CH 19 Respiratory (Thorax and Lungs)

Question 1

Structure and Function (thoracic cage)

Answer 1

sternum
12 pairs of ribs
31 thoracic vertebrae
diaphragm - floor of thoracic cage (separates the thoracic cavity from abdomen)

Question 2

Thoracic Landmarks (anterior)

Answer 2

surface landmarks are important for assessing underlying respiratory structures

landmarks include:

• suprasternal notch (jugular notch)
• sternal angle (angle of louis)
  - useful location to start counting ribs
• costal angle (90 degrees or less)

Question 3

Thoracic Landmarks (posterior)

Answer 3

more difficult to count ribs because of muscle mass and soft tissue

landmarks include:

• vertebra prominens (beginning point/ help start to palpate spine)
• spinous processes (correlated with rib number)
• inferior border of scapula

Question 4

Reference Lines

Answer 4

Anterior chest - midsternal line and midclavicular line

Lateral Chest - anterior axillary, posterior axillary, and midaxillary

Posterior Chest - vertebral line (midspinal) and scapular line

Question 5

Thoracic Cavity (sturctures)

Answer 5

mediastinum (middle section containing esophagus, trachea, heart, and great vessels)

Pleural Cavities (contain left and right lungs)

Apex of Lung (highest point - 3-4cm above clavicle)

Base of Lung (lower border - rests on diaphragm)

Question 6

Lobes of the Lungs

Answer 6

Paired but not symmetric

Right Lung
- 3 lobes

Left Lung

• 2 lobes
• more narrow because of cardiac notch
• LUL better to auscultate anteriorly and LLL better to auscultate posteriorly

Question 7

Pleurae

Answer 7

serous membranes that envelop between lungs and chest wall

Question 8

Visceral vs parietal pleurae

Answer 8

visceral - lines outside of lungs

parietal - lines inside of chest wall and diaphragm

Question 9

Pleural Cavity

Answer 9

• space filled with lubricating fluid which enable lung
  movement during inspiration and expiration
• negative pressure holds lungs tightly against chest all
• costodiaphramatic recess (pleural space beneath the
  lungs)
  - potential space to abnormally fill with fluid or air
  (compromises lung expansion)

Question 10

Trachea and Bronchial Tree

Answer 10

Acinus - where gas exchange occurs

- bronchioles -> alveolar ducts -> alveolar sacs -> alveoli

Question 11

Respiration (4 major functions)

Answer 11

Supply oxygen to the body for energy production

Removing CO2 as a waste product of energy reactions

Maintaining homeostasis (acid/base balance)

Maintaining heat exchange

Question 12

Respirations

Answer 12

major negative feedback loop (reaction that causes a decrease in function to stabilize the system)

increase of CO2 in blood (hypercapnea) is normal stimulus to breathe

respiratory control center in brainstem = involuntary control of respirations

Question 13

Inspiration vs expiration

Answer 13

inspiration - air rushing into lungs
(diaphragm contracts, flattens, descends)

Expiration - air is expelled/ chest recoil
(diaphragm relaxes)

Question 14

Developmental Considerations: Infant/children

Answer 14

susceptible to adverse effects of second-hand smoke

Question 15

Developmental Considerations: Pregnant Women

Answer 15

increased oxygen demand for fetus

enlarges uterus, displaces diaphragm

increased estrogen allows widening of costal angle

Question 16

Developmental Considerations: The Aging Adult

Answer 16

• costal cartilage becomes calcified/thorax less mobile - respiratory muscle strength declines
• lung is more rigid and hard to inflate
• decreased number of alveoli

Question 17

Inspection

Collecting Objective Data: Inspection

Answer 17

observe for retractions and use of accessory muscles

observe the rate, rhythm, depth, and effort of breathing

Question 18

Observations to make

Collecting Objective Data: Inspection

Answer 18

Lips: observe color, pursed lip breathing? 
Nares: nasal flaring? 
Skin: cyanosis? 
Nails: Clubbing?
Chest symmetry or deformity?
Costal angle – >90 degrees?

Question 19

Breathing Position

Collecting Objective Data: Inspection

Answer 19

NORMAL - upright and relaxed
ABNORMAL - tripod (leaning forward on stationary object/with elbows on their knees)
- respiratory distress (pursed lip breathing)

Question 20

Thorax Configurations (normal, abnormal, congenital abnormalities)
(Collecting Objective Data: Inspection)

Answer 20

normal - transverse diameter is approx 2x the AP diameter (AP:T 1:2)

abnormal (barrel chest) - transverse diameter is the same as AP diameter (AP:T 1:1)

Pectus Excavatum (sunken sternum/funnel chest) - sternum grows inward, chest wall skins

Pectus Carnatum (forward protrusion of the sternum) - creates more room in chest wall

Question 21

Collecting Objective Data: Palpation (anterior and posterior)

Answer 21

Anterior
- identify areas of tenderness/deformity by palpating ribs and sternum (examine thoracic expansion for symmetry)

Posterior
- identify areas of tenderness, crepitus (air in tissue), or deformity
- palpate for chest excursion (deviation) (normal = chest expansion symmetrical)
- Tactile Fremitus (feeling for vibration on chest wall when patient speaks)
- should be diminished and difficult to feel once you
start moving down from trachea

Question 22

Stethoscope (what to listen for, where, and how)

Collecting Objective Data: Auscultation

Answer 22

• listen for one full breath cycle

- start at apices; side to side comparison with Greek key pattern

Question 23

Normal Breath Sounds

Collecting Objective Data: Auscultation

Answer 23

Vesicular - heard over most lung fields
Bronchovesicular - heard over main bronchus area
Bronchial/Tracheal - heard only over trachea

Question 24

Decreased Breath Sounds (occurs if…)

Collecting Objective Data: Auscultation

Answer 24

• fluid/puss accumulation in pleural space
• secretions/foreign body obstructs bronchi
• lungs are hyper-inflated
• shallow breathing

Question 25

Adventitious Breath Sounds | Collecting Objective Data: Auscultation

Answer 25

Extra sounds -Crackles (rales) - fine, medium, or coarse /// fluid in lower airways // heard during inspiration/// usually not cleared with cough - Rhonchi - loud, low coarse ///thick secretion in airway /// heard during inspiration and expiration /// may be cleared with cough (productive) - Wheeze - high-pitched/// narrow airway /// heard on inspiration and expiration, but louder on expiration///can hear in the rest of lung field - Stridor - inspiratory only wheeze associated with upper airway obstruction

Question 26

Assessment of Respiratory System (respiratory patterns: normal and abnormal)

Answer 26

Normal – rate 12-20; even volume and rhythm; comfortable Bradypnea – rate < 12 Tachypnea – rate > 20 Hyperventilation – rate and depth increase Sighing – frequently interspersed deeper breath Apnea – cessation of breathing

Question 27

Assessment of Respiratory System (respiratory conditions)

Answer 27

Atelectasis - partial/complete collapse of a lung or lobe of a lung Bronchitis - acute (infection of trachea and larger bronchi) /// chronic - prolonged inflammation of trachea and larger bronchi Emphysema - hyperinflated lungs//destruction of pulmonary connective tissues Pleurisy - pulmonary infection when lining of lung becomes inflamed Pleural effusion - excessive fluid in the pleural space Pneumonia - inflammatory response to infection Pneumothorax - air in pleural cavity resulting in collapsed lung Asthma - allergic hypersensitivity to certain inhaled allergens, irritants, microbes, stress or exercise - raised concern if patient has absent breath sounds when wheezes were previously heard

Question 28

Incentive Spirometer (purpose, who is it useful for, how to use)

Answer 28

- prevents lung consolidation (filled with liquid) (Ex. pneumonia) - useful for surgical patients or bedbound patients - instruct patient to slowly take deep breath in (expanding lungs as much as possible)

Question 29

Peak Flow Meter (what is PEFR and how it is performed)

Answer 29

Peak Expiratory Flow Rate (PEFR) is used to monitor pulmonary function in asthma patients - Ask patient to inhale deeply and then exhale into meter as fast as possible, expelling as much air

Question 30

Signs and Symptoms of Hypoxia

Answer 30

``` Restlessness – The #1 Sign/Symptom Apprehension, anxiety Disorientation Decreased Level Of Consciousness Increased fatigue Increased pulse, B/P, RR Dyspnea Arrhythmias Pallor Cyanosis (late) Clubbing (chronic) Behavioral changes ```