nursing assessment

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

It articulates and supports clavicles and it is located at the sternum

Where is the site for the attachment of the 2nd rib

Junction of manubrium and sternal body

ICS named according to rib immediately superior

Coastal ridges of _____ articulate with sternal body

Ribs 8-10

____ rib tip is located in lateral thorax

What ribs are unattached and termed floating ribs

Location of of 12th rib tip

In women, this process of respiration is more costal

All ribs articulate with thoracic vertebrae-

Respiration tend to be more diaphragmatic, with more use of abdominal muscles in men, children and when sleeping

Anteriorly, 3 lobes, middle underlies breast.
Posteriorly and laterally, 2 lobes

The angle formed by blending together of coastal margins at the sternum, usually less than 90 degrees and widens with chest barreling

Posteriorly tip of scapulae is usually at

Bifurcation of trachea into right and left main bronchi is at

Main bronchi divide into ____ on right lobe and _______ on left lobe

What main bronchus is wider, shorter, more vertically placed and more susceptible to aspiration of foreign bodies

Primary muscles of respiration

Extends anteriorly about 2-4cm above 1st rib into base of neck

In this process of respiration, lower borders rise to about T9, when forced

Where is the diaphragm located posteriorly, laterally, and anteriorly

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

About 2-4 cm above inner 1/3rd of clavicle also called kronig's isthmus

_______ 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

Diaphragm pulled to resting position

Clear and white sputum can be indicative of _____ infection

Tan, yellow or green sputum production is indicative of:

An active process that requires energy

Pain that increases with deep breathing suggests;

_______ rises to about T1 level posteriorly

During inspiration ______ takes place:

Chest pain may have _____, ______, or ______ origin

Loud, musical sound produced by upper airway obstruction (larynx or trachea).
Becomes inspiratory and expiratory as airway becomes more obstructed

With an intact CNS______ is a relatively passive process

This suggests left ventricular failure

With aging, Chest wall becomes

Cheyne-stokes

Cyanosis is a late sign of

Respiration common in people with severe anxiety attacks, metabollic acidocis characterized by hyperpnea and hyperventilation, no pauses (fast and deep)

Maladorous breath is due to:

Crepitus;

Occurs when air passes through fluid or exudate or if air escapes from lung or other airways into subcutaneous tissue

Diaphragm relaxes and elastic recoil properties of lungs expel air

Used when diaphragm and external intercostal muscles are ineffective

Anteriorly, posteriorly and laterally 2 lobes

Intercostal retraction during inspiration;

Intercostal bulging during expiration (indicates trapped air)

Shortness of breath.
Breathing cannot meet body's metabollic needs for O2

normal respiration

entirely or predominantly inspiratory wheeze

Severe atelectasis

Where is thoracic expansion (respiratory excursion) done

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"

Permanent hyper inflation of lung beyond terminal bronchioles, with destruction of alveolar walls

Normal breath sounds in trachea

Normal bronchial breath sounds

If bronchial sounds heard over peripheral lung tissue, suspect

Combination of bronchial and vesicular

Normal bronchovesicular breath sounds

Bronchovesicular breath sound location anteriorly and posteriorly

Location of Bronchial breath sound

Location of Vesicular breath sounds

Normal vesicular breath sounds

Crackles

Fine crackles

Medium crackles

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

2 categories of wheezes

Wheezes are

Stridor loudest in _________ while wheezing loudest in ________

Airflow through fluid filled passages
Discontinuous
occurs in inspiration

Airflow through inflammed, constricted passages
Continous
Occurs in expiration

Air passing rapidly through constricted passages caused by swelling, secretions or tumor

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

This was fromerly called Ronchi

Low pitched snoring sound or moaning quality
heard primarily during expiration but may be heard throughout respiratory cycle

This may clear with cough usually indicating mucus accumulation in trachea or large bronchi
snoring before episode of sleep apnea