Guide Solutions
inspect the chest - ANSWER✔✔-without clothes on; 1st assess shape and size; 2nd
check for symmetry; 3rd thoracic landmarks; 4th color of skin; 5th check for
supernumerary nipples; 6th superficial venous patterns; and 7th observe for rib
prominence
thoracic landmarks - ANSWER✔✔-midline trachea, costal angle, angle of ribs,
intercostal spaces, suprasternal notch
symmetry of chest - ANSWER✔✔-thoracic expansion at costal angle, w/o use of
accessory muscles
hx questions for cc of resp issue - ANSWER✔✔-What is the nature of your cough?; Do
you produce any sputum?; Is your cough related to activity?; What position are you
most comfortable in?; How many pillows do you sleep with at night?; Is your SOB
related to activity?
normal respirations - ANSWER✔✔-rate between 12 to 20/min; ratio of resp to heart
beats= 1:4; pt should breathe easily, regularly w/o apparent distress; pattern should be
even, not too shallow or too deep
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, hypopnea - ANSWER✔✔-term for abnormally shallow respirations
tachypnea - ANSWER✔✔-term for resp rate greater than 20, but consistent and may
occur during hyperventilation; often a symptom of pain
bradypnea - ANSWER✔✔-term for resp rate less than 12; may indicate neurologic or
electrolyte disturbances, infection, or conscious response to protect against the pain of
pleurisy or other irritative pneumonia. Can also be 2/2 level of cardio fitness
hyperventilation - ANSWER✔✔-term for fast and deep, heavy respirations, can be
caused by exercise, anxiety, and CNS and metabolic diseases
hyperpnea - ANSWER✔✔-term for abnormally deep respirations
kussmaul respirations - ANSWER✔✔-deep and mostly rapid respirations, used to
describe resp effort of metabolic acidosis
cheyne stokes respirations - ANSWER✔✔-regular breathing with intervals of apnea by
crescendo decrescendo breathing; can be seen in sleeping pts, but mostly pts who are
very ill, esp with brain damage
biot respirations - ANSWER✔✔-irregular breathing that varies in depth and is
interrupted irregularly by intervals of apnea; associated with severe and persistent
increased intracranial pressure, resp compromise from drug poisoning, or brain
damage at the medulla and generally equals poor prognosis
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