Exam 3 - Thorax & Lungs Flashcards
What should you ask a pt if they have a cough?
If it’s productive / unproductive
If productive, need to know color, odor, and if there’s blood
Term for coughing up blood
Hemoptysis
Trouble breathing / shortness of breath (spelling)
Dyspnea
Trouble breathing while laying down (spelling)
Orthopnea
Sudden shortness of breath at night (spelling)
Paroxysmal nocturnal dyspnea
What do we do if pt has chest pain with breathing?
Assume cardiac first
Can differentiate from cardiac pain by the location and if pt is coughing a lot
If you suspect a pt has paroxysmal nocturnal dyspnea, what should you ask them?
1 - do you wake up suddenly gasping for air?
Not as important, but can also ask how many pillows they sleep with at night
What should you ask pt about respiratory infections?
If they have a history of RI, ask when last one was and what kind of treatment they had for it (usually steroids, antibiotics, and an inhaler)
What should you ask pt if they smoke?
How much?
What type of tobacco?
What does environmental exposure mean when asking pt about thorax and lungs?
What kind of work do they do and are they exposed to chemicals regularly?
What self-care behaviors do we ask about thorax and lungs?
Do they get an annual TB skin test? (Date/results)
Do they get the flu or covid vaccines? (Date of last one)
If pt is older or has other conditions, do they get pneumonia vaccine?
Reference line down center of chest
Midsternal line
Reference line passing under pt’s armpit
Anterior axillary line
Reference line passing next to pt’s nipple
Midclavicular line
Reference line passing down center of pt’s back
Vertebral line
Reference line passing down pt’s scapula
Scapular line
Reference line passing down middle of pt’s side
Midaxillary line
Reference line passing down back of pt’s armpit
Posterior axillary line
Order of exam for pt’s lungs and thorax
Posterior 1 - inspection 2 - palpation 3 - percussion 4 - auscultation
Lateral chest
Anterior 1 - inspection 2 - palpation 3 - percussion 4 - auscultation
What do we look at during inspection?
Shape/configuration of chest wall
Anteriorposterior (AP) diameter
Position of person
Skin color and condition
What is AP diameter?
Shape of chest, related to chronic respiratory issues
Normal is 1 to 2
Barrel chest is 1 to 1
Why would a pt have a barrel chest?
Long term respiratory issues
Use accessory muscles to breathe, and over time, *compensatory hypertrophy occurs. Intercostal spaces become larger
What do we do during palpation?
- Palpate the chest (look for lumps, bumps, anything abnormal)
- Perform chest expansion
How do you perform chest expansion on pt?
Put hands like butterfly on pt’s back with thumbs along spine and have pt take deep breath
Should rise and fall at same time and feel equal
Normal finding for chest expansion
Symmetric
What could abnormal chest expansion mean?
Marked atelectasis
Lobar pneumonia
Pleural effusion
Thoracic trauma (fractured ribs or pneumothorax)
How many breaths during normal respiration?
10-20 breaths per min
What is tachypnea? How much per min?
Rapid shallow breathing with >24 breaths per min
What is bradypnea?
Slow breathing with <10 breaths per minute
When would tachypnea be normal?
Fever
Pt just ran
What could cause bradypnea?
Drugs
Altered LOC
Brain stem issue
How do you check for fremitus?
Use palm
Feel for vibration when pt says “ninety-nine”
Have to follow path 1,1,2,2,3,3,4,4,5,5, starting at apex and moving down. Ending with 5s which are toward pt’s laterals
What does normal fremitus feel like?
Felt most at apex
Decreases as move down chest
Symmetric
How would you document normal fremitus?
Symmetric fremitus, bilateral
What does consolidated fremitus feel like?
Vibrations are stronger from dense areas
What could consolidated fremitus be from?
Pneumonia or infection
What does decreased fremitus feel like?
No vibration
What could cause decreased fremitus?
Emphysema
Collapsed lung
Chronic respiratory issue
(Any disease that is causing collapse of some alveoli)
Explain the percussion technique
1- Place middle finger of non-dominant hand on pt with palm off of pt’s body
2- Use middle finger of dominant hand to percussion, Non-dominant finger should be firmly on pt’s chest
3- Use tip of finger and hit below fingernail using relaxed wrist motion. Percussion 2-3 times in each location
What does normal lung tissue in adults sound like with percussion? (Spelling)
Resonance
What does normal lung tissue in children sound like with percussion?
Hyper resonance
Intensity of resonance
Loud
Pitch of resonance
Low
Duration of resonance
Long
Quality of resonance
Hollow
Normal location of resonance
Peripheral lung
What is a sigh respiration pattern?
- Occasional sighs: punctuate the normal breathing pattern and are purposeful to expand alveoli
- Frequent sighs: may indicate emotional dysfunction and may lead to hyperventilation and dizziness
What is a tachypnea respiration pattern?
- Rapid, shallow breathing
- increased rage, > 24 per min
When would tachypnea occur and still be normal?
In response to fever, fear, or exercise
When would tachypnea occur and be abnormal?
Respiratory insufficiency Pneumonia Alkalosis Pleurisy Lesions in the pons
What is bradypnea respiration pattern?
Slow breathing
A decreased but regular rate <10 per min
When would bradypnea occur?
Drug - induced depression of respiratory center in medulla
Increased intracranial pressure
Diabetic coma
What is hyperventilation breathing pattern? What does it cause?
Increase in rate and depth
Blows off CO2 causing a decreased level in the blood (alkalosis)
What could cause hyperventilation?
Extreme exertion
Extreme fear
Extreme anxiety
Diabetic ketoacidosis (Kussmaul respirations)
Hepatic coma
Salicylate overdose (prod, a respiratory alkalosis to compensate for the metabolic acidosis)
Lesions of the midbrain
Alterations in blood gas concentration (either increase of CO2 or decrease in oxygen)
Hypoventilation respiration pattern definition
Irregular shallow pattern
What causes hypoventilation?
Overdose of narcotics or anesthetics
Prolonged bed rest
Conscious splinting of chest to avoid respiratory pain
Cheyne-Stokes respiration definition
- Cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing.
- Breathing periods last 30-45 seconds, with periods of apnea (20 seconds) alternating the cycle
- Occurs normally in infants and older adults during sleep
What causes Cheyenne-Stokes?
Severe heart failure Renal failure Meningitis Drug overdose Increased intracranial pressure
Biot’s respiration definition
- Similar to Cheyne-Stokes respiration, except that the pattern is irregular
- Series of normal respirations (3-4) is followed by a period of apnea
- Cycle length varies from 10 sec to 1 min
What causes Biot respiration?
Head trauma Brain abscess Heat stroke Spinal meningitis Encephalitis
Chronic obstructive breathing definition
Normal inspiration and prolonged expiration to overcome increased airway resistance
What causes chronic obstructive breathing? And what happens during chronic obstructive breathing?
Occurs in a person with a chronic obstructive lung disease
Any situation calling for increased heart rate (exercise) may lead to dyspnea episode (air trapping) b/c person doesn’t have enough time for full expiration
Explain technique for auscultation of thorax and lungs
Use same pattern every time, starting up at thorax
1,1,2,2,3,3,4,4,5,5,6,6,7,7,8,8,9,9
6 & 7 are start of lateral and 8&9 are lateral
Do this on posterior and anterior
What can interfere with auscultation?
Stethoscope tubing Tubing bumping together Pt shivering Hairy chest Rustling of paper gown
What does interference of auscultation sound like?
Crackles
Term for breath sounds over peripheral lung fields (spelling)
Vesicular breath sounds
Aka clear breath sounds
What do vesicular breath sounds sound like?
Low pitch
Breezy or rustling like sound of wind in trees
Soft amplitude
Duration I>E
Term for normal sound over major bronchi
Bronchovesicular breath sounds
What do bronchovesicular breath sounds sound like?
Moderate pitch and amplitude Mixed quality (wind, but inspiratory louder than expiratory) Duration: I = E
Normal sound heard over trachea or larynx
Bronchial breath sounds
What do bronchial breath sounds sound like?
High pitched
Harsh or tubular quality
Loud amplitude
Duration: I
Normal location for vesicular breath sounds
Peripheral lung fields
Normal location for bronchovesicular breath sounds
Over major bronchi
Posterior - between scapulae
Anterior - upper sternum 1st - 2nd ICS
Normal location of bronchial breath sounds
Trachea or larynx
Abnormal location for bronchial breath sounds
Peripheral lung fields
What does adventitious sounds mean?
Abnormal sounds
What do fine crackles sound like?
Normal inspiration/expiration, just with crackles added (sound like rice crispies)
Are crackles continuous or discontinuous?
Discontinuous because sound comes and goes
They are discrete
Why do crackles in breath sounds occur, and what is the difference between fine and coarse crackles?
Fluid in lungs - bubbles popping
Depends on how much fluid present
Coarse = more fluid and bigger bubbles popping
What does pleural friction rub sounds like?
Low pitched
Superficial
Grating quality
Like crackles, but close to the ear
What is pleural friction rub caused by?
Inflamed tissue rubbing together causing friction
What does stridor sound like?
High-pitched Monophonic Inspiratory Crowning sound Louder in neck than over chest wall
What causes stridor?
Originates in larynx or trachea, caused by upper airway obstruction from swollen or inflamed tissues (allergic reaction) or a lodged foreign body
In children: croup
What does a high-pitched wheeze sound like?
- High-pitched
- Musical squeaking sounds
- Predominate in expiration but may occur in both expiration and inspiration
Another name for a high-pitched wheeze sound
Sibilant
What causes a high-pitched wheeze sound?
Very constricted airways
Due to an obstruction, acute asthma, chronic emphysema
What does a low-pitched wheeze sound like?
Low-pitched Monophonic Single note Musical snoring Moaning sounds More prominent on expiration
Another name for low-pitched wheeze
Sonorous rhonchi
What causes low-pitched wheeze sounds?
Airflow obstruction
Bronchitis
Single bronchus obstruction from airway tumor
Tests that test voice sounds
Bronchophony
Egophony
Whispered pectoriloquy
How do you do bronchophony test?
Ask pt to repeat “99” as you listen over chest wall
Normal bronchophony result
Pt’s voice is “Soft, muffled, indistinct”
Abnormal bronchophony result
Sound more distinct over areas of increased density (consolidated areas)
What could consolidated areas indicate?
Pneumonia
Tumor
How to perform the egophony test
Ask pt to repeat “E” while you listen over chest wall
Normal result of egophony test
Pt sounds “soft, muffled, hear “E””
Abnormal egophony result
Pt sounds louder, changes to “A” over area of consolidation
How to perform whispered pectoriloquy test
Ask pt to whisper “1-2-3” as you listen over lungs
Normal result of whispered pectoriloquy test
Pt sounds “faint, muffled, almost inaudible”
Abnormal result of whispered pectoriloquy test
Pt sounds clear, distinct (like whispering directly into stethoscope) over areas of consolidation
