Module 05: Anterior and Posterior Thorax (Part 01) Flashcards
What should be the priority assessment and intervention under the respiratory system?
(1) Airway
(2) Breathing
(3) Circulation
(a) Color of lips
(b) Color of nail beds
(c) Shape of the chest
(d) Positioning
This is the problems in exhalation due to inflammation and increase of sputum production or the narrowing or blockage of air pathways that leads to hyperinflation of the lungs.
Obstructive Lung Disorder
What are the different examples of Obstructive Lung Disorder?
(1) Asthma
(2) Chronic obstructive pulmonary disease (COPD)
(3) Chronic Bronchitis
(4) Cystic Fibrosis
This is known as the problem with inhalation and lung expansion.
Restrictive Lung Disorder
What are the different examples of Restrictive Lung Disorder?
(1) Asbestos, sarcoidosis and pulmonary fibrosis
(2) Myasthenia gravis, myopathies
(3) Kyphoscoliosis
(4) Tuberculosis, pneumonia and Acute respiratory syndrome (ARDS)
When examining the posterior thorax, what are the imaginary landmarks that should be identified?
(1) Vertebral Line
(2) Left and Right Scapular Lines
How should the nurse examine the posterior thorax?
(1) Identify imaginary landmarks
(2) Inspect curvature of the spine (Kyphosis, Lordosis, and Scoliosis)
(3) Observe for symmetry drop of shoulder towards one side
(4) Inspect skin for lesion, redness, bumps, and rashes
(5) Inspect chest shape and breathing pattern
What are the abnormal findings in a COPD patient?
(1) Pursed lip breathing
(2) Tripod breathing
(3) Barrel Chest
This is the hyperinflated lung seen among patients.
Barrel Chest
The Barrel Chest is most commonly observed among patients with:
(1) COPD
(2) Emphysema
(3) Chronic Asthma
(4) Cystic fibrosis
This type of breathing is characterized to have 14 to 20 breaths per minute.
Normal respiration
This type of breathing is characterized to have more 24 breaths per minute and is known to be shallow.
Tachypnea
This type of breathing is characterized to be regular and less than 10 breaths per minute.
Bradypnea
Where can tachypnea be observed?
(1) After exercise
(2) Pneumonia
(3) Pleurisy
Where can bradypnea be observed?
(1) Drug induced (narcotics)
(2) Neurological Patients
This is characterized to be the increased rate and depth.
Hyperventilation
Hyperventilation is most commonly seen as:
(1) Extreme exercise
(2) Diabetic Ketoacidosis
(3) Drug OD (Salicylates)
(3) Severe anxiety
This is characterized to be the decreased rate and depth along with irregular patterns.
Hypoventilation
Hypoventilation is most commonly observed in patients whom:
Overmedication (narcotics or anesthesia)
This is known as the alternating periods of deep, rapid breathing followed by periods of apnea and regular pattern.
Cheyne’s - Strokes Respiration
Cheyne’s - Strokes Respiration is most commonly observed in patients whom
(1) Congestive heart failure (CHF) or Kidney Failure
(2) Increased Intercranial Pressure
(3) Drug Overdose
This is characterized as the irregular pattern with varying depths of respiration followed by periods of apnea.
Biot’s respiration
Biot’s respiration is commonly observed among patients who have:
(1) Meningitis
(2) Brain Damage
How should the nurse palpate the posterior lungs?
(1) Palpate using your palms and follow the systematic sequence
(2) Vocal fremitus: Use your ulnar side of palm as you follow the systematic sequence; note for vibration over major airways.
(3) Thoracic expansion: locate the 10th rib and place your hands on each side with thumbs align and observe the thumb movement
What is the normal documentation of a patient following palpation?
No pain nor tenderness; vocal fremitus vibration felt over major airways; lung movement symmetrical on both directions.
How should the nurse percuss the posterior thorax?
Use your longest bone of the middle fingers; dominant hand as a “hammer”
This sound is heard if air is present and is usually heard over the lung areas.
Resonance
This sound is heard if area is a solid tissue like over the liver fluid or tumor.
Dull
This sound is heard over bone like over the intercostal spaces or scapulae.
Flatness
This sound is usually heard over people with emphysema.
Hype resonance
Dull sounds are most commonly heard in what areas?
(1) Bony prominence
(2) Heart
(3) Liver
What sounds are heard over the stomach region?
Tympanic
These auscultated sounds are heard when there is air movement in the lungs.
Vesicular Sounds
These auscultated sounds are heard when there is air inside a “pipe”
Bronchial sounds
These auscultated sounds are a combination of bronchial and vesicular sounds.
Bronchovesicular sounds
This adventitious breath sound is characterized as a high pitched musical tone heard on both inspiration and exhalation in Acute Asthma and chronic emphysema.
Sibilant (Wheezes)
This adventitious breath sound is characterized as low pitched moaning sounds heard mostly on expiration in bronchitis; snoring before sleep apnea.
Sonorous (Wheezes)
This adventitious breath sound is heard upon inspiration.
Crackles
This adventitious breath sound is is characterized to be popping, high pitched and heard in atelectasis and pneumonia.
Fine crackles
This adventitious breath sound is characterized to be a bubbling sound heard with pneumonia, pulmonary edema and fibrosis.
Coarse crackles
What is the anatomical landmark to be identified during blunt percussion of the kidney?
Posterior Flank or Costovertebral Angle
What should the nurse do during blunt percussion of the kidney?
(1) Below the 12th rib and above the posterior hip bone
(2) Place palm on the area and use other hand like a fist and thump on top of the other hand
What is the normal documentation of the blunt percussion of the kidney?
No tenderness, no pain
What are the normal lung sounds?
(1) Vesicular (normal lung sound when there is a passing of air)
(2) Broncho vesicular
The apex of lungs in posterior is located where?
Level of cervical prominence
The apex of lungs in anterior is located where?
Above the clavicle
The lung is covered by what?
Pleura (In blood trauma, you can have a pleural effusion or a lung filled with fluid. If you don’t remove the fluid, it will push back the entire lung)
This is the inflammation of the pleura, it hurts so much that it needs to be treated with antibiotics.
Pleuritis
This is the inner layer that covers the lungs.
Vesicular Pleura
This is the outer layer that covers the lung and attaches to the chest wall.
Parietal Pleura
How do you get better expansion of the lungs?
If you move your arms little bit higher, you will have a better expansion of the lungs.
What kind of position do people with lung disease use?
Most of the people with lung disease use tripod position by leaning forward and putting arms away from the chest to get better inhalation and expiration. This gives better expansion of the lungs.
What kind of position do obese people use?
Anatomically, an obese person’s expansion of the lungs will only be limited – instead of fully expanding, it will only move limitedly because of arm’s fat heaviness
This is the lining of the inner chest wall.
Parietal Pleura
This is the lining of the lungs.
Visceral Pleura
What happens to your pleura when you get hit by a car?
When you get hit by car, the side of the body gets hit, the pleura will have a confusion and a hole which will result in pleural effusion and occupy space; hence leading to a limited expansion of the lungs; thus compromising the patient’s oxygenation.
What does no lung sounds and have dull sounds instead of resonant sounds indicate?
Pleural Effusion (Intervention: Chest Tube)
This is the u-shaped notched form clavicle going to the middle.
Suprasternal notch
This is the anatomical landmark below the suprasternal notch.
Manubrium
This is the elevated part of the chest, where your second intercostal space starts and where heart sounds can be heard. This is also where the bronchus ends and separates as bronchioles.
Angle of Louis
This is the area spanning from the angle of louis to the xiphoid process (where the sternum ends.)
Sternum
How does a nurse enact CPR?
In doing CPR, heel of palm should be below angle of louis and two fingerbreadths above the xiphoid process, it is exactly where your heart is.
This anatomical landmark is important because it is where your heart starts, where pulmonary veins are.
Angle of Louis
This anatomical landmark is the top of the manubrium.
Suprasternal Notch
This anatomical landmark is the “tie in necktie.”
Manubrium
This anatomical landmark is the connection between the manubrium and sternum (where your aorta is).
Angle of Louis
Where are aortic sounds heard?
Right Angle of Louis
Where are pulmonic sounds heard
Left Angle of Louis
This anatomical landmark is the end of your sternum.
Xiphoid Process
How many lobes does your right lung have?
3 Lobes
How many lobes does your left lung have?
2 lobes
What should the nurse inspect for the anterior chest?
(1) Skin rash, lesions
(2) Nodules, masses and scars
How should the nurse percuss anent assessment of anterior thorax?
Percussions is not used in cardiac assessment but of the anterior chest (do not percuss the heart, we percuss the lungs).
How should the nurse auscultate anent assessment of anterior thorax?
(1) Use diaphragm of stethoscope on ICS to listen to breath sounds
(2) Start at the Rt supraclavicular area
(3) Follow systemic sequence 1-10
(4) Ask patient to inhale and exhale slowly as you move the stethoscope
(4) When you listen to your lungs, it doesn’t need to be near the sternum but when you listen to your heart, it needs to be near the sternum
Where are bronchial sounds heard in the anterior chest?
Neck (louder)
Where are bronchovesicular sounds heard in the anterior chest?
Below the clavicle away from the sternum (not soft, nor loud)
Where are vesicular sounds heard in the anterior chest?
In the intercostal spaces (middle of the chest); near the sternum
What are the following risk factors when assessing the heart?
(1) Age
(2) Sex
(3) Lifestyle (Sedentary)
(4) Smoking
(5) Alcohol Abuse
(6) Drug Abuse
(7) Obesity
(8) Hyper cholesteronemia
What are the most common problems in the heart?
(1) Disease of coronary arteries
(2) Disease of the heart valves
Explain the disparity of mortality anent heart attacks based on sex.
Mortality of heart attacks is higher in women and risk factors of having heart attack is higher in men. (Smoking and drug abuse is very high risk in heart attack)
This auscultated sounds pertains as to where the first sound “lub” is louder. This correlates with systole.
S1 - located in the aortic area
S1 - located in the aortic area transpires due to ___.
The closure of the AV valves called the Mitral and Tricuspid Valves
What is S1 - located in the aortic area in pqrs EKG?
R
This auscultated sound is where the second sound “dubb” is perceived louder. This correlates with diastole.
S2 - located in the pulmonic area
S2 - located in the pulmonic area transpires due to what?
The closure of semi-lunar valves called aortic and pulmonic valves.
This correlates with diastole and is perceived as “lubudub lubudub”
S3 - located in the tricuspid area
This correlates with diastole and is perceived as “lububdub lububdub”
S4 - located at the mitral area (where lub and dubb are perceived the loudest)
This pericardium is the perceived as the outer layer.
Fibrous Pericardium
This pericardium is the perceived as the parietal and visceral layer.
Serous Pericardium (Usually lining the pericardial cavity)
What is the abnormal sound in the pericardium?
Pericardial rub (usually associated with pericarditis)
This transpires to patients who have kidney failure and refuse to partake in dialysis.
Pericarditis
In this serious complication of pericarditis, the blood pressure will drop and the jugular vein will be perceivable. Usually heard as lubKK lubKK
Cardiac Tamponade
Where is S1 heard?
Aortic Area - Right Second Intercostal Space - Lub is more prominent
Where is S2 heard?
Pulmonic Area - Left Second Intercostal Space - Dubb is more prominent
Where is S3 heard?
Tricuspid Area - Between the left 4th and 5th sternal intercostal space (murmur heard near the sternum) - the Lub and the Dubb are equally prominent
Where is S4 heard?
Mitral Area - Murmur heard at the 5th intercostal midclavicular (below the nipple) - This is the area where the Lub and the Dubb are heard the loudest
What should the nurse do when auscultating for S3 and S4?
Switch to the bell of stethoscope
In this, (Lub louder than Dubb) right side, 2nd intercostal space (ICS).
S1
In this, (Dubb us louder than Lub) left side, 2nd ICS.
S2
In this, lubudub lubudub (abnormal sound – heart murmur heard in the tricuspid area) 4th ICS near sternum.
S3
In this, lububdub lububdub (abnormal sound – heart murmur heard at the mitral area) 5th ICS; usually bellow nipple.
S4
How should the nurse position and locate the client when obtaining the Point Maximum Impulse (PMI)?
(1) Position patient on the left side
(2) Locate PMI: use your second and third fingers, press fingers below the nipple line (male), 5th intercostal space midclavicular
(3) Female with large breasts, ask patient to lift up the left breast with hand during assessment
How do you describe the anatomy of the breast with patients who have breast implants?
For People with breast implants, the implant gets hard over time (after 20 years) like a rock because our fats shrink in time.
What should the nurse inquire a female patient prior to conducting the breast examination?
Ask patient first if they’re on their period – because breast is tender when on period.
This is a predominant factor considered in cases of breast cancer.
Heredity
How will you compare the adipose tissue of men in contrary to women?
Adipose tissue in men are smaller.
This medical condition is observed when men have large adipose tissues; resulting to an enlarged breast.
Gynecomastia
What should the nurse do when inspecting the breasts?
The nurse should observe for:
(1) Skin changes (Peau de Orange) – orange like skin; means advanced cancer
(2) Symmetry (are they symmetrical or equal?) Dimpling and retractions on four positions
What are the four (4) positions that the nurse instructs the client to do when observing for dimpling and abnormal retractions?
(1) Arms on waist
(2) Arms and hands above hear
(3) Bend Over
(4) Hands or palms squeezed together
How should the nurse palpate?
(1) Use 2nd, 3rd, and 4th fingers
(2) Start at medial chest; move in circular motion around the breast and end at the nipple area.
How should the nurse enact the nipple pinch?
(1) Observe for drainage (If clear fluid comes out, the patient is most likely to have breast cancer)
(2) Observe for Pain and tenderness in the area examined.
How should the nurse palpate the lymph nodes?
(1) Palpate axillary lymph nodes using 2nd, 3rd, and 4th fingers
(2) Palpate in a circular motion
What are the lymph nodes to be palpated in the axillary region?
(1) Brachial (Lateral)
(2) Midaxillary (Central)
(3) Subscapular (Posterior)
(4) Pectoral (Anterior)
(5) Supraclavicular
(6) Infraclavicular
How should the nurse document the breast examination?
(1) Inspection: Lt and Rt breasts
(a) Skin – no lesions Lt and rt breasts are symmetrical
(b) No dimpling and no retractions upon change in positions
(2) Palpation: no mass/ nodule nipples WNL (within
normal limits) without drainage
How should the nurse perform bi-manual examination?
(1) Performed when breasts are very large and pendulous
(2) Use 4 fingers of both hands; place one hand superior and second hand inferior of the breast
(3) Upper hands are used to apply pressure while lower hand is used to detect deep structures
(4) Move upper hand with circular motion with light to moderate pressure
