nursing assessment

  1. It is a depression at the base of anterior neck and you can assess strength and regularity of aortic pulsations with fingertips at this site
  2. It articulates and supports clavicles and it is located at the sternum
  3. Where is the site for the attachment of the 2nd rib
    Angle of louis or Manubriosternal junction
  4. Junction of manubrium and sternal body
    Angle of louis
  5. ICS named according to rib immediately superior
    Angle of louis
  6. Coastal ridges of _____ articulate with sternal body
    1st 7 ribs
  7. Ribs 8-10
    attached to coastal cartilages just above ribs
  8. ____ rib tip is located in lateral thorax
    11th rib
  9. What ribs are unattached and termed floating ribs
  10. Location of of 12th rib tip
    posterior thorax
  11. In women, this process of respiration is more costal
  12. All ribs articulate with thoracic vertebrae-
  13. Respiration tend to be more diaphragmatic, with more use of abdominal muscles in men, children and when sleeping
  14. Anteriorly, 3 lobes, middle underlies breast.
    Posteriorly and laterally, 2 lobes
    Right lung
  15. The angle formed by blending together of coastal margins at the sternum, usually less than 90 degrees and widens with chest barreling
    Coastal angle
  16. Posteriorly tip of scapulae is usually at
    7th rib
  17. Bifurcation of trachea into right and left main bronchi is at
  18. Main bronchi divide into ____ on right lobe and _______ on left lobe
    3 and 2
  19. What main bronchus is wider, shorter, more vertically placed and more susceptible to aspiration of foreign bodies
    Right main bronchus
  20. Primary muscles of respiration
    Diaphragm and intercostal muscles
  21. Extends anteriorly about 2-4cm above 1st rib into base of neck
  22. In this process of respiration, lower borders rise to about T9, when forced
  23. Where is the diaphragm located posteriorly, laterally, and anteriorly
    • At level of T10 spinous process, posteriorly.
    • At 8th rib MAL, laterally
    • At right dome, level of T10 spinous process, anteriorly
  24. This symptom of respiratory dysfunction is a respiratory defense mechanism in response to irritation in tracheobronchial system.
    It can be productive or non-productive
    intermittent or constant.
    effective (forcefully expels substanes from airway) or ineffective
  25. About 2-4 cm above inner 1/3rd of clavicle also called kronig's isthmus
  26. _______ is a respiratory defense mechanism.
    Normally, is clear to white, tasteless, odorless and scant
    but during a pulmonary infection, changes in color, taste, smell or amount
    Sputum production
  27. Diaphragm pulled to resting position
  28. Clear and white sputum can be indicative of _____ infection
  29. Tan, yellow or green sputum production is indicative of:
    Bacterial infection
  30. An active process that requires energy
  31. Pain that increases with deep breathing suggests;
    Pleuritic disorder
  32. _______ rises to about T1 level posteriorly
  33. During inspiration ______ takes place:
    • Diaphragm descends about 1.5 cm & flattens.
    • Abdominal contents lowered to increase intrathoracic space.
    • Intercostal muscles contract, increasing AP diameter.
    • Inyrathoracic volume increases.
    • intrathoracic pressure decreases, drawing air into lungs.
    • Deep inspiration about 5-6cm (about T12)
  34. Chest pain may have _____, ______, or ______ origin
    • Pulmonary
    • Cardiac or
    • MS
  35. Loud, musical sound produced by upper airway obstruction (larynx or trachea).
    Becomes inspiratory and expiratory as airway becomes more obstructed
  36. With an intact CNS______ is a relatively passive process
  37. This suggests left ventricular failure
  38. With aging, Chest wall becomes
    • Stiffer and harder to move
    • Respiratory muscles may weaken.
    • Decreased cough reflex increases risk of aspiration
  39. Cheyne-stokes
    End of life
  40. Cyanosis is a late sign of
  41. Respiration common in people with severe anxiety attacks, metabollic acidocis characterized by hyperpnea and hyperventilation, no pauses (fast and deep)
    Kussmaul's respiration
  42. Maladorous breath is due to:
    Intrathoracic infection
  43. Crepitus;
    Crackling sensation, like bones or hairs rubbing together
  44. Occurs when air passes through fluid or exudate or if air escapes from lung or other airways into subcutaneous tissue
  45. Diaphragm relaxes and elastic recoil properties of lungs expel air
  46. Used when diaphragm and external intercostal muscles are ineffective
    Accessory muscles
  47. Anteriorly, posteriorly and laterally 2 lobes
    Left lung
  48. Intercostal retraction during inspiration;
  49. Intercostal bulging during expiration (indicates trapped air)
  50. Shortness of breath.
    Breathing cannot meet body's metabollic needs for O2
  51. normal respiration
    12 -20 breaths per min
  52. entirely or predominantly inspiratory wheeze
  53. Severe atelectasis
    Collapse or incomplete expansion as in pnuemonia and chest trauma
  54. Where is thoracic expansion (respiratory excursion) done
    • T10 posteriorly; anteriorly, thumbs along costal margin pointing toward xiphoid process.
    • Thumbs diverge during quiet and deep breathing, 4-6 cm, symmetrical with no lag
  55. Vibrations of air in bronchial tubes transmitted to chest wall,
    dependent on intensity and pitch of voice
    position and distance of bronchi in relation to chest wall
    usually felt by examiner when examinee is saying "99"
    Tactile fremities
  56. Permanent hyper inflation of lung beyond terminal bronchioles, with destruction of alveolar walls
  57. Normal breath sounds in trachea
    • Very loud, high pitched, coarse(harsh) and hollow sounds
    • Inspiration=expiration with short pauses because airflow encounters little resistance
  58. Normal bronchial breath sounds
    • Loud, high pitched, harsh or hollow
    • Expiratory sound last longer than inspiratory[E > I]
  59. If bronchial sounds heard over peripheral lung tissue, suspect
    • Air-filled lungs replaced with fluid-filled or solid lung tissue
    • Abnormal
  60. Combination of bronchial and vesicular
  61. Normal bronchovesicular breath sounds
    • Intensity and pitch of expiratory sound intermediate
    • I = E, with no pause
  62. Bronchovesicular breath sound location anteriorly and posteriorly
    • Anteriorly- 1st and 2nd ICS at sternal border over major bronchi
    • Posteriorly- between scapula at T4
  63. Location of Bronchial breath sound
    Just below the clavicles on each side of sternum, next to trachea and over manubrium
  64. Location of Vesicular breath sounds
    • Over lesser bronchi, bronchioles and lobes
    • In areas away from larger airways in healthy lung tissue
  65. Normal vesicular breath sounds
    • Soft, low pitched, breezy or swishing quality
    • I > E, long in inspiration and short in expiration, with no pause between sounds.
    • usually diminished in overweight or very muscular person
  66. Crackles
    Intermittent, non-musical and brief sounds
  67. Fine crackles
    • High-pitched, discrete or discontinuos cracklin (popping) sounds
    • Very brief dots in time (5-10sec)
    • Does not clear with cough
  68. Medium crackles
    • Lower, more moist sounds in mid inspiration
    • Does not clear with cough
  69. This abnormal breath sound may indicate pneumonia or pulmonary edema
    Is loud, lower pitched with bubbly noise during inspiration
    May persist from early inspiration to early expiration
    Coarse crackles
  70. 2 categories of wheezes
    sibilant and sonorous
  71. Wheezes are
    Continuous sounds
  72. Stridor loudest in _________ while wheezing loudest in ________
    one side of neck, over trachea, below cricoid cartiage, chest
  73. Airflow through fluid filled passages
    occurs in inspiration
  74. Airflow through inflammed, constricted passages
    Occurs in expiration
  75. Air passing rapidly through constricted passages caused by swelling, secretions or tumor
    Siblilant wheezes
  76. Prolonged (longer than crackles), high pitched, musical or whistle sound heard during expiration
    may also be heard on expiration
    May be indicative of acute asthma or chronic emphysema
    Sibilant wheezes
  77. This was fromerly called Ronchi
    Sonorous wheezes
  78. Low pitched snoring sound or moaning quality
    heard primarily during expiration but may be heard throughout respiratory cycle
    sonorous wheezes
  79. This may clear with cough usually indicating mucus accumulation in trachea or large bronchi
    snoring before episode of sleep apnea
    sonorous wheezes
Card Set
nursing assessment
assessment of thorax and lungs