing care is provided post-thoracentesis? - ANS - monitor respiratory status (hypoxia and pneumothorax)
- pulmonary hygiene
- send specimens to lab
- chest xray (pneumothorax) How would the patient be instructed to maintain pulmonary hygiene? - ANS - TCDB
- IS
- don't suppress cough What is measured by a pulmonary function test (PFT)? - ANS lung volume and air flow What is the purpose of a PFT? - ANS - diagnose pulmonary disease (asthma, COPD)
- monitor disease progression
- evaluate disability
- assess response to bronchodilators
What is the function of a ventilation-perfusion (V/Q) scan? - ANS to assess ventilation and perfusion of the lungs How is a V/Q scan conducted? - ANS pt inhales radioactive gas that outlines the alveoli โ imaging What is a V/Q scan used to commonly diagnose? - ANS pulmonary embolism (ventilation w/o perfusion) What is the purpose of a positron emission tomography (PET) scan? - ANS to distinguish benign from malignant tumors How is a PET scan conducted? - ANS a radioactive, glucose-containing nuclear tracer substance is injected โ imaging โ hot spots = cancer What nursing care is provided the patient before a PET scan? - ANS - NPO 4+ hrs before
- hold all glucose-containing IVFs
- monitor glucose levels
- encourage fluids What is the ideal glucose before a PET scan to ensure accurate glucose metabolic activity? - ANS < mg/dL
