Ch 16: Thorax And King Assessment Flashcards
What is the function of the upper respiratory portion
What is the function of the lower respiratory portion
Upper: warm, moisturize, transport air to lower
Lower: oxygenize, ventilation occurs
Give a few structures of the mid thoracic cavity
Mediastinum heart and great vessels lungs - R: 3lobes -L: 2 lobes thoracic nerves -T1-T12 -phrengic -intercoastal nerves Thoracic muscles Arterial blood supply Pulmonary arteries (2) -deoxy Pulmonary veins (2) -oxy
Give the thoracic nerves and whaT they innervate

Phrenic nerve: innervate diaphragm
Intercostal nerve: innervate coastal muscles
Name the thoracic muscles all 5
1. Intercostal
- Transverse thoracic
- Subcostal
- The Levator posterium
- Serratus posterior
What landmarks do we use to document accurately in relation to the anterior chest
(Give the 2 types)
Vertical: ribs (with isc)
Horizontal: UP AND DOWN horizontal lines provide a reference land mark for documentation (midclavicular)
What are other names for the sternal angle
Where is the sternal angle brief description
Angle of Louis, and sternal manubrial angle
The origin for the second rib (bump)
How do you get posterior thoracic landmarks
Ribs plus vertical spinal processes
Give the true ribs, false ribs, how many ribs are in the anterior and posterior structure
Give the location of the coastal angle and what it should be
True: 1-7
False: 8-12
There are a total of 12 ribs anterior and posterior
Coastal angle is at the. bottom of sternum at the xiphoid process. Should be 90°
What is the exact purpose of the reference lines and ribs
The reference lines and ribs used to document findings accurately when assessing
How do you find the sternal angle
Start at trachea you go down to the sternal notch walk 4-5 cm to the bony manubrium, the little hill is known as your sternal angle (angle of Louis) 
What are the anterior reference lines parallel to
Give the anterior reference lines
How far do the lines run
What is the most important reference line to establish
Anterior reference lines parallel to sternum

Reference lines:
1. Midsternal: center of sternum
*2. Mid clavicular: from clavicle to 12th rib
3. Anterior axillary: extends from anterior axillary fold when arms are at side 
The lines from all the way down the 12th rib
The most important reference line to establish is the mid clavicular
What are the posterior reference lines parallel to
Give the posterior reference lines
How do you determine the vertebral line beginning
Posterior reference lines parallel to vertebra line
Posterior reference lines 1. Vertebral line 2. Mid scapular line 3. Posterior auxiliary line 4 mid auxiliary line
Determine vertebral line beginning by having patient flex neck to expand process C7 and T1
What is each lung divided by and how many lobes do each lung have
(R and L)
Give reference line landmarks in auscultating of right middle lobe
What is The anterior reference line you want to use to discover the right middle lobe
Each long is divided by oblique fissure
R: three lubes
L-two lobes
How to find right middle lobe:
-Right mid lobe extends from 4th rib at sternal boarder to 5th rib at mid axillary line ANTERIORLY
Use right mid clavicular to assess right middle lobe
What is a variation you have to implement for women to be able to hear the right middle lobe and how do you do it
In women you may have to move the breast (displays tissue) by asking patient to move breast or lifting it with your forearms
What is the only lung divided into thirds
Where is the base of the lung
where is the Apex along
What is a key difference in relation to the apex of both lungs and how do we acknowledge this difference when auscultating
Only the right lung is divided into thirds
Base= big =bottom
Apex =top
In relation to both Apex:
-right apex of right lung displaced higher than left Apex about (2 to 4 cm) Above of clavicle which is why we auscultate supraclavicular

What side do we hear the right middle lobe on anterior or posterior and why
Right middle lobe heard anteriorly because it is blocked in the posterior section
Where does your lower respiratory tract begin
Lower respiratory tract begins at the trachea is bifurcation to right and left at the Carina
Give characteristics of the right main bronchus
what is most likely to happen to the right main bronchus
How do we ensure this mistake does not happen
Right mean bronchus: shorter, wider more vertical
Right Main Bronchus more likely to be intubated because
-people go too far in
Which ends up blocking the left lung
We ensure this does not happen by always auscultating after insertion and comparing lung sounds
Give the structural progression of the branches of the lower respiratory tract along with the progression of sounds
From bronchi, to bronchioles, to aveoli
Loud larger airway sounds to softer, finer, more difficult to auscultate airways sounds
1 INDICATOR
How do you know if someone’s airway is narrowing/worsening asthma
You will hear wheezes
Where is the pleura and what does it contain in relation to the visceral and parietal layers
What does this substance cause
Pleura located within the thorax
Plural contains plural fluid in plural space that lubricates visceral ( outer lung) and parietal (lines thoracic wall)
The plural fluid causes smooth sliding movements of lungs during respiration
What is the main trigger for breathing
An increase in CO2
What are things that can alter breathing patterns
(Give medication‘s and others)
Give specific example and how bidy responds 
Medications
-opiates, sedatives, overdose, hypoventilation
• OPIATES : decrease respiratory rate so not enough oxygen is reaching brain and a decrease in body acidity (pH)
Anxiety
Brain injury
Hyperventilation
What can fear and anxiety lead a patient to in relation to breathing
What do you want to do with a patient was having an anxiety attack

Fear and anxiety can lead to patient to progressively stop breathing and an MI
Aka HYPERVENTILATION
NEVER LEAVE OATIENT HAVING ANXIETY ATTACK you want to stay with the patient who’s having an anxiety attack and try to calm them down THEN get help
What are two things you’re gonna notice in a patient with a heroin overdose
What do you use to combat the overdose
With a heroin overdose patient will have
- pinpoint pupils
- CNS depression
Use Narcan (naloxone) to combat overdose
What is our ultimate goal during inhalation
What is the typical amount of air entering lung during inhalation and what is it known as
Our ultimate goal during inhalation is to increase thoracic diameter and pressure
Typical amount of air entering lung during inhalation is 500 to 800 mL
- AKA: title volume
What is the normal SP O2 of someone with COPD/emphysema
What is their main breathing trigger
If COPD/emphysema SPO2: 88%
COPD/emphysema main breathing sugar equals low O2 concentration that causes a decrease in acidity triggering decrease in SPO2
Normal SPO2 of healthy person
Normal: 94–95%
During inhalation what does the diaphragm do to the lungs, what do thorax and lungs increase, and what increases in the external intercostals
What is inhalation pressure greater than
During inhalation:
- diaphragm pulls lungs down
- thorax and lungs increase vertical diameter/pressure
- external intercostals increase diameter
Tidal volume greater v atmospheric pressure
What kind of process is respiration
What kind of process is expiration
Respiration(inhalation) : automatic
Expiration: passive process
What does expiration Involve in relation to internal structures
Expiration involves diaphragm, internal intercostal, abdominals relax
Air ispushed out of the lungs and chest, while the abdomen relaxes
Name conditions at altar respirations
Obesity pregnancy muscular dystrophy fractures anxiety pneumonia asthma COPD/emphysema * tension/ pneumo * Hemothorax *head injury *spinal injury *pulmonary embolism
How specifically does a tension pneumothorax/pneumothorax affect respirations
Attention/pneumothorax causes an accumulation of air in the pleural cavity compressing the lung
Breath sounds ABSENT (are not auscultatable )on affected side
How does a brain stem injury Alter respirations
Where is injury most likely to be located
With a brainstem injury you lose involuntary respiratory control
Location of injury C3 – C5
What are signs and symptoms of pulmonary embolisms
- unilateral chest pain
- Highly anxious
- Flailing of doom
- Dyspnea
- Petichea on chest
What are complications/causes of DVT otherwise known as risks
- Prolong bedrest
- Patient after surgery Involving anesthesia
- Oral contraceptives
- smoking
What happens in any and every disease lung process
In any disease lung process you will have a decrease lung sound in lung base
What do you need to be careful for when a doctor or practitioner is placing a central line
Why does this happen
How do you prevent it /complications
Be vigilant of a pneumothorax due to the nicking of the lung at the Apex
Nicking happens because Apex is above clavicle
Pneumothorax/ Complications prevented by auscultating and comparing lung sounds post insertion
What are the effects of aging on respiration
Strength Elasticity Flexibility Bone Density AP ratio
Respiratory strength decreases
-doesnt have strength to cough up sputum or swallow
Lungs lose elasticity
-decrease elasticity equals decrease function
decreasing flexibility in rib cartilage
Decreased bone density
-easy rib fx risk
Decreased AP ratio
- norm: 1:2
- Abnorm: 1:1 barrel chest
- cannot inhale deeply
When does surfactant production start in infants and what is it used for
What happens if a baby is born before the start of surfactant production
Surfactant production begins 32 weeks gestation
Used to keep aveloi open and for lung development
If born before 32 weeks surfactant will have to be administered because they dont have enough 
What is a normal finding in relation to the AP ratio of an infant and when does it normalize
Normal finding of infant AP ratio: Barrel chest (1:1 ) until 2 YOA then normalizes
What is a normal finding in women’s excratory capacity as compared to men
 Women have lower forced expiratory capacity compared to men because the thoracic size is smaller
What influences inhale and exhale
Chest size
What type of breathing requires an urgent assessment
And What interventions would you rapidly assessed with
When is it appropriate to give an inhaler for severe dyspnea
Acute SOB severe dyspnea
If acute SOB, severe dyspnea get rest rate, pulse, blood pressure, O2 
You can even give inhaler if facility has a policy of a standing order
In someone with acute SOB/severe dyspnea what do you wanna do to the head of bed and if patient has anxiety
With acute SOB/ severe dyspnea
-Elevate HOB to enhance breathing
-If patient has anxiety control breathing and relax thru:
• breathing techniques
• imagery
In a patient who often gets fatigue but is currently stable how do you wanna organize care
why do you do this
and what do you prioritize
Impatient who is stable but often gets fatigued cluster care to not tire the patient out
Prioritize subjective data (SOB/Disney
If a patient is post MVC how do you know they have severe brain damage
Post MVC IF A PATIENT has severe dyspnea with varying respiration depth an rates followed by apnea in a case of your brain damage which is an emergency
What other characteristics of a patient with dyspnes would cause you to call rapid response
 patient has dyspnea Cyanosis anticipated SPO2 in 80s use of accessory muscles confusion retractions
Call rapid response 
During the subjective data what past medical history do you collect
Any history of asthma, COPD, TB, URI bronchitis
What is subjective data you collect in relation to thorax and lung assessments
Past medical history
-asthma, COPD, URI, TB, bronchitis
Lifestyle/personal habits
-smoker/2nd hand smoke
Occupational history
-coal miners, farmers, firefighters
Environmental exposures
-pollution from city
medications
-ace inhibitors, inhalers, 02, vaccines
Family history
- respiratory family problems
- pneumococcal disease
- cancer/TB

What patient past history is relevant for risk reduction and health promotion
Any diagnosis of asthma, emphysema, positive TB in family or allergic reactions
What are health goals for risk reduction and health promotion in relation to the thorax and lungs
2
Copd
Smoking
- Decrease count of COPD
- Decrease smoking/create smoke free environment

What do you always want to do for a patient who smokes when they visit you at clinic/hospital
Always ask smokers if they are interested in stopping smoking
For risk reduction health promotion in relation to occupational and environmental exposure what do you want to encourage the use of and why
In relation to occupation and environment exposures encourage use of mask if exposed to chemicals that injure lung
To prevent asthma what do we want to decrease the amount of and what are common triggers for people to understand and know their own
To prevent asthma we want to decrease the number of ER visits due to asthma
Triggers:
- dust/mites
- mold
- smoking
- stressors
- allergies
- feather animals
- cockroaches
- cold weather
What immunizations do you want to ensure the patient has if an adult
Insure flu and pneumococcal vaccines (pcv13)
Give a few common respiratory symptomssymptoms
Chest pain dyspnea orthopnea PND cough/ sputem wheezing decreased functional ability
Common respiratory symptoms
What is important to do with chest pain
and what does unilateral chest pain indicate
If chest pain: rule out MI
If you know lateral trust pain indicates pulmonary embolism
How do you know if a patient has orthopnea or paroxysmal nocturnal dyspnea (PND)
What does (tripod position) indicate
Patient is sleep sitting
- in recliner
- using 3 to 4 pillows to sleep
Patient assumes tripod position because they cannot breathe due to accumulation of fluid overload
Give the different types of sputum a patient may have and what it indicates
What does it mean if a patient has pink frothy sputum in the upper airway
Mucoid sputum
-bronchitis
Purulent
-inf
Tenacious
-dehydration
Hemoptosis
-blood

Pink frothy sputum in upper airway= CHF
What cultural population has an increase incidence of TB And what vaccine do you want to assess for
Immigrants have an increased incident of TB
Assess for BCG vaccine
What respiratory conditions can cause tripod position
Why does patient Assume tripod position
COPD, emphysema any respiratory distress causes tripod position
Patient seems trip out position because they cannot breathe due to accumulation of fluid overload
In younger patients with pneumonia what is the first noted signs and symptoms
Younger patients with pneumonia will have :
- fever ***
- chills
- dyspnea
- chest pain
- may be a cough
As compared to younger patients what is the first signs and symptoms of pneumonia in your older population  And why is it not the same as your younger
First one at symptom of pneumonia and older is
-AN ALTERED MENTAL STATUS
* confusion
Can have dehydration
Older patients often don’t present with the fever as the first sinus of them due to thermal regulation (lower body temp)
What breath sounds do you hear in a patient with a pneumothorax and how will chest expansion look
Patients with pneumothorax will have absent breath sounds and have asymmetrical chest extension 
What are key factors when inspecting the patient you want to look at
Look at the skin color, clubbing, dyspnea, used to accessory muscles, tripod position, AP LAT ratio
Breath sounds describe and locate :
Bronchial
Bronco vesicular
 Vesicular
Bronchial: trachea/larynx
-loud high-pitched
Bronco vesicular: centrally major bronchi
-medium pitch medium volume
Vesicular: periphery (bases fine airway)
-soft low pitch
What disease processes cause course or diminished breath sounds
Pneumonia causes course or diminished breath sounds
Adventitious breath sounds describe:
1.Crackles
2. Wheezes
3. Rhonchi
4. Rails
- Crackles: Velcro
- Low pitch, moist
- pneumonia/CHF - Wheezes: whistle
- high-pitched whistle worse on inspiration
- asthma - Rails
- soft, bubbly, on inspiration
- 
When percussing what is the normal tone of the lungs/Tone of lungs with emphysema
What is the normal sound of fremitus at the basis
Normal: resident
COPD/emphysema: hyperresonance
Norm frematus: Decrease Fremitus at bases
 What affects breathing in relation to configuration
What is normal configuration
(Give exact descriptive word)
Give configurations for barrel chest
(coastal margins,ribs and ratio)
Abnormal thoracic configurations affect breathing
Norm: fascicle elliptical shaped chest
-symmetrical AP ratio 1:2 
Barrel chest: widened coastal margins, horizontal ribs
-AP ratio 1:1
- Describe pectus Excavatum
- Describe kyphoscoliosis
- Describe pectus carinatum
- Describe flail chest
Describe, if congenital, and causes
-  pectus excavatum: funnel chest
- depression on lower sternum
- congenital - Kyphoscoliosis
- decreased and impaired respiratory lung volume/breathing
3. Pectus carinatum: pigeon chest
- sternum displaced anteriorly
- congenital
- Flail chest
-rib cage separates from chest wall
-ineffective I and E
Due to multiple rib fractures

How do you conduct tactile fremitus
Norm findings
Abnormal findings and who do you see abnormalities in
Tactile fremitus: have patients say 99 use ulnar side of hand and inspect different places
Norm: strong vibration and symmetrical
Abnorm: crepitus (air in subcutaneous fat)
-common in patients with chest tubes

How do you conduct bronchophony
Norm
Abnorm and what does it mean
Bronchophony: auscultate long landmarks for patient says 99
Normal: muffled words indistinguishable
Abnorm: can distinguish 99
-Means pneumonia
How do you conduct Egophany
Norm
Abnormal and what it means
Egophany : Auscultate over lung landmarks and have patients say “EEE”
Norm: sounds like “EEE”
Abnorm: sounds like “Aaa” 
-means pneumonia fluid in lungs

How do you conduct whispered Pectriloquy
Norm
Abnorm what is +?
whispered pectriloquy: Auscultate over lung landmarks while patient whispers 123
Norm: faint, muffled not audible
Abnorm: clear and you can hear one to three
-Equals positive
What do you see in pregnant women and why
I’m pregnant women we see dyspnea, rib straining because of the rest of cage expansion
What do you note in your older population in relation to breathing and cough
Older populations have noted weakness in breathing and a decrease cough strength strength which leads to ineffective sputum production
If you have a rib fracture or pneumothorax what can lead to and what do you not have the strength to do
With a rib fracture it can lead to severe pneumonia
Patients do not have the strength to cough up sputum
When auscultating lung sounds what do you want to get a complete of
Get a complete respiration 1+1 = 1
What does a plasma D dimer test used to indicate
When do the D dimer levels increase

What does a D dimer test rule out

what are norm values
what are abnormal values
Plasma D dimer test used to indicate PE pulmonary embolism
D dimer levels increase in the setting of clot formation
Plasma D dimer tests rule out blood clots, DVT, CVA, PE
Normal: below 250 NG/ML
Abnorm: above 250 NG/ML
Name other laboratory diagnostic tests used for thorax in Lung assessment
Plasma D dimer test, x-ray, pulmonary function tests +CBC
When you’re getting ABGs Who gets the ABGs
how (where) do you get them from
What is vital to ensure before getting the ABG
What tests conducted before getting an ABG
Respiratory therapists draw ABGs
You get them from the radio artery
Before you get an ABG you must ensure ulnar artery blood flow is intact
The ALLEN test is conducted to draw ABGs
Describe the Allen test technique
What is the normal finding and what does it mean
Have patient make a fist with pressure and apply pressure to both the radio and older arteries
Only release older artery and have patient open hand to see return of blood flow
Norm: reddening of hand means intact ulnar artery Loeffler
Give nursing interventions related to thorax and long assessments
Auscultate breath sounds every two hours
Position patient to optimal respiration
Teach and encourage incentive spirometry every two hours
Give nursing diagnosis related to thorax and long assessment
Impaired gas exchange
Ineffective airway clearance/breathing pattern
Excess fluid volume
Give nursing outcomes related to thorax and lung assessment
Maintain clear lung fields
Demonstrate effective coughing
Demonstrate improved ventilation and adequate oxygenation
