Jenny

Question 1

respiratory rate

Answer 1

12-16

Question 2

spo2

Answer 2

94-98

Question 3

temp

Answer 3

35.7-38

Question 4

HR

Answer 4

60-100

Question 5

BP

Answer 5

(S=95-140, D=60-90)

Question 6

Airways

Answer 6

• Air is black, tissue or fluid is white
  Look for trachea
• The trachea is normally located centrally or deviating very slightly to the right
  True trachial deviation
• Pushing of the trachea: large pleural effusion or tension pneumothorax.
• Pulling of the trachea: consolidation with associated lobar collapse.
  Apparent tracheal deviation
• Rotation of the patient can give the appearance of apparent tracheal deviation, inspect the clavicles to rule out the presence of rotation

Question 7

bones

Answer 7

• Scapula
• Clavicle
• Vertebra
• Ribs
  Pathologies
• Fractures #
• Dislocations
• Rib crowding
• Previous surgery
  ○ Plates
  ○ Pins
  ○ Cages

Question 8

Cardiac

Answer 8

• right- 1/3rd
• left- 2/3rds
  sail sign cardiac
• wedge of collapsed tissue behind the heart boarder
• left lower lung collapse
• appears like a boat sail

Question 9

Diaphragm

Answer 9

• right hemidiaphragm is higher than the left due to the liver
• stomach underlies left hemidiaphragm
• The diaphragm should be indistinguishable from the underlying liver
• if free gas is present (bowel perforation) air accumulates under diaphragm causing it to lift and become visibly separate from the liver

Question 10

Expansion

Answer 10

• To assess the degree of inspiration it is conventional to count ribs down to the diaphragm. The diaphragm should be intersected by the 5th to 7th anterior ribs in the mid-clavicular line. Less is a sign of incomplete inspiration.
• Less than 5 ribs indicates incomplete inspiration
• More than 7 ribs suggests lung hyper-expansion

Question 11

Fields & Fissures

Answer 11

• The left lung has two lobes and the right has three
• Fine grey lines that extend throughout the lung fields to within 2cm of the lung edge
  o Equal density within the left and right lung fields
  o Looking for areas that appear whiter (dense tissue or fluid) OR darker (air) than you would expect

Question 12

horizontal fissure

Answer 12

• Fluid in horiz fissure and associated pleural effusion.
• Opacity below the horiz fissure so it is clearly defined suggesting infection in middle lobe.
• Horiz fissure has moved from where you would expect it to be suggesting collapse of upper lobe.

Question 13

Gadgets

Answer 13

1. Pacemaker
2. ECG lead
3. Tracheostomy
4. Chest Drain
5. Stomach tube Nasogastric
6. Sternal wires - Holds sternum back together
7. ETT endotracheal tube
8. Rods

Question 14

Hilar or hidden areas

Answer 14

• increased density around the hilar
• bats wing pattern
• pulmonary odema/ fluid overload/ heart failiure & increased blood flow to the area
• The left hilum is often positioned slightly higher than the right, but there is a wide degree of variability between individuals.
• The hilar are usually the same size, so asymmetry should raise suspicion of pathology.
• The hilar point is also a very important landmark; anatomically it is where the descending pulmonary artery intersects the superior pulmonary vein. When this is lost, consider the possibility of a lesion here (e.g. lung tumour or enlarged lymph nodes).

Question 15

Causes of hilar enlargement or abnormal position

Answer 15

• Bilateral symmetrical enlargement is typically associated with sarcoidosis.
• Unilateral/asymmetrical enlargement may be due to underlying malignancy.
• inspect for evidence of the hilar being pushed (e.g. by an enlarging soft tissue mass)
• or pulled (e.g. lobar collapse).

Question 16

Atelectasis

Answer 16

• Collapse of the small airways – lower lobe collapse
• Alveoli collapse due to lack of deep breathing
• Mucus plug. A mucus plug is a buildup of sputum or phlegm in your airways. It commonly occurs during and after surgery because you can’t cough.
• reduced airway expansion & sputum retention is typical after abdominal surgery and use of general anesthetic
  Assessment
• increased respiratory rate & reduced oxygen saturations hypoxia
• hear fine crackles over the affected pulmonary tissue
  Appearance
• uniform white appearance
• can be localised to one lobe or whole lung
• rib crowding
• evidence of reduced expansion
• movements of structures towards the area that is more white

Question 17

Auscultation

Answer 17

• Normal turbulence of air flowing in and out of the lungs produces ‘breath sounds’.
• Louder on inspiration and faded/minimal on expiration
• Inspiratory sounds heard for longer than expiratory
• Over the trachea – bronchial
• Over the lung fields – soft and muffled (described as vesicular), becoming quieter as you move to the base of the lungs.

**Fine crackles – atelectasis
Increased vocal resonance.
**

Question 18

ACBT

Answer 18

1. Breathing control 20-30 seconds
2. Huffing followed by cough if needed (FET)
3. Breathing control
4. 3-4 deep breaths (TEE)
5. Breathing control
6. 3-4 deep breaths (TEE)

Question 19

breathing control

Answer 19

Tidal breathing
- Relaxation of upper chest
1. Diaphragmatic breathing
One hand on stomach and one hand on chest, breathe in through your nose.
You’ll feel your stomach expand against your hand and your chest should barely move
Breath out through your mouth and you’ll feel your stomach sink back down.
Use of proprioceptive facilitation can be helpful. (push into my hand)

Question 20

2. Forced Expiratory Technique (Fet)

Answer 20

• Forcefully expelling air through an open throat and
  mouth
• “fogging up a mirror ‘
• Also known as a “huff’
• Helps move sputum from small to larger airways
• Don’t do too many — can cause bronchospasm
• May initiate a cough
• Can be challenging with surgical pain — + supported

Question 21

huff

Answer 21

Medium volume huff
- moves from more peripheral airways
- normal breath in and long huff out
High volume huff
- moves from more central airways
- deep breath, short sharp huff out

Question 22

3. Thoracic expansion

Answer 22

• Encouraging lateral chest expansion — hands on for proprioceptive feedback
• Can add a 3’s hold and a ‘sniff’
• Increases collateral ventilation
• Monitor - patients can become lightheaded, 3-5 +/-

Question 23

3 sec hold

Answer 23

shown to decrease collapsed lung tissue and may be good for those with lung pathology as air will first fill in the unobstructed area and the hold may give time for ventilation of collateral pathways.

• Air will first fill in the unobstructed area of least resistance and have incomplete equilibrium.
• A insp hold, gives time for ventilation of collateral pathways allows and recreates equilibrium by providing additional routes for air to reach alveoli