NCCC NUR 211 Test 1
Chest Assessment Abbreviations
IPPA - Inspection, Palpation, Percussion, Auscultation
Inspections
Look for deformities, retraction, symmetry, rate, rhythm of breathing, pursed lip breathing, use of
accessory muscles
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Palpation
an examination technique in which the examiner's hands are used to feel the texture, size,
consistency, and location of certain body parts
Observe for tenderness, abnormalities, elicit vocal and tactile fremitus
Percussion
tapping on a surface to determine the difference in the density of the underlying structure
Observe for dullness, flatness, resonance, hyper resonance, tympany
Auscultation
Listening with a stethoscope
Listen to both sides and compare tracheal, bronchial, bronchovesicular, vesicular
Tracheal Breath Sounds
,very loud, harsh sounds that are heard by listening over the trachea in the neck
Bronchial breath sounds
normal breath sounds made by air moving through the bronchi, harsh, tubular quality
Bronchovesicular breath sounds
inspiration is unchanged from that of vesicular breathing, but expiration is as loud, equal in
length and similar in pitch
fine crackles breath sounds
rales, sounds similar to rubbing hair together, can be found in CHF, emphysema, or pneumonia;
probably produced by reopening of small airways or alveoli that are collapsed during previous
expiration or fluid in the alveoli
coarse breath sounds
gurgles or rhonchi, continuous sound produced when air passes through narrowed bronchus;
found in COPD and CHF; gurgles heard on both inspiration and expiration; can change with
cough
wheeze breath sounds
whistling or sighing that results from narrowing of the lumen of the respiratory passageway;
Usually on expiration;
Asthma, COPD, foreign body aspiration
pleural friction rub
continuous, dry grating sound caused by inflammation of pleural surfaces and loss of lubricating
pleural fluid; produced when two inflamed surfaces rub together during respiration cycle; found
in pleurisy, TB, pulmonary infarction, pneumonia, or lung cancer
Front View Auscultation
RUL, LUL, LLL, RLL, RML
Back view auscultation
LUL, RUL, LLL, RLL
, How many points to check anteriorly during auscultation?
10 at minimum
fremitus
a palpable vibration from the spoken voice felt over the chest wall
Normal percussion sound in lung
Resonance
Egophony
"ee" to "ay" change
suggests lobar consolidation. (most common in patients with pneumonia)
The sound of the ee heard through the stethoscope; muffled is normal; clear ay is abnormal
Bronchophony
the spoken voice sound heard through the stethoscope, which sounds soft, muffled, and
indistinct over normal lung tissue; "99"
whispered pectoriloquy
a whispered phrase heard through the stethoscope that sounds faint and inaudible over normal
lung tissue
reasons to suction trach
wheezes crackles gurgling on inspiration or expiration audible without auscultation, unexplained
increase in work of breathing; vomiting, cyanosis, increased pulse and respirations
Nursing diagnosis for trach care
ineffective airway clearance; ineffective breathing pattern; altered O2/CO2
Yankauer Suction
a large filter-tipped rigid plastic suction catheter used mainly in the mouth or other large body
cavity; least invasive trach suction available; clean technique with gloves and goggles
Oral Airways bite block
