4. SESSION 4.3: Thorax & Breast Flashcards
Four components of the anterior thoracic cage
- Suprasternal notch
- Sternum
- Manubriosternal angle
- Costal angle
Four components of the anterior thoracic cage
- Suprasternal notch
- Sternum
- Manubriosternal angle
- Costal angle (Less than 90 degrees. Greater than 90 degrees would be barrel chested. Under xiphoid process.)
Body has ___ pairs of ribs.
Body has ___ thoracic vertebrae.
12, 12
Name the three components of the sternum.
- Manubrium (top part)
- Body (middle)
- Xiphoid process (tiny bone at bottom)
First ___ pairs of ribs connect to the ___ with ______.
Ribs ___ & ___ are free-floating.
First 7 pairs of ribs connect with the STERNUM with COSTAL CARTILAGE.
Ribs 11&12 are free-flowing.
The tip of the scapulae come down around ____ (what vertebra?)
T8
What landmark is at C7?
Vertebra prominens – a little spinous process
What landmark is at 12th rib?
Palpate midway between spine and side to find the location free tip.
Anterior reference lines (3):
- Midline: “Midsternal line”
- “Midclavicular line” - At midpoint of clavicle (closer to armpit than to midline)
- In line with armpit: “Anterior axillary line”
Posterior reference lines (3):
- “Vertebral line” (middle of spine)
- “Scapular line” (midway between vertebral and axillary)
- “Posterior axillary line”
- What is the media steinum?
- What four components are included?
“The heart and the great vessels that lie between the lungs on either side”
- The heart
- The trachea
- The esophagus
- The great vessels
Lateral reference lines (3)
- “Posterior axillary line”
- “Mid-axillary line”
- “Anterior axillary line”
Right pleural cavity holds _____
Left pleural cavity holds ______
The right lung, the left lung.
How many lobes on the left lung?
How many lobes on the left side?
Which lung is shorter and why?
- Left lung = 2 lobes
- Right lung = 3 lobes
- Right lung is shorter because of the liver underneath.
Which lobe does a lot of nurses forget about? Why is this important?
Right middle lobe. This is the lowest draining spot of the right lung, so it is actually at a higher risk for infection or pneumonia.
The apex of the lung is _________
- About 3cm above the clavicle
Costa diaphragmatic recess
- Where is it?
- What is a problem that can happen here?
- A 3cm space below the lungs
- Pleural effusion - Too much fluid due to cancer or an infection
What is the pleura?
- Name the two types
- Why is this important?
Thin, slippery lining that forms an envelope around the lungs and the chest wall.
- Visceral pleura lines lungs themselves
- Parietal pleura lines inside of chest wall.
- Small amount of fluid to allow for movement.
Difference in R & L bronchi:
- Right main-stem bronchus is a little wider, shorter and staighter than left.
- Left has sort of an angle. It’s harder to aspirate things into the left side of the lung.
Where does the biforcation of the bronchi into right and left occur?
At the angle of louis
____ pressure occurs upon inhalation
____ pressure occurs upon exhalation
**what happens to the diaphragm?
NEGATIVE upon inhalation (forces air in, diaphragm contracts).
POSITIVE upon exhalation (forces air out, diaphragm relaxes and domes).
1) Morning cough is due to ________
2) Afternoon cough is due to ________
3) Congestive or hacking cough is due to ______ or ______
4) Dry cough is usually _________
1) Smoking
2) Irritant
3) Bronchitis or pneumonia
4) Cardiac-related
Costocondritis
- What is it?
- What happens?
- Inflammatory or rheumatic problem:
- CT between ribs and sternum becomes painful to the touch.
Subjective Data- Health History Questions
Seven things to ask about for the LUNG (7)
1) Cough
2) Dyspnea
3) Orthopnea
4) Chest pain with breathing
5) Hemoptysis
5) Past history of respiratory infections
6) Smoking history
7) Environmental exposure
What is dyspnea? (2)
- Shortness of breath
- Coughing more than every 12 words
What is orthopnea?
- What is it?
- How do you ask about it?
- Increased dyspnea while laying down.
- “How many pillows do you need to breathe comfortably at night?”
What happens if there is not enough fluid between the pleura?
Chest pain
- What is the word for coughing up blood?
- What two things will cause this?
HEMOPTYSIS
- Heart failure
- Pulmonary embolus
Six elements of pulmonary physical assessment
1) Inspection
2) Respiratory excursion
3) Palpate for tactile fremitus
4) Percuss for symmetry
5) Diaphragmatic excursion
6) Auscultate posterior chest
How do you identify a barrel chest? (2)
- Back to side ratio is less than 2:1 (Barrel chest is more like a 1:1 ratio)
- Costal angle is less than 90 degrees
What is “normal” respiration?
- 4 things to look for
- Facial expression indicates no discomfort
- Regular, even
- 10-20 breaths per minute
- Skin color consistent with ethnic background
_________is when the sternum dips in closer to heart (two causes)
Pectus excavatum
- usually due to long term smoking, chronic bronchitis.
Two facial expressions to look for with chronic obstructive pulmonary disease.
(1) Facial expression 1:
- Caused by what?
- 3 characteristics
(2) - Facial expression 2:
- Caused by what? (2)
- 3 characteristics
- “pink puffer” - severe emphysemia.
Significant dyspnea, thin, uses intercostal muscles. - “blue bloater” - was a chronic smoker, now has chronic bronchitis.
Air trapped in lungs, cyanosis, right heart failure.
Chronic obstructive pulmonary disease is associated with what two diseases?
- Chronic bronchitis
- Emphysema
Tachypnea
- Definition
- 3 causes
- Breathing faster than 24 respirations per minute
- Fever, pneumonia, exercise
Kussmaul
- Definition
- One cause
- Looks normal, but breaths are much deeper, labored
- Seen in diabetics with acidosis (trying to breathe off their CO2)
Bradypnea
- Define
- 2 causes
- Less than ten respirations per minutet
- Certain drugs
- Increased ICP
Cheyne-Stokes
- Definition
- 3 causes
- Breathing waxes and wanes with periods of apnea
- CHF, Renal failure, increased ICP
Name this condition:
- Quick and shallow breaths with apnea breaks
- Grim prognosis. End of life. [Severe trauma, heat stroke.]
Biot’s
How do you palpate for symmetric expansion (respiratory excursion)?
- Place both hands on posterior chest with thumbs at T9 and T10. When patient inhales, your hands should go down to T12.
What is tactile fremitus?
Vibration intensity felt or auscultated on the chest wall with certain spoken words (vocal fremitus). “Ninety nine.”
How do you plapate for tactile fremitus? (2)
What are you listening for? (1)
Why does this work?
- Use palmar base of finger or ulnar edge, touch chest while patient says ninety-nine
- Start over apices and palpate from side to side or compare sides
- Sound is conducted better through a dense or solid structure than porous so anything that increases density of lung will increase fremitus.
What do you percuss first in the lung exam? Where?
- Apices of the lungs
- Down about 9 places on the back
When conducting tactile fremitus:
- What is one thing that would cause the vibrations to be stronger?
- What is one thing that would cause the vibrations to be harder to detect?
- An accumulation as in pneumonia = vibrations are stronger
- If you have an analectasis (some reason the lung is not explanding) = vibrations are going to be harder to detect.
What sound do you hear if you percuss a barrel chest?
Hyperresonance. Longer, louder and deeper sound.
Diaphragmatic excursion
- Where?
- How large?
- What are you checking?
- The space around T10-T12
- 3-5cm. A person who does a lot of exercise might have even 7cm.
- Are lungs symmetrical?
Vesicular breath sounds
- Length of inspiration v. Expiration
- Sound (3)
- Normal location
- Problematic location
- Inspiration is about 2.5x longer than expiration
- Soft, low-pitched, breezy quality
- You hear these sounds in the main part of the lung (not along upper spine, not base of the spine)
- If you hear this in the bases of the lung, you should be worried about pneumonia.
Adventitious breath sounds
Breath sounds that are “additive” to normal breath sounds.
Bronchovesicular breath sounds
- Length of inspiration / expiration
- Pitch
- What do you hear?
- Where are they considered normal?
- Inspiration = expiration
- Pitch is moderate
- A blowing sound
- At the base of the lung.
Ronchi / Sonorous wheezes
- What does it sound like? (2)
- Mainly expiration or inspiration?
- Two causative disease processes
- Low pitched - like snoring
- Mainly expiration
- Bronchitis, single bronchus obstruction
Fine crackles (rales)
- 4 sound characteristics
- Disease processes (3)
- Soft, high-pitched, brief, like rubbing hair together by ear.
- Restrictive disease
- Pneumonia
- CHF
Siblant wheeze
- What does it sound like?
- Mainly inspiration or expiration?
- Disease process (2)
- Like a vibrating reed: Highly pitched, musical, squeaking
- mostly on expiration.
- Asthma, chronic emphysema
Stridor Wheeze
- What does it sound like?
- Mainly inspiration or expiration?
- Disease process (3)
- High pitched crowing
- Mainly inspiration
- Croup, acute epiglottis, foreign body inhalation
Bronchophony
- What does it sound like?
- When does it occur? (One disease)
- “99” is clear rather than muffled.
- Occurs with pneumonia
Bronchophony - abnormal
- What does it sound like? (3)
- When does it occur? (One disease)
- Low pitched
- Increased intensity as the pt talks louder
- “99” is clear rather than muffled.
- Occurs with pneumonia
Egophony.
- Define
- What does it sound like?
- What are you listening for?
- Lung is compressed by fluid, as in pleural effusion. Most sensitive sign for consolidation.
- High when abnormal, otherwise low.
- “E” to “A” changes when practitioner listens to vowel sounds through posterior lungs.
Front of the chest is mostly ________ breath sounds, except around the _________, and the _______ breath sounds around the trachea.
Vesicular
Media steneum
Bronchovesicular
Whispered pectoriloquy
- How do you test it?
- What will you hear?
- What might it indicate?
- Pt whispers “99”
- With stethoscope, it sounds high and clear rather than faint or absent
- May indicate consolidation
Five components of a normal lung
- Trachea is midline
- Tactile fremitus is normal
- Percussion is resonant
- Breath sounds are vesicular except perhaps over bronchi or trachea
- No adventitious sounds
CONSULTATION Atelectasis (Lobar instruction): Five things to look for
- Trachea may be shifted to one side
- Tactile fremitus: usually absent over area of obstruction
- Percussion: Dull over airless area
- Breath sounds: Usually absent when bronchial plug
- Adventitious sounds: None
CONSULTATION
Pneumonia: Five things to look for
- Trachea: Midline
- Tactile fremitus: Increased over involved area with bronchophony, egophony, whispered pectoriloquy
- Percussion: Dull over airless area
- Breath sounds bronchial over involved area
- Adventitious sounds: Late inspiratory crackles over involved area.
CONSULTATION
Bronchitis: Five things you’re looking for.
- Trachea: Midline
- Tactile fremitus: Normal
- Percussion: Resonant
- Breath sounds: Vesicular except perhaps over large bronchi or trachea
- Adventitious sounds: None or scattered coarse crackles in early inspiration and perhaps expiration, wheezes and rhonchi.
Emphysema
- Trachea: Midline
- Tactile fremitus: Decreased
- Percussion: Hyperresonant
- Breath sounds: Decreased to absent
- Adventitious sounds: None or scattered coarse crackles in early expiration; or wheezes and rhonchi associated with chronic bronchitis.
Asthma
- Very similar to _________
- 3 characteristics
Very similar to bronchitis, except asthma also gets bronchial spasms and edema in addition to mucus.
Pleural effusion
- Define
- Five things you look for.
Fluid compresses against the lung
- Trachea is shifted toward side opposite large effusion
- Tactile fremitus is decreased to absent
- Percussion is dull to flat over fluid
- Breath sounds are decreased to absent, but bronchial sounds may be heard near top of large effusion.
- Adventitious sounds: None, except for a possible rub.
Pneumothorax
- Two possible causes
- Five things to look for
- Two kinds of pneumothorax that collapse the lung: Rupture in lung wall or leak in chest wall.
- Trachea: Shifted toward opposite side if much air
- Tactile fremitus: Decreased to absent over pleural air
- Percussion: Hyperresonant to tympanic over pleural air
- Breath sounds: Decreased to absent over pleural air
- Adventitious sounds: None, except a possible pleural rub.
CHF
- Define
- Five things to look for
Gorged capillaries because the pressure is building back into the lungs from the heart.
- Trachea: Midline
- Tactile fremitus: Decreased
- Percussion: Resonant
- Breath sounds: Vesicular
- Adventitious sounds: Late inspiratory crackles in the dependent portion of lungs. Possibly wheezes.
External anatomy of the breast
- Lies between the 2nd and 6th rib
- Between sternal edge to mid axillary line
- The nipple is just below center
- The superior lateral corner called “tail of spence” projects up and into the axilla
Three types of tissue in the breast:
1) First tissue
- Tissue type
- Where is it located?
2) Second tissue
- Tissue type
- Function
3) Third tissue
- Location
** Which type predominates?
1) Glandiular tissue
- Located into 15-20 lobes surrounding the nipple
2) Fibrous bands of tissue
- including suspensatory ligaments (coopers) which support the glandular tissue
3) Adipose tissue
- Surrounds the breast tissue
* * Predominates the breast tissue.
Clinical points of reference (3)
- Look at the breast like a clock. “There is a mass at 12 O’clock”
- Sometimes discussed like quadrant.
- Flatten out the breast. Hand behind head, side supported by pillow.
Lymphatics: Axillary nodes (4)
- Central axillary nodes: Deep in axilla
- Pectoral nodes: Anterior, underneath pectoral muscles
- Subscapular nodes: Back of armpit
- Lateral axillary nodes: Against the humorous here
Breast health history questions (10)
1) Pain
2) Lump
3) Discharge from nipples
4) Rashes, redness
5) Swelling
6) Trauma
7) History of breast disease
8) Surgery
9) Breast cancer risk
10) Self-care behaviors (Perform self-breast-exam? Last mammogram?)
Objective data - physical exam of breast
- Six things
- Size and symmetry (usually one breast is larger than the other)
- Countour (masses, dimpling, flattening)
- Skin color, thickening, edema, venous pattern
Retraction maneuvers
- Hand over head
- Hands on waist, squeeze
- Bend forward
Inspection of the nipple
- 3 things to look at
- 4 negative things
- Size
- Shape
- Direction they point
- Discharge?
- Rashes?
- Ulcers?
- Alterations?
What is the word for an extra nipple?
Supernumerary nipple. Follows the milk line.
Breast palpatation
- Best positition is _______
- How long should this take?
- Motion
- Pay attention to:
- Best position is when tissue is flattened
- A thorough exam should take 3 minutes per breast or longer
- Concentric circles
- Pay attention to the tail of Spence
Bimanual breast palpation
- Used with large-breasted women.
- Because their breast tissue never lays very flat.
If any notes are present in the breast exam, note (6)
- Location
- Size
- Shape
- Consistency
- Mobility
- Distinctness
Fibroadenomas
- What are they?
- What age group usually gets them?
- Four characteristics.
- Benign masses in the breast.
- Usually age 15-25
- Usually firm, well delineated, non-tender, very mobile.
Fibrocystic breast
- What are they?
- What age group usually gets them?
- Four characteristics.
- Soft, tender, mobile lumps in the breast
- Age 50-30
- Usually elastic, well delineated, mobile, tender.
Breast cancer
- Configuration (4)
- What do you palpate (2)?
- What age group usually gets them?
- Usually single. Usually irregular or stellate. Not clearly deliniated.
- Firm or hard. Usually nontender.
- Age 30 or over, most common over 50
Tanner stages
Stages of breast growth, genitalia development for adolescent girls
What is the manubriosternal angle?
- Other name
- What is it?
- Where is it?
- “Angle of Louis”
- Small bridge of bone
- At base of manubrium, on the bone where the manubrium turns into the sternum. Located at the second rib and atria of the heart.
- Where is the costal angle?
- What should you check for with this?
- Less than 90 degrees.
- Greater than 90 degrees would be barrel chested.
- Under xiphoid process.
What is Hemoptysis?
- What four conditions cause it?
Coughing up blood
- Occurs with heart failure
- definitely with pulmonary embolus.
- Sometimes with bronchitis or pneumonia
______is when the sternum pokes out a little bit
Pectus carinatum
Vertebral issue, prevents the lungs from being able to fully inflate
Scholiosis
____ is a spine disorder in elderly, usually due to ______. Hunchback.
Kyphosis - usually due to osteoperosis
Four functions of changing chest size
- Supply Oxygen to body for energy production
- Remove CO2 as a waste product
- Maintain acid-base balances of arterial blood
- Maintain heat exchange
Bronchial (tubular) breath sounds
- Inspiration to expiration ratio
- What do they sound like?
- Where are they considered normal?
- Inspiration < Expiration (1:2)
- High pitch, Like air blown through a hollow tube
- Considered normal over the trachea
Coarse crackles
- How do they compare to fine crackles (3)?
- Sounds (3)
- Disease processes (3)
- Somewhat louder, lower, longer than fine crackles
- Bubbling, gurgling, velcro
- Pulmonary edema, pneumonia, atelectasis
Name the organ you would normally associate with each type of percussion resonance:
1) Resonant
2) Hyperresonant
3) Tympany
4) Dull
5) Flat
1) Over normal lung tissue
2) Over lungs with increased amount of air (child’s lung - abnormal in adult)
3) Air-filled viscus (eg stomach, intestine)
4) Dense organ (eg liver, spleen)
5) No air present - thigh muscles, bone, tumor.
Five factors that increase the risk for breast cancer.
- No children
- childbearing after the age of 30
- alcohol
- obesity
- personal or family history of breast, ovarian or colon cancer
If you find any abnormalities in the breast exam, you should go onto look for (5):
- Nipple characteristics
- Overlying skin (erythema, dimpling, retraction)
- Tenderness
- Lymphenopathy
- Heart
