NR 302 EXAM 3 STUDY GUIDE / NR302 EXAM 3 STUDY GUIDE : 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSING,
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Course
NR 302 (NR302)
Institution
CHAMBERLAIN COLLEGE OF NURSING
NR 302 EXAM 3 STUDY GUIDE / NR302 EXAM 3 STUDY GUIDE : 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSING,NR 302 EXAM 3 STUDY GUIDE / NR302 EXAM 3 STUDY GUIDE : 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSING,NR 302 EXAM 3 STUDY GUIDE / NR302 EXAM 3 STUDY GUIDE : 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSING,NR...
- Physical assessment of the respiratory system requires the use of inspection,
palpation, percussion, and auscultation.
- During each of the procedures, the nurse is gathering data related to the
client’s breathing and level of oxygenation.
- The nurse inspects skin color, structures of the thoracic cavity, chest
configuration, and respiratory rate rhythm and effort.
- Adults normally breathe at a rate of 12 to 20 breaths per minute. Infants and
children have higher rates, up to 40 breaths per minute in newborns.
- Normal Findings:
o Breathing should be even, regular, and coordinated. Chest movement
should be uniform; the structures of the thorax should be aligned and
the thorax should be symmetric.
o The sternum is midline and flat. The costal angle is less than 90
degrees in an adult.
o The vertebrae are midline and follow the pattern of cervical, thoracic,
and lumbar curves.
o The anterior to posterior diameter of the chest should be half of the
lateral diameter.
o Pink skin or pink undertones indicate normal oxygenation.
Assessment for pink-colored tongue or oral mucous membranes may
be required in dark-skinned individuals.
o The color of the skin of the thorax should be consistent with that of
the rest of the body.
- Physical Assessment:
o It begins with a client survey followed by inspection of the anterior
thorax and complete assessment of the posterior thorax.
o The assessment ends with palpation, percussion, and auscultation of
the anterior thorax
o The nurse includes the anterior, posterior, and lateral aspects of the
thorax when conducting each of the assessments.
, o Misalignment of clavicles may be caused by deviations in the vertebral
column such as scoliosis.
o Increase in the costal angle in an adult may indicate COPD
o The thorax of children is rounder than that of adults
o The adult transverse diameter is approximately twice that of the
anteroposterior diameter (AP:T =1:2). (Chest Configuration)
o Intercostal muscle retraction and prominent sternocleidomastoids
may be seen in respiratory distress.
o Respirations in the obese client may be shallow and rapid
o Use the finger pads to lightly palpate symmetric areas on the posterior
thorax.
Include the entire thorax by starting at the areas above each
scapula and move from side to side to below the 12th rib and
laterally to the midaxillary line on each side
Crepitus is a crunching feeling under the skin caused by air
leaking into subcutaneous tissue.
o Use the finger pads to palpate each spinous process.
Move to the left and right to identify ribs and intercostal spaces
from C7 through T12.
o Place the palmar surface of your hands, with thumbs close to the
vertebrae, on the chest at the level of T10 to palpate for respiratory
expansion
Pinch up some skin between your thumbs. Ask the client to
take a deep breath
Unilateral decrease or delay in expansion may indicate
underlying fibrotic or obstructive lung disease or may result
from splinting associated with pleural pain or pneumothorax.
o Use the ulnar surface of the hand or the palmar surface of the hand at
the base of the fingers at the metacarpophalangeal joints when
palpating for tactile fremitus
Fremitus is the palpable vibration on the chest wall when the
client speaks
Fremitus is strongest over the trachea, diminishes over the
bronchi, and becomes almost nonexistent over the alveoli of
the lungs.
Palpate and compare symmetric areas of the lungs by moving
from side to side from apices to bases while the client repeats
“Ninety-Nine”
Increased fremitus occurs with fluid in the lungs or in
infection.
o The usual sound in the thorax when over lung tissue is resonance, a
long, low-pitched hollow sound.
o An unexpected finding would be hyperresonance, which is heard in
conditions of overinflation of the lungs as in emphysema, or with
pneumothorax.
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