which respiratory assessment finding would the nurse report as abnormal for an adult patient?

Auscultation findings for common disorders An older adult with pneumonia or consolidation may also have abnormal voice sounds such as bronchophony. Assess this by having your patient say “ninety-nine” as you auscultate his lungs.

Full Answer

What data does a nurse collect during a respiratory assessment?

With an understanding of the basic structures and primary functions of the respiratory system, the nurse collects subjective and objective data to perform a focused respiratory assessment. Collect data using interview questions, paying particular attention to what the patient is reporting.

What is an abnormal assessment of the respiratory system?

This abnormal assessment finding may be the patient’s baseline or normal and might also include wheezes and fine crackles as a result of chronic excess secretions and/or bronchoconstriction. [10],[11] See Table 10.3b for a comparison of expected versus unexpected findings when assessing the respiratory system.

What is included in a respiratory assessment?

A thorough respiratory assessment consists of inspection, palpation, percussion, and auscultation in conjunction with a comprehensive health history. Use a systematic approach and compare findings between left and right so the patient serves as his own control. If possible, have him sit up. Is 30 breaths a minute normal?

How do you assess the respiratory rate of a newborn?

Attempt to assess an infant’s respiratory rate while the infant is at rest and content rather than when the infant is crying. Counting respirations by observing abdominal breathing movements may be easier for the novice nurse than counting breath sounds, as it can be difficult to differentiate lung and heart sounds when auscultating newborns.

Which of the following are abnormal findings of a respiratory assessment?

Signs of abnormal breathing include:Crackling, popping, or bubbling sounds, which may indicate pneumonia or pulmonary edema.Wheezing, which can signal pulmonary disease, asthma, allergies, or an infection.Pleural friction. This grating sound occurs when the pleural surfaces rub together and suggests pneumonia.

What are abnormal breath sounds called?

Adventitious sounds are the medical term for respiratory noises beyond that of normal breath sounds. The sounds may occur continuously or intermittently and can include crackles, rhonchi, and wheezes.

Which breath sounds would the nurse consider normal?

Normal findings on auscultation include: Loud, high-pitched bronchial breath sounds over the trachea. Medium pitched bronchovesicular sounds over the mainstream bronchi, between the scapulae, and below the clavicles. Soft, breezy, low-pitched vesicular breath sounds over most of the peripheral lung fields.

When performing a respiratory assessment on a patient the nurse notices?

The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest. When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees.

What does wheezing sound like in adults?

Wheezing is simply a whistling sound made when breathing. It is typically heard when a person exhales (breathes out) and sounds like a high-pitched whistle. Sometimes it is heard when inhaling — or breathing in — as well. It is not simply loud breathing or the sound of congestion or mucus when you breathe.

What does crackles in the lungs mean?

Crackles occur as a result of small airways suddenly snapping open. They may indicate that a person's lungs have fluid inside them or are not inflating correctly.

What are the 4 respiratory sounds?

The 4 most common are:Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales). ... Rhonchi. Sounds that resemble snoring. ... Stridor. Wheeze-like sound heard when a person breathes. ... Wheezing. High-pitched sounds produced by narrowed airways.

Which assessment finding of the respiratory system is considered normal?

Normal/ideal values The rate of respiration will vary with age and gender. A respiratory rate of 12-18 breaths per minute in a healthy adult is considered normal (Blows, 2001). Tachypnoea: the rate is regular but over 20 breaths per minute. Bradypnoea: the rate is regular but less than 12 breaths per minute.

What are 3 types of normal breath sounds?

Breath sounds are classified into normal tracheal sound, normal lung sound or vesicular breath sounds, and bronchial breath sound.

How do you assess respiratory distress?

Two BLS vital sign measurements that are helpful in assessing and monitoring the degree of respiratory distress are respiratory rate and oxygen saturation. Tachypnea in adults is generally defined as a respiratory rate greater than 25 breaths per minute.

When do you hear coarse crackles?

Coarse crackles are heard during early inspiration and sound harsh or moist. They are caused by mucous in larger bronchioles, as heard in COPD. Fine crackles are heard during late inspiration and may sound like hair rubbing together.

What is the normal respiration rate for adults?

Respiration rates may increase with fever, illness, and other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing. Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.

What is the assessment technique that produces sounds by the examiner tapping on the patient's chest wall?

Percussion is an assessment technique which produces sounds by the examiner tapping on the patient's chest wall. Just as lightly tapping on a container with your hands produces various sounds, so tapping on the chest wall produces sounds based on the amount of air in the lungs.

What is the purpose of respiratory assessment?

THE PURPOSE of respiratory assessment is to ascertain the respiratory status of the patient and to provide information related to other systems such as the cardiovascular and neurological systems. Breathing is usually the first vital sign to alter in the deteriorating patient.

Why should a nurse document chest excursion?

Rationale: Because chest excursion should be symmetric, i.e., equal on both sides, the nurse should document this normal finding on the assessment record. No additional intervention is warranted. If the chest excursion is asymmetric, the nurse should take further action to determine the cause of the asymmetry.

Is confusion an indicator of oxygenation?

Rationale: Confusion may be an indicator of decreasing oxygenation, especially in the older person. Based on the client's signs of worsening pneumonia coupled with the confusion, his respiratory rate and effort along with his oxygen saturation level should be obtained before the nurse contacts the HCP.

What is objective assessment of respiratory function?

A focused respiratory objective assessment includes interpretation of vital signs; inspection of the patient’s breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds using a stethoscope.

What is the normal respiratory rate for an adult?

The normal range of a respiratory rate for an adult is 12-20 breaths per minute at rest, and the normal range for oxygen saturation of the blood is 94–98% (SpO₂) [3] is less than 12 breaths per minute, and is greater than 20 breaths per minute.

How many breaths per minute is considered a normal lifespan?

Rapid breathing greater than 20 breaths per minute in and adult or outside the range expected for lifespan considerations, and often shallow.

How many breaths per minute for a child?

The respiratory rate in children less than 12 months of age can range from 30-60 breaths per minute, depending on whether the infant is asleep or active.

How long do babies breathe?

Infants have irregular or periodic newborn breathing in the first few weeks of life; therefore, it is important to count the respirations for a full minute. During this time, you may notice periods of lasting up to 10 seconds. This is not abnormal unless the infant is showing other signs of distress.

How to listen to the movement of air through the airways during inspiration and expiration?

Auscultation. Using the diaphragm of the stethoscope, listen to the movement of air through the airways during inspiration and expiration. Instruct the patient to take deep breaths through their mouth. Listen through the entire respiratory cycle because different sounds may be heard on inspiration and expiration.

What is the purpose of percussion?

Percussion is an advanced respiratory assessment technique that is used by advanced practice nurses and other health care providers to gather additional data in the underlying lung tissue. By striking the fingers of one hand over the fingers of the other hand, a sound is produced over the lung fields that helps determine if fluid is present. Dull sounds are heard with high-density areas, such as pneumonia or