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health assessment 1 ABSN Summer23 > Lecture 6: Pulmonary Assessment: Thorax & Lungs > Flashcards

Lecture 6: Pulmonary Assessment: Thorax & Lungs Flashcards

1
Q

Learning Objectives

A

Learn the structure and function of the thorax and lungs
Understand the methods of examination of the respiratory system
Identify lung sounds that are normal
Describe the characteristics of adventitious lung sounds
Accurately record the assessment

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2
Q

Structure and Function

A
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3
Q

Objective Data: Pulmonary Inspection

A

Facial expression- relaxed, anxious? (do not describe as normal)
-Skin color of face, lips, cheeks
-Nasal flaring
-Nailbeds for capillary refill, clubbing, shape and color
-Conversational dyspnea
-Client’s positioning (tripod)-chest forward maximal use of accessory muscles
-Chest shape
-Use of accessory muscles
*Muscles of neck, back, abdomen, intercostal muscles

Secondary polycythemia- body’s response to chronic hypoxia in patients with COPD, kidneys produce more erythropoietin to manufacturer red blood cells which carries the O2 through the body

Tri pod position- chest forwards-allows us to use all of our accessory muscles

Use of accessory muscles including sternomastoid, diaphragm

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4
Q

Inspection- Respiration

A

Rate:
12 to 20 breaths/minute in resting adult

Rhythm:
Even, regular

Symmetry
Retractions:
chest wall appears to cave in

Paradoxical breathing:
diaphragm moves in opposite direction than it should when inhaling/exhaling- acute respiratory distress

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5
Q

Inspection: Skin Tone

A

Normal- evenly colored skin tone, appropriate for race

Ruddy to purple-secondary polycythemia- Chronic Obstructive Pulmonary Disease (COPD)-chronic hypoxia (low levels of O2 in body tissue)-erythropoietin in kidneys stimulates red blood cell (RBC) production

Cyanosis- makes white skin appear blue-tinged- indicates hypoxia/decreased perfusion

Pallor/pale- hypoxia (low levels of O2), anemia

Jaundice (yellow)- excess bilirubin in blood-liver disease
- Dark-skinned clients- sclera will be jaundice

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6
Q

Abnormalities of Thoracic Cage: Barrel Chest

A

AP to Transverse Diameter = 1:1
(2 hands to 2 hands, like 2:2)
Ribs horizontal
Costal angle >90 degrees
Associated with normal aging, emphysema

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7
Q

Abnormalities of Thoracic Cage: Pectus Excavatum

A

Funnel Chest

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8
Q

Abnormalities of Thoracic Cage: Pectus Carinatum

A

Pigeon Chest

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9
Q

Abnormalities of Thoracic Cage: Scoliosis

A
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10
Q

Abnormalities of Thoracic Cage: Kyphosis

A
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11
Q

hypoxia level via pulse oximetry

A

SaO2 > 92%

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12
Q

Clubbing

A

(increased capillary density from chronic hypoxia)
normal is 160 degrees
clubbing is 180

Clubbing present 80% of lung cancer patients

Normal nail beds are flat, notice the downward sloping of the nail bed with clubbing

Normal nail beds are pink, notice the pallor and cyanosis of the clubbed nail beds

Schamroth Sign (fingers together to see for normal gap)

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13
Q

Capillary Refill

A

Clubbing present 80% of lung cancer patients

Normal nail beds are flat, notice the downward sloping of the nail bed with clubbing

Normal nail beds are pink, notice the pallor and cyanosis of the clubbed nail beds

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14
Q

Respiratory patterns

A

Normal is regular and comfortable at rate of 12 -20 per min and regular

Tachy meaning more than 24 breaths min and shsllow as in fever

Brady meaning less than 10 breaths per minute as in well conditioned athletes

Hyper increased rate and increased depth with severe anxiety

Kussmaul in diabetic ketoacidosis rapid, deep and labored

Hypo decreased rate, decreased depth, irregular, overdose of narcotics

Cheyne-Stokes which is irregular pattern with alternating periods of deep, rapid breathing followed by period of apnea or no breathing

Air trapping increasing difficulty in getting breath out in COPD, air is trapped in the lungs during expiration

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15
Q

Pulmonary Exam- Palpation

A

Position of trachea (trachea moves away from collection of fluid or tension pneumothorax, moves toward collapsed lung or consolidation)

Chest bones and muscles

Crepitus (air in the subcutaneous tissue)

Palpate for thoracic expansion

Tactile Fremitus (vibration transmitted, use ulnar surface of hand)

Palpate for pleural friction rub - feels like leather rubbing on leather

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16
Q

Thoracic Expansion

A

assessment of chest movement

Have patient inhale

Thumbs should come together

Have patient exhale

Thumbs should separate

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17
Q

Palpation of Tactile Fremitus

A

Palpable vibrations when the patient speaks

Sound generated from the larynx

Vibrations of air in the bronchial tubes transmitted to the chest wall

Best felt parasternally at 2nd ICS
-Decreases as you progress down

Use the palmar base or ball of hands

Note symmetry

“99” or “blue moon”

18
Q

Percusion

A

Percuss for resonance, hyperresonance, dullness
-Helps determine if underlying structure is air filled, fluid or solid
-Use indirect (mediate) percussion to elicit sound
-Start at apices and percuss band of normally resonant tissue across tops of both shoulders
-Percuss in interspaces
*Contralateral -Avoid percussing over scapulae and ribs

Normal:
Resonance: low-pitched, clear, hollow sound that predominates in healthy lung tissue in adult

19
Q

Percussion Notes

A

Resonance: dull (chart)

20
Q

Auscultation

A

DO NOT LISTEN OVER CLOTHES or GOWNS!

Listen anteriorly, posteriorly and laterally in proper locations and order

Listen for normal, adventitious, bilaterally

Use the diaphragm of the stethoscope

Right middle lobe best heard axillary area
Auscultating posterior chest

Patient’s head bent slightly forward,
arms crossed in front over chest

21
Q

Directions for Client

A

Take deep breath through open mouth

If you hear adventitious lung sounds, ask client to cough and try to clear

Discourage hyperventilation
-Use deep, slow breaths

22
Q

Normal Breath Sounds: Bronchial

A

Normal location:
Trachea

Quality: Harsh or hollow
Pitch: High
Amplitude: Loud
Duration: Insp < Exp 1:2

23
Q

Normal Breath Sounds: Bronchovesicular

A

Normal Location:
Over major bronchi
(sternal border)

Quality: Mixed
Pitch: Medium
Amplitude: Moderate
Duration: Insp = Exp 1:1

24
Q

Normal Breath Sounds: Vesicular

A

Normal location:
Peripheral lung tissue

Quality: soft, blowing
Pitch: Low
Amplitude: Soft
Duration: Insp > Exp 2.5:1

25
Q

Adventitious (Unexpected) Breath Sounds

A

ask pt to cough and if clears it normal (?)

  1. disscontinuous
    Discrete/Intermittent
    Crackles
    Pleural friction rub
  2. continuous
    connected:
    Wheeze
    Rhonchi
    Stridor
26
Q

Adventitious Breath Sounds:Discontinuous

crackles

A

Crackles:

High-pitched, discontinuous sounds heard during inspiration
Crackling or popping sound
Bases in lungs
Causes: fluid, i.e. pulmonary edema (CHF)

27
Q

Adventitious Sounds: Discontinuous

Pleural Friction Rub

A

Pleural Friction Rub
Mechanism:
inflamed pleura cause friction during respiration
Usually, unilateral
Coarse, low, grating
Like pieces of leather rubbing, walking on fresh snow, “creaky”
Causes: inflammation of the pleura, tissues that line the lungs
Painful

–
Break the words down:
Visceral = internal organs in the main cavities of the body

Parietal = relating to the wall of the body or of a body cavity

28
Q

Adventitious Sounds: Continuous

Wheeze

A

Wheeze
high pitched/musical
Mechanism: air flow through compressed or swollen airways
Predominate in expiration
Examples: COPD, asthma, tumors, bronchitis

29
Q

Adventitious SoundsContinuous

Rhonchi

A

Rhonchi
low pitched, musical snoring, heard throughout cycle
Mechanism: airflow obstruction by secretions
Clears somewhat with cough or suctioning
Bronchitis major cause in outpatients

30
Q

Adventitious SoundsContinuous:
STRIDOR

A

medical emergency

Obstruction or constriction of larynx
Increased pitch, inspiratory, crowing sound
Louder in neck
Originates larynx or trachea
Examples: anaphylaxis, croup in children, epiglottis
Medical emergency- ABCs- airway, breathing, circulation- may skip the history during emergency- what is the priority?

31
Q

Vocal Resonance/Voice sounds

A

Egophony- (EE to AY changes)
Bronchophony
Whispered pectoriloquy

Pathology that increases lung density enhances transmission of voice sounds.

32
Q

Egophony

A

Auscultate chest while person phonates a long E sound

Normal:
hear E sound through stethoscope

Abnormal:
sound changes to bleating long A sound
Indicates consolidation or compression

33
Q

Bronchophony

A

Ask patient to say “ninety-nine” several times in a normal voice
Auscultate several symmetrical areas over each lung

Normal:
Sounds should be muffled and indistinct

Abnormal:
if sounds are louder and clearer- consolidation

34
Q

Whispered Pectoriloquy

A

Ask patient to whisper “ninety-nine” several times
Auscultate several symmetrical areas over each lung

Normal:
faint sounds or nothing

Abnormal:
Positive whispered pectoriloquy = you hear sounds clearly

35
Q

Abnormal Exam Findings: Lobar Pneumonia

A

Percussion- dull (abnormal density)
Tactile Fremitus- increased
Bronchophony, egophony and whispered pectoriloquy present
Abnormal bronchial sounds in areas where they don’t belong

36
Q

Abnormal Exam Findings: Pneumothorax

A

Pneumothorax:
Percussion- hyperresonant (abnormal density)

Tactile Fremitus- decreased or absent

Breath sounds ↓or absent

Usually, unilateral
Unequal chest expansion

No adventitious sounds

Tracheal shift away from affected side

37
Q

Abnormal Exam Findings: pleural effusion

A

Pleural Effusion (excess fluid between layers of pleura outside lungs)

-Percussion - dull to flat
-Tactile fremitus - decreased or absent
-Breath sounds decreased or absent
-Tracheal shift away from affected side
-CHF, Cancer, Pneumonia

38
Q

Abnormal Exam Findings: COPD

A

Chronic Obstructive Pulmonary Disease (COPD) Sequela-bronchitis & emphysema)
- ↑ AP diameter, ↓chest expansion
- Percussion- hyperresonant (due to air trapping, too much air)
- Tactile fremitus- decreased
- Breath sounds- decreased with prolonged expiration, occasional wheeze

39
Q

Abnormal Exam Findings: Atelectasis (lung collapse)

A

↓expansion on affected side

Percussion: Dull (abnormal density)

Tactile fremitus- decreased or absent

Breath sounds decreased or absent over affected area

Occasional fine crackles if bronchus patent

Tracheal shift toward affected side

Blunt injury, medical procedures

40
Q

Summary for Thorax & Lungs Exam:

A

Inspection
Thoracic cage, respirations, skin color, condition, nail beds, clubbing, cap refill, persons’ facial expression& LOC

Palpation
Confirm symmetric expansion, tactile fremitus, crepitus, detection of any lumps, masses, or tenderness

Percussion
Lung fields

Auscultation
Assess breath sounds, not abnormal/ adventitious breath sounds
Perform bronchophony, egophony, or whispered pectoriloquy, if needed.

41
Q

Respiratory Practicum

A
  1. Introduce self to client. Two identifiers for patient verification. (1) (patient safety)
  2. Explain procedure and rationale for assessment. (1) (patient-centered care)
  3. Provide for privacy. (1) (patient-centered care)
  4. Wash hands. (1) (patient safety)
  5. Position- patient in relaxed seated position
  6. Inspect-
    Facial expression (2)
    Skin color (2)
    Resp rhythm (2)
    Use of accessory muscles (2)
    Assess AP/T diameter (2)
    Capillary Refill (2)
    Nail clubbing (2)
  7. Palpate
    Anterior (front) chest for crepitus (2)
    Posterior (back) chest for tactile fremitus (2)
    Posterior (back) chest respiratory expansion (2)
  8. Percuss
    Posterior (back) chest for resonance (2)

9.Auscultate
Anterior, lateral and posterior (normal, adventitious, compare bilaterally)
Instruct client to take deep breaths, with attention to avoid hyperventilation (2)

  1. **Place stethoscope on bare skin (4)
  2. Auscultate anterior or posterior and left or right lateral (2)
  3. Use contralateral placement of stethoscope, which is no greater than 2 inches apart (2)
  4. Chart (10)
    Date, time, signature, credentials, only chart what you assess, do not chart what you omit, correct use of abbreviations, landmarks, bilaterally, do not use “normal or good” to describe findings, do not use complete sentences

health assessment 1 ABSN Summer23 (7 decks)

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