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Actual Dx - (ANSWER)Actual Diagnosis related to (R/T) ________(Related Factors) as evidenced by (AEB)
________ (Defining Characteristics)
Risk - (ANSWER)Risk for __________as evidenced by _________ (Risk Factors).
Readiness - (ANSWER)Readiness for __________as evidenced by "_________" (Defining characteristics).
Asthma - (ANSWER)chronic hyper-reactive condition. Obstruction. Wheezing. Dyspnea, increased RR,
use of accessory muscles, anxiety, prolonged expiration.
Palpation- decreased tactile fremitus
Percussion- resonance. Hyperresonance with chronic.
Auscultation- wheezing, decreased voice sounds. Severe; no breath sounds.
Atelectasis - (ANSWER)obstruction of airflow. Increased RR, dyspnea, cyanosis, trachea shift to affected
side in severe cases.
Palpation- lack of tactile fremitus. decreased lung expansion on affected side
Percussion- dullness over affected area
Auscultate- absent or diminished but normal breath sounds bilaterally.
Chronic Bronchitis - (ANSWER)inflammation of tracheobronchial tree. Early morning, congested, chronic
productive cough. White or clear sputum. Wheezes or rhonchi. Dyspnea, tachypnea, use of accessory
muscles.
Emphysema - (ANSWER)COPD. Obstruction of the alveoli. Tripod posture. Use of accessory muscles.
Cyanosis. Clubbing of fingers. Pursed lip breathing. SOB on exertion.
Palpation- Absent or decreased tactile fremitus. Decreased chest expansion.
Percussion- Hyper-resonance.
Auscultate- diminished but normal breath sounds bilaterally, decreased vesicular sounds, wheezing.
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COPD - (ANSWER)>90 costal angle. Barrel chest AP=T. ↓ Tactile fremitus palp. Tripod posture. Use of
accessory muscles. Cyanosis. Clubbing of fingers. Pursed lip breathing. SOB on exertion.
Lobular Pneumonia - (ANSWER)infection of the alveoli, Consolidation. Tachypnea, congested, hacking,
productive cough, chills, chest pain with breathing. Mucosal edema. Sputum- rust.
Palpation- increased tactile fremitus. Decreased chest expansion on affected side.
Percussion- dullness over affected area.
Auscultation- Egophony changes e to a. Clear Whispered pectoriloguy & bronchophony. Bronchial
breath sounds and crackles.
Pleural effusion - (ANSWER)fluid in the pleural space. Dyspnea. Tracheal shift to unaffected side.
Palpation- Absent or decreased tactile fremitus. decreased chest expansion side affected.
Percussion- Dullness
Auscultation- unilateral lung sounds. Decreased/absent breath/voice sounds. Pleural rub.
Pneumothorax - (ANSWER)air in pleural space, collapse of the lung. Tachypnea, tracheal shift to
unaffected side.
Palpation- Decreased Tactile fremitus. Unilateral decrease or delay in respiratory expansion.
Percussion- Hyper-resonance
Auscultation- unilateral of normal lung sounds. Decreased/absent breath/voice sounds.
Congestive heart failure - (ANSWER)Increased pressure in the pulmonary veins causes interstitial edema
around the alveoli and may cause edema of the bronchial mucosa. Pulmonary congestion.
Increased respiratory rate, shortness of breath (especially on exertion), orthopnea, peripheral edema,
pallor. S3. Hypertrophy. Dry cough.
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.
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◦ Left-sided CHF - (ANSWER)lung symptoms. 1st Fatigue. Pink frothy sputum. Pulmonary edema.
Hypoxia. SOB, crackles/rales, cough, orthopnea, anxiety, confusion, PND. S3
Rt CHF - (ANSWER)peripheral symptoms. Skin pale, gray, or cyanotic; nausea, vomiting; pitting edema,
peripheral/bilateral edema, ascites, JVD, HJR, weak pulse, cool moist skin, decreased urine output,
increased B.P., weight gain, liver congestion. Cor Pulmonale
Crackles/Rales - (ANSWER)discontinuous, intermittent, non-musical, and brief. C-collapsed or fluid-filled
alveoli open. end inspiration, do not clear w cough.
Fine rales - (ANSWER)soft, high pitched, and very brief.
Coarse rales/crackles - (ANSWER)louder, moist, lower in pitch, longer, bubbling.
Wheezes (sibilant) - (ANSWER)inspiration/expiration when severe. continuous high pitched with a shrill
quality. C- blocked air flow; asthma, infection, foreign body obstruction.
Rhonchi (sonorous) - (ANSWER)Expiration/ inspiration. Change/disappear w cough. Continuous low
pitched with a snoring, rattling. Fluid-blocked airways.
Stridor - (ANSWER)inspiration. Loud high pitched crowing heard without stethoscope. Obstructed upper
airways.
Friction rub - (ANSWER)inhalation/exhalation. Low pitched grating, rubbing, pleural inflammation
Aortic stenosis - (ANSWER)narrowing of the aortic valve. Rheumatic heart DX, atherosclerosis,
congential.
Mitral regurgitation - (ANSWER)backflow of blood from lft ventricle into left atrium. Rheumatic fever,
MI.