NR 302 Chapter 15 - Respiratory System

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1. Mediastinum Middle section of thoracic cavity. 16. Wheezes High pitched, continuous. Occur on
Contains the heart, trachea, esophagus, (sibilant) expiration and inspiration when severe.
and major blood vessels of the body Caused by blocked airflow as in asthma,
2. Pleural Cavity Each contains a lung infection, or foreign body obstruction

3. Inspiration Active phase. For air to enter the body, 17. Stridor Loud, high pitched crowing heard without
respiratory muscles contract, the chest stethoscope. Occurs on inspiration.
expands, alveolar pressure decreases Caused by obstructed upper airway.
and the negative intrapleural pressure 18. Friction Rub Low pitched, grating, rubbing. Occurs on
increases --> allowing air to enter the inspiration and expiration. Caused by
lungs pleural inflammation
4. Expiration Passive phase. The activities reverse 19. Tachypnea -Rapid, shallow respirations.
themselves, the lungs recoil --> air leaves -Rate >24
the body -Fever, fear, exercise, respiratory
5. Eupnea Regular, even depth, rhythmic pattern of insufficiency, pleuritic pain, alkalosis,
inspiration and expiration. Normal pneumonia
breathing 20. Bradypnea -Slow, regular respirations.
6. Dyspnea A change in eupnea, producing shortness -Rate <10
of breath (SOB) or difficulty in breathing -Diabetic coma, drug induced respiratory
depression, increased intracranial
7. Fremitus Palpable vibration on the chest wall pressure
when client speaks. Strongest over the
trachea, diminishes over the bronchi, and 21. Hyperventilation -Rapid, deep respirations
becomes almost nonexistent over the -Rate >24
alveoli of the lungs -Extreme exertion, fear, diabetic
ketoacidosis (Kussmaul's), hypoxia,
8. Resonance Long, low pitched hollow sound. Usual salicylate overdose, hypoglycemia
sound in the thorax
22. Hypoventilation -Irregular, shallow respirations
9. Tracheal Sounds Harsh, high pitched . Heard when the -Rate <10
client inhales and exhales -Narcotic overdose, anesthetics,
10. Bronchial Sounds Loud, high pitched heard next to the prolonged bed rest, chest splinting
trachea. Are louder on exhalation 23. Cheyne-Stokes -Periods of deep breathing alternation
11. Bronchovesicular Medium in loudness and pitch. Heard with periods of apnea
Sounds between the scapula, posteriorly and -Regular Pattern
next to the sternum, and anteriorly upon -Normal children and aging, heart failure,
inhalation and exhalation uremia, brain damage, drug induced
12. Vesicular Sounds Soft, low pitched. Heard over the respiratory depression
remainder of the lungs. Longer on 24. Biot's (Ataxic) -Shallow, deep respirations with periods
inhalation than exhalation Respirations of apnea
13. Adventitious Breath sound that is not normally heard -Irregular Pattern
Sounds -Respiratory depression, brain damage

14. Rales/Crackles End inspiration, do not clear with cough. 25. Sighing -Frequent sighing
Caused by collapsed or fluid-filled -Precipitating factors: hyperventilation
alveoli open. syndrome, nervousness
FINE: High pitched, short, crackling -Causes: dyspnea, dizziness
COARSE: Loud, moist, low pitched, 26. Barrel Chest The anteroposterior diameter is equal to
bubbling the lateral diameter, and the ribs are
15. Ronchi Low pitched, continuous, snoring, rattling. horizontal. Occurs with aging and in
(sonorous) Occur on both expiration and inspiration. COPD
Change/disappear with cough. Caused 27. Funnel Chest Congenital deformity characterized by
by fluid-blocked airways (Pectus depression of the sternum and adjacent
Excavatum) costal cartilage. (Sunken in)
28. Kyphosis Exaggerated posterior curvature of the
thoracic spine. Associated with aging. May
decrease lung expansion and increase cardiac
problems
29. Asthma Chronic, hyperactive condition resulting in
broncospasm, mucosal edema and increased
mucus secretion. Usually occurs in response to
inhaled irritants or allergens.
INSPECTION: Dyspnea, increased respiratory
rate, use of accessory muscles, anxiety,
audible wheeze, prolonged expiration
PALPATION: Decreased tactile fremitus
PERCUSSION: Resonance. Hyperresonance
when chronic
AUSCULTATION: Breath sounds obscured by
wheezes. Decreased voice sounds. In severe
asthma, air movement may be so limited that
no breath sounds are heard
30. Atelectasis Condition in which there is an obstruction of
airflow. The alveoli or entire lung may collapse
from airway obstruction, such as a mucous
plug, lack or surfactant or a compressed chest
wall.
INSPECTION: Decreased lung expansion on
the affected side, increased respiratory rate,
dyspnea, cyanosis. If severe, the trachea shifts
to the affected side.
PALPATION: Lack of tactile fremitus
PERCUSSION: Dullness over the affected area
AUSCULTATION: Decreased or absent breath
sounds and voice sounds
31. Chronic Chronic inflammation of the tracheobronchial
Bronchitis tree leads to increased mucus production and
blocked airways. Productive cough present.
INSPECTION: Dyspnea, chronic productive
cough, tachypnea, use of accessory muscles
PALPATION: Normal tactile fremitus
PERCUSSION: Resonance
AUSCULTATION: Wheezes and rhonchi may
be present
32. Emphysema Condition in which chronic inflammation of the
lungs leads to destruction of alveoli and
decreased elasticity of the lungs. As a result,
air is trapped and lungs hyperinflate.
INSPECTION: SOB especially on exertion,
barrel chest, pursed lip breathing, use of
accessory muscles, cyanosis, clubbing of
fingers, tripod posture
PALPATION: Decreased chest expansion,
decreased tactile fremitus
PERCUSSION: Hyperresonance
AUSCULTATION: Decreased vesicular sounds
and possible wheeze
33. Lobar An infection causes fluid, bacteria and
Pneumonia cellular debris to fill the alveoli.
INSPECTION: Tachypnea, productive cough,
chills
PALPATION: Increased tactile fremitus,
decreased chest expansion of the affected
side
PERCUSSION: Dullness over the affected
area
AUSCULTATION: Bronchophony, egophony,
whispered pectoriloquy, bronchial breath
sounds and crackles
34. Pleural Fluid accumulates in the pleural space.
Effusion INSPECTION: Dyspnea. In severe effusion,
tracheal shift to the affected side
PALPATION: Decreased tactile fremitus and
chest expansion on affected side
PERCUSSION: Dullness over the fluid
AUSCULTATION: Breath sounds and voice
sounds decreased or absent. Possible
pleural rub
35. Pneumothorax Condition in which air moves into the
pleural space and causes partial or
complete collapse of the lung. Can be
spontaneous, traumatic or tension.
INSPECTION: Tachypnea, decreased
expansion of the chest wall on affected
side, tracheal shift to UNaffected side
PALPATION: Decreased tactile fremitus
PERCUSSION: Hyperresonance
AUSCULTATION: Breath sounds and voice
sounds are decreased or absent
36. Congestive Increased pressure in the pulmonary veins
Heart Failure cause interstitial edema around the alveoli
and may cause edema of the bronchial
mucosa.
INSPECTION: Increased respiratory rate,
SOB especially on exertion, orthopnea,
peripheral edema, pallor
PALPATION: Normal tactile fremitus. Skin
cool and clammy
PERCUSSION: Resonance
AUSCULTATION: Normal breath sounds
and voice sounds, wheezes or crackles at
the bases of the lungs
37. An eight- 2. This is normal finding during the third 38. The nurse is 1. Above the clavicles.
month- trimester of pregnancy. auscultating -The apex (superior portion) of each lung is
pregnant -As the uterus enlarges during pregnancy, the apices of slightly superior to the inner third of the
female is the pressure in the abdominal cavity also the lungs. In clavicle. Below the scapula, the lower lobes
sitting increases. As a result, diaphragmatic which area would be assessed. Anteriorly, at the third
quietly, her excursion is limited and can result in more should the intercostal space, the upper lobes would be
respiratory rapid and shallow respirations. Maternal nurse place assessed. The base of the lungs is located
rate is 20 respiratory rate increases approximately two the posteriorly at the level of T10.
and shallow. breaths per minute. Shortness of breath and stethoscope?
She states dyspnea, especially in the last trimester, are
that she common as the maternal and fetal demand 1. Above the
feels short of for oxygen increases. This is a normal finding clavicles
breath. What and doesn't require pulse oximetry readings. 2. Below the
does this Use of accessory muscles to assist in scapula
finding respiration suggests a pathological condition, 3. Anteriorly,
suggest to not a normal finding in pregnancy. at the third
the nurse? intercostal
space
1. The nurse 4. On the
should check posterior
the pulse chest at the
oximetry level of T10
reading 39. A client with 4. The strained muscle is an accessory muscle
since this is a strained of respiration.
not a normal trapezius -The accessory muscles of the neck
finding for muscle (trapezius, scalene, and sternocleidomastoid),
an eight- complains of abdomen (rectus), and chest (pectorals) assist
month- having the respiratory cycle as necessary, especially
pregnant occasional during respiratory distress and conditions of
woman. shortness of pathology. Tachypneic respirations are rapid,
2. This is a breath. What shallow respirations >24 breaths per minute.
normal might be the The pleural membranes consist of the visceral
finding reason for and parietal pleura, which cover the thoracic
during the this wall and lungs. They are not related to the
third symptom? trapezius muscle. The diaphragm and internal
trimester of and external intercostal muscles are the
pregnancy. 1. He is primary muscles of breathing.
3. Due to her experiencing
feeling of occasional
shortness of periods of
breath, she is tachypnea.
using her 2. He may
accessory have
muscles to inflammation
breathe. of the
4. This is an pleural
abnormal membranes.
finding and 3. The
suggests that diaphragm
the fetus muscle is
may be at also injured.
risk for 4. The
decreased strained
oxygenation. muscle is an
accessory
muscle of
respiration.
40. When performing a 2. The Angle of Louis. 42. When 1. Considers these normal findings for a
respiratory -The manubrium joints the body of the performing an child of this age.
assessment, the sternum and forms a horizontal ridge assessment on a -During childhood, the chest is usually
nurse palpates the referred to as the sternal angle or four-year-old, round (cylindrical) with the lateral and
sternum and feels a angle of Louis, which is at the level of the nurse notes anterior-posterior diameters being almost
horizontal ridge on the second rib anteriorly. The that the child's equal. Abdominal breathing is normal in
the sternum at the manubrium is the superior portion of chest is childhood until about 5 to 7 years of age.
level of the second the sternum. The xiphoid process is the cylindrical in Costal breath is the expected pattern
rib. The nurse inferior portion of the sternum. The shape and the after 7 years of age. The round
identifies this body of the sternum lies between the child is using the appearance of the chest is a normal
structure as: Angle of Louis and the xiphoid abdominal finding for a child until the age of seven.
process. muscles to There is no need to notify the health care
1. The manubrium of breathe. The provider since these are normal findings
the sternum nurse: for a child of this age.
2. The Angle of
Louis 1. Considers
3. The xiphoid these normal
process findings for a
4. The body of the child of this age
sternum 2. Knows that a
41. The nurse is 4. Scapular line. child of this age
assessing the -The upper lobes posteriorly are should
client's upper lobes located between T1 and T4. The demonstrate
posteriorly. At vertebral line extends from the tip of costal breathing
which area can the the scapula to T10, which is the area of patterns
nurse assess this the lower lobes posteriorly. The lungs 3. Considers the
portion of the lung? are not assessed directly over the shape of the
scapula, but between the scapulae. child's chest to
1. Vertebral line The level of T8 is the area of the lower be an abnormal
2. Over the scapula lobes. finding
3. Right anterior 4. Performs a
axillary line complete
4. Scapular line respiratory
assessment
before calling
the health care
provider
43. When performing a 1. A normal finding. 45. When performing a 3. Considers these normal
respiratory -The normal costal angle of any age respiratory assessment on bronchovesicular breath
assessment on a client is less than 90 degrees. A client an adult client, the nurse sounds for this location.
60-year-old client, with an AP:T ratio of 1: 1 has a barrel notes breath sounds that -Bronchovesicular breath
the nurse notes a chest-the costal angle would be are of medium pitch and sounds are normally located
costal angle of greater than 90 degrees in this loudness with the ratio of near the sternal border and
approximately 90 situation. A long-standing history of inspiration to expiration between the scapulae. They are
degrees. The nurse smoking may cause emphysema, which being equal near the of medium loudness and pitch
considers this could cause the costal angle to be anterior sternal border. and have an equal ratio of
finding: greater than 90 degrees. The normal The nurse: inspiration to expiration. This is
costal angle is less than 90 degrees a normal finding; a more in-
1. A normal finding regardless of age. 1. Knows that these are depth assessment is not needed
2. An abnormal bronchial breath sounds at this time.
finding for a client and an expected finding
unless they have a for this area of the chest Bronchial breath sounds are
history of smoking 2. Documents the located next to the trachea.
3. A change related presence of vesicular They are loud and high-pitched
to aging breath sounds with expiration longer than
4. Related to 3. Considers these normal inspiration. Vesicular breath
emphysema bronchovesicular breath sounds are located throughout
44. When performing a 1, 4, 5. sounds for this location the lungs, and are soft and low-
respiratory -Shallow breathing: Bilateral 4. Performs a more in- pitched with the inspiratory
assessment, the diminished breath sounds may indicate depth respiratory phase being longer than the
nurse notes that the shallow breathing. assessment based on expiratory phase.
breath sounds are -Pneumothorax: This condition of air in these findings
diminished the pleural space would cause
throughout all lung diminished breath sounds over the
fields. This finding affected area, but not throughout all
may indicate which lung fields.
of the following? -Pneumonia: This condition would
Select all that cause increased breath sounds due to
apply. the consolidation present over a
specific area.
1. Shallow breathing -Bronchospasm: This condition can
2. Pneumothorax cause diminished lung sounds
3. Pneumonia throughout the lung fields.
4. Bronchospasm -Emphysema: This condition of air
5. Emphysema trapping in the alveoli causes
diminished breath sounds throughout
the lung fields.
46. After completing 2. Considers these normal findings. 48. The nurse notes 1. Cheyne-Stokes respirations.
a respiratory -Normal assessment findings include an that a client has -Cheyne-Stokes respirations are
assessment, the AP:T diameter of 1:2, bilateral periods of deep periods of deep breathing alternating
nurse documents symmetrical chest expansion, a breathing with periods of apnea. Precipitating
the following respiratory rate between 12 to 20, and alternating with factors include aging, heart failure,
findings: AP:T vesicular breath sounds. These are periods of apnea. uremia, brain damage, and drug-
diameter 1:2, normal findings and do not suggest a The nurse induced respiratory depression.
symmetrical respiratory infection. Vesicular breath documents the Dyspnea is shortness of breath or
chest expansion, sounds are the predominant breath presence of which difficulty breathing. Obstructive
respiratory rate sound auscultated in the lung fields. of the following? breathing has a prolonged expiratory
16 and regular, Percussion for areas of hyperresonance phase and is seen in conditions such as
vesicular breath is heard in conditions of hyperinflation of 1. Cheyne-Stokes COPD, asthma, and chronic bronchitis.
sounds. The the lungs. Resonance would be the respirations Biot's respirations are shallow, deep
nurse: expected finding in this situation. 2. Dyspnea respirations with periods of apnea and
3. Obstructive an irregular pattern.
1. Suspects a breathing
potential 4. Biot's (ataxic)
respiratory respirations
infection 49. When assessing 1. Pulmonary consolidation (pneumonia)
2. Considers for the presence of -In the presence of bronchophony, the
these normal bronchophony, the words sound loud and more distinct
findings nurse notes that over areas of lung consolidation such
3. Performs a the words the as pneumonia. With a pneumothorax,
more in-depth client is speaking there is increased air in the pleural
respiratory are clear and space, not consolidation, so
assessment distinct over the bronchophony would not be present.
because of the left upper lobe. Bronchophony is not present with
abnormal breath This assessment emphysema (air trapping within the
sounds finding suggests aveoli). Asthma causes decreased air
4. Percusses the the presence of movement in the lungs and not
lung fields for which of the consolidation or bronchophony.
areas of following
hyperresonance conditions?
47. When performing 3. The client cound have pneumonia.
an assessment, -Fremitus is the palpable vibration on the 1. Pulmonary
the nurse notes chest wall when the client speaks. consolidation
increased tactile Findings should be symmetrical with (pneumonia)
fremitus over the increased fremitus over the trachea and 2. Pneumothorax
lower left lung. major airways and diminished or 3. Emphysema
What is the nonexistent over the alveoli and lower 4. Asthma
significance of lung fields. Increased fremitus occurs
this finding? with fluid in the lungs or with an infection.
Unilateral increased fremitus is not a
1. This is a normal normal finding. Findings should be
finding. symmetrical. The conditions of
2. The client may pneumothorax and asthma cause
have a decreased or absent fremitus.
pneumothorax.
3. The client
could have
pneumonia.
4. The client may
have asthma.