Prefinal - Thorax Flashcards
maneuver is a test used in an exam of neurological function for balance
Romberg’s Test
Excessive swaying when eyes are open or closed =
cerebellar deficit/cerebellar ataxia
Excessive swaying only when eyes are closed = (this is a positive Romberg’s sign)
procioceptive deficit/sensory ataxia
Nasal abnormality during breathing that is significant with labored or dyspnea and is indicative of hypoxia.
Nasal flaring
is a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis
Hypoxia
Nasal abnormality during breathing that is significant in asthma, CHF, and COPD.
Pursed lip breathing
is indicative of emphysema (gradual thinning and destruction of the alveoli or air sacs) due to hyperventilation of the lungs.
Barrel-chest
The gradual thinning and destruction of the alveoli or air sacs
Emphysema
The client should not be using accessory (trapezius/shoulder) muscles to assist breathing.
This position is taken by clients with difficulty breathing. It includes the inability to lie flat, leaning forward with arms and elbows supported over the bed table.
Tripod position
Possible Etiology for the Tripod Position
COPD, Asthma in exacerbation, and pulmonary edema indicate moderate to severe respiratory distress
Exaggeration of thoracic curve caused by muscular weakness or structural changes in vertebral bodies/ intervertebral discs. It is often due to weakness in the spinal bones that causes them to compress or crack
Kyphosis
Exaggeration of lumbar curve caused by diseases of the vertebral column like spondylolisthesis. There are several causes and risk factors, including congenital conditions, uneven posture, and injuries.
Lordosis
is a condition that occurs when one vertebral body slips with respect to the adjacent vertebral body causing radicular or mechanical symptoms or pain.
Spondylolisthesis
Kyphosis = stomach in, Lordosis = stomach out
Palpate posterior thorax for tenderness. Palpate also crepitus and fremitus (vibrations of air in the bronchial tubes transmitted to the chest wall). Ask the client to say 99.
This lung sound is usually significant in bronchial obstruction (foreign body, tumor, thick secretions, spasm), air trapping in emphysema (thinning and destruction of alveoli), pleural effusion (water in the lungs), and pneumothorax (air leakage).
Unequal fremitus
Normally, a 2-5” chest expansion can be observed.
Symmetric chest expansion
Place warmed hands on posterolateral chest wall with thumbs at level of T9 or T10 Slide hands medially to pinch up a small fold of skin between thumbs
Ask the person to take a deep breath As the person inhales, the thumbs should move apart symmetrically Unequal chest expansion occurs with atelectasis, pneumonia, thoracic trauma
Pain accompanies deep breathing when pleurae are inflamed
Unequal chest expansion is significant in clients with the following disorders:
- Severe atelectasis, collapse or incomplete expansion
- Pneumonia, lung infection
- Chest trauma
- Pneumothorax
- COPD
drum-like sounds heard over air-filled structures during the abdominal examination
Tympany -
(pneumothorax), said to sound similar to percussion of puffed-up cheeks, extremely abnormal sound
Hyperresonance -
the sound produced by percussing a normal chest.
Resonance
similar to percussion of a mass such as a liver
Dullness
heard on hard surfaces like bone
Flatness
Harsh, high-pitched
I=E
Above the supraclavicular notch, over the trachea
Tracheal
Loud, high-pitched
I<E
Just above the clavicles on each side of the sternum, over the manubrium
Bronchial
Medium in loudness and pitch
I=E
Next to the sternum, between the scapulae
Bronchovesicular
Soft, low-pitched
I>E
Remainder of lungs
Vesicular
is a deformity of the chest wall where there is an unusual bulging of the anterior thoracic wall.
Pectus carinatum
is a deformity of the anterior thoracic wall that produces a caved-in or sunken appearance of the chest.
Pectus excavatum
Retraction of the thoracic cage is significant in increased inspiratory effort. Bulging is indicative of trapped air like asthma.
Inspect pulsations with the client in a supine position with the head elevated between 30 and 45 degrees. The nurse should stand on the client’s right side.