and Answers 100% Pass
inspect the chest - ✔✔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 - ✔✔midline trachea, costal angle, angle of ribs, intercostal spaces,
suprasternal notch
symmetry of chest - ✔✔thoracic expansion at costal angle, w/o use of accessory
muscles
hx questions for cc of resp issue - ✔✔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 - ✔✔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 - ✔✔term for abnormally shallow respirations
tachypnea - ✔✔term for resp rate greater than 20, but consistent and may occur during
hyperventilation; often a symptom of pain
bradypnea - ✔✔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 - ✔✔term for fast and deep, heavy respirations, can be caused by
exercise, anxiety, and CNS and metabolic diseases
hyperpnea - ✔✔term for abnormally deep respirations
kussmaul respirations - ✔✔deep and mostly rapid respirations, used to describe resp
effort of metabolic acidosis
cheyne stokes respirations - ✔✔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 - ✔✔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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