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Health Assessment > Thorax and Lungs (Exam 2) > Flashcards

Thorax and Lungs (Exam 2) Flashcards

1
Q

Thoracic Cage Structure

A

• sternum
• 12 pairs of ribs
• 12 thoracic vertebrae
• diaphragm

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2
Q

Diaphragm

A

floor of the thoracic cage; separates the thoracic cavity from the abdomen

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3
Q

Anterior Thoracic Landmarks (4)

A

• suprasternal notch (jugular notch)
• sternum
• eternal angle (angle of Louis)
• costal angle

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4
Q

Components of the sternum (3)

A

• manubrium
• body
• xiphoid process

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5
Q

Components of the sternal angle

A

• location to begin counting ribs
• site of tracheal bifurcation into right and left main bronchi

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6
Q

Costal angle

A

90° angle or less, increases with chronic inflammation

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7
Q

Why is it more difficult to count ribs posteriorly?

A

presence of muscle mass and soft tissue

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8
Q

Posterior Thoracic Landmarks (3)

A

• vertebra prominens
• spinous processes
• inferior border of the scapula

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9
Q

Vertebra prominens

A

• beginning point
• flex the head and feel for most prominent bony spur

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10
Q

Spinous processes

A

number correlates with rib number, angle downward from their vertebral body (T1, T2, etc.)

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11
Q

Anterior Chest Reference Lines (2)

A

midsternal line and midclavicular line

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12
Q

Lateral Chest Reference Lines (3)

A

anterior axillary, posterior axillary, and midaxillary

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13
Q

Posterior Chest Reference Lines (2)

A

vertebral (midspinal) line and scapular line

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14
Q

Mediastinum

A

middle section of thoracic cavity containing the esophagus, trachea, heart and great vessels

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15
Q

Pleural cavities

A

right and left, contains the lungs

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16
Q

Apex of the lung

A

3-4 cm above clavicle

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17
Q

Base of the lung

A

lower border, rests on the diaphragm

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18
Q

Right Lung v. Left Lung: Right

A

• shorter than the left
• has three lobes
• lobes are separated by fissures (oblique lines)

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19
Q

Right Lung v. Left Lung: Left

A

• longer than the right
• narrower than the right (heart bulges to the left)
• two lobes separated by oblique lines

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20
Q

What are pleurae and what are the 2 types?

A

serous membranes that form an envelope between the lungs and the chest wall; visceral and parietal

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21
Q

Visceral pleura

A

lines the outside of the lungs

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22
Q

Parietal pleura

A

lines the inside of the chest wall and diaphragm

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23
Q

Pleural cavity- Inside the envelope

A

space filled with few mL of lubricating fluid, which enables lung movement during breathing; vacuum or negative pressures to hold lungs tightly against the chest wall

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24
Q

Costodiaphragmatic recess

A

pleural space beneath the lungs; potential space for abnormal fill with fluid or air which compromises lung expansion

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25
Q

Bronchia components for protection (2)

A

• goblet cells
• cilia

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26
Q

Goblet cells

A

secrete mucous to entrap particles

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27
Q

Cilia

A

sweep particles upward to be expelled/swallowed

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28
Q

Acinus (functional respiratory unit) Components (4)

A

• bronchioles
• alveolar ducts
• alveolar sacs
• alveoli
GAS EXCHANGE OCCURS HERE

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29
Q

4 major functions of the respiratory system

A

I- supplying oxygen to the body for energy production
II- removing CO2 as a waste product of energy reactions
III- maintaining homeostasis (acid/base balance)
IV- maintaining heat exchange

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30
Q

Control of Respirations MAJOR FEEDBACK LOOP includes…(3)

A

• increase of CO2 in the blood (hypercapnia) is normal stimulus to breathe
• cellular demands may alter breathing patterns subconsciously
• respiratory control center in the brainstem results in involuntary breathing

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31
Q

Inspiration

A

air rushes into lungs
• diaphragm contracts, descends, and flattens
• FORCED inspiration due to exercise or chronic disease uses accessory neck muscle

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32
Q

Expiration

A

chest recoil, air is expelled and diaphragm relaxes
• FORCED expiration uses abdominal muscles to assist diaphragm

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33
Q

Vertical diameter of thoracic during respirations

A

downward/upward movement of diaphragm

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34
Q

Anteroposterior (AP) diameter of thoracic during respirations

A

elevation or depression of the ribs; increases or decreases

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35
Q

Developmental Considerations: Pregnant Women

A

• increased O2 demand from fetus
• enlarged uterus displaces diaphragm
• increased estrogen levels relax chest cage ligaments, allowing costal angle widening

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36
Q

Developmental Considerations: The Aging Adult

A

• costal cartilage becomes calcified and thorax is less mobile
• lung is more rigid and harder to inflate
• decreased number of alveoli, meaning less available surface area for gas exchange
• MORE AT RISK FOR POST OP COMPLICATIONS (decreased ability to cough, loss of protective reflexes, increased secretions)

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37
Q

Subjective Data: Respiratory System (13)

A

• cough (OLDCARTS)
• sputum (color, odor?)
• hemoptysis (coughing up blood)
• dyspnea (orthopnea, paroxysmal nocturnal dyspnea)
• chest pain (with/without breathing?)
• history of respiratory infections
• fatigue
• past health history
• family history
• psychosocial (child w/asthma? elderly w/memory concerns?)
• environmental conditions (working with pollutants?)
• smoking (pack years- # of packs/day x years)
• weight changes, fever, night sweats (TB?)

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38
Q

Orthopnea

A

difficulty breathing when supine

39
Q

Paroxysmal Nocturnal Dyspnea

A

awakening from sleep with SOB (shortness of breath)

40
Q

Tripod position

A

respiratory distress; leaning forward with elbows on knees

41
Q

Objective Data: Inspection

A

observe for retractions and use of accessory muscles
• lips (color, PURSED LIP BREATHING?)
• nares (nasal flaring, SOB)
• skin (cyanosis)
• nails (clubbing?)
• chest (symmetry or deformity, costal angle 90°)

42
Q

Signs and Symptoms of Hypoxia (11)

A

• RESTLESSNESS!!!!
• agitation, behavior changes
• decreased LOC
• apprehension and anxiety
• disorientation
• increased fatigue, HR, BP, and RR
• dyspnea
• arrhythmias
• pallor
• cyanosis (late)
• clubbing (chronic)

43
Q

Normal Adult Thorax

A

• elliptical shaped chest
• transverse diameter is 2x the AP diameter (AP:T= 1:2)

44
Q

Barrel Chest

A

• transverse diameter is same as AP diameter
• older adults, COPD

45
Q

Pectus Excavatum: Sunken Sternum/Funnel Chest

A

• present at birth
• sternum grows inward, causing chest wall to sink, can cause pressure on lungs and heart

46
Q

Pectus Carinatum: Forward protrusion of the sternum

A

• can increase during growth spurts
• braces or surgery can be done if it becomes painful, otherwise left alone

47
Q

Objective Data: Palpation for Anterior Chest

A

examine thoracic expansion (place hands along aterolateral wall with the thumbs pointing along costal margins toward xiphoid process)

48
Q

A lag in thoracic expansion may indicate…

A

atelectasis, pneumonia, and postoperative guarding

49
Q

A palpable grating sensation with breathing may indicate…

A

pleural friction fremitus

50
Q

Crepitus

A

air in the tissues

51
Q

Objective Data: Palpating Posterior Chest

A

chest expansion (place hands at base of chest with fingers spread and thumbs 5 cm apart, at 8th and 10th rib, place thumbs toward spine and create skin fold)

52
Q

Lung consolidation

A

occurs when normally air filled lung is engorged with fluid or tissue and fremitus becomes more pronounced; pneumonia

53
Q

Pleural effusion

A

collects in space between lung and chest wall, displacing lung upward; fremitus is decreased

54
Q

Objective Data: Palpating Tactile Fremitus

A

feeling for vibrations on chest wall when patient speaks; strongest over trachea, diminishes over bronchi and nonexistent over alveoli

have patient repeat ninety nine or one two three, use palmar or dorsal surface of hand and compare side to side from apex to base

55
Q

Objective Data: Percussion

A

• indirect, percuss over intercostal spaces in GREEK KEY PATTERN
• start with apices and progress in symmetrical fashion

56
Q

Resonant

A

healthy lung and bronchitis; clear, long low-pitched sound

57
Q

Dull

A

heard over fluid/masses in lungs; short, high-pitched, thudding sound that vibrates weirdly

58
Q

Hyperresonant

A

heard with air trapping and emphysema; a louder and longer, lower-pitched sound

59
Q

Objective Data: Auscultation

A

use diaphragm, patient breathing through MOUTH deeper than normal; start at apices, Greek key

60
Q

Breath sounds are produced by…

A

turbulent air flow

61
Q

Tracheal Breath Sound

A

normal; I<E; harsh, high-pitched

62
Q

Bronchial Breath Sound

A

normal; next to trachea; E>I; loud, high-pitched

63
Q

Bronchovesicular Breath Sounds

A

normal; sternal border between scapula; I=E; medium loudness and pitch

64
Q

Vesicular Breath Sounds

A

normal; heard over most lung fields; I>E; soft, low-pitched

65
Q

Decreased breath sounds occurs if… (4)

A

• fluid/pus has accumulated in pleural space
• secretions or foreign body obstructs bronchi
• lungs are hyperinflated
• shallow breathing

66
Q

Adventitious Breath Sounds

A

added sounds that are heard in addition to usual breath sounds

67
Q

Discontinuous sounds

A

crackles

68
Q

Continuous sounds

A

rhonchi, wheeze

69
Q

Crackles (rales)

A

may be fine, medium or coarse; caused by fluid in lower airways and heard during inspiration; not cleared with cough; sounds like RUBBING HAIR BETWEEN FINGERS

70
Q

Rhonchi

A

loud, low coarse noises during inspiration and expiration (increased with E); rumbling/snoring quality; may clear with cough; caused by thick secretions of muscular spasm in airways and passage of air through obstructed airway

71
Q

Wheeze

A

high-pitched, musical noise that is heard on I and E but is louder with E; caused by high velocity airflow through a narrowed airway

72
Q

Stridor

A

inspiration wheeze associated with upper airway obstruction

73
Q

Sighing

A

frequently interspersed deeper breathing

74
Q

Atelectasis

A

partial or complete collapse of a lung or lobe
• alveoli become deflated
• could occur due to fluid in lung, lung tumors, and chest injuries

75
Q

Atelectasis Complications (6)

A

• cyanosis
• cough
• increased RR and HR
• dull percussion
• breath sounds decreased or absent
• occasional fine crackles

76
Q

Acute Bronchitis

A

infection of the trachea and larger bronchi; cough greater than 3 weeks; large airways are narrowed; smokers, aging adults, children and winter

77
Q

Acute Bronchitis Complications (3)

A

• increased mucous production
• loss of cilia function
• swelling of epithelium

78
Q

Chronic Bronchitis

A

cigarette smoking; crackles over deflated areas and may have wheeze

79
Q

Chronic Bronchitis Complications (4)

A

• dyspnea
• fatigue
• cyanosis
• possible clubbing of fingers

80
Q

Emphysema

A

hyperinflated lungs and destruction of pulmonary connective tissue; permanent enlargement of alveoli with destruction of septa (alveolar walls); increases airway resistance especially on expiration

81
Q

Emphysema Complications (5)

A

• decreased breath sounds at auscultation
• prolonged expiration
• hyperresonance at percussion
• increased AP diameter
• accessory muscle use

82
Q

Pleurisy

A

lining of the lung becomes inflamed due to pulmonary infections; idiopathic

83
Q

Pleural Effusion

A

excessive fluid in pleural space with decreased or absent sounds; crackles, pleural rub; INCREASED RESPIRATIONS, DYSPNEA
• congestive heart failure, fluid overload or infection

84
Q

Pneumonia

A

inflammatory response to an infective agent; alveoli congested with WBC and bacteria causing consolidation; rhonchi or gurgles over affected area

85
Q

Pneumothorax

A

air in the pleural cavity resulting in lung collapse; unequal chest expansion and tracheal shift to opposite side; breath sounds decreased or absent on affected side
• tachypnea, cyanosis and apprehension may occur

86
Q

Asthma

A

bronchospasm and inflammation; WHEEZING, DYSPNEA AND CHEST TIGHTNESS
• raised concern if absent breath sounds

87
Q

Incentive Spirometer

A

prevents lung consolidation and pneumonia
• useful for surgical and bedbound patients
• instruct patients to inhale fully at a steady pace NOT EXHALE!!!

88
Q

Peak Flow Meter

A

used to monitor pulmonary function in asthma patients; patient must cooperate, ask them to inhale deeply and the exhale as fast as possible

89
Q

Ineffective Airway Clearance: Priority Nursing Diagnosis

A

• impaired cough
• incisional pain
• decreased LOC
• excessive tenacious secretions

90
Q

Impaired Gas Exchange: Priority Nursing Diagnosis

A

• decreased lung expansion
• prescence of pulmonary secretions
• inadequate O2 intake

91
Q

Ineffective Breathing Pattern: Priority Nursing Diagnosis

A

• depressed ventilation
• neuromuscular damage
• airway obstruction

92
Q

Risk for Infection: Priority Nursing Diagnosis

A

stasis of pulmonary secretions

93
Q

General Patient Goals for Respiratory Insufficiency (6)

A

• manage dyspnea
• maintain patient airway
• achieve and maintain adequate lung expansion
• achieve improved activity tolerance
• maintain and improve tissue oxygenation
• maintain and improve gas exchange

Health Assessment (19 decks)

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