Thorax and Lungs (Exam 2) Flashcards
Thoracic Cage Structure
• sternum
• 12 pairs of ribs
• 12 thoracic vertebrae
• diaphragm
Diaphragm
floor of the thoracic cage; separates the thoracic cavity from the abdomen
Anterior Thoracic Landmarks (4)
• suprasternal notch (jugular notch)
• sternum
• eternal angle (angle of Louis)
• costal angle
Components of the sternum (3)
• manubrium
• body
• xiphoid process
Components of the sternal angle
• location to begin counting ribs
• site of tracheal bifurcation into right and left main bronchi
Costal angle
90° angle or less, increases with chronic inflammation
Why is it more difficult to count ribs posteriorly?
presence of muscle mass and soft tissue
Posterior Thoracic Landmarks (3)
• vertebra prominens
• spinous processes
• inferior border of the scapula
Vertebra prominens
• beginning point
• flex the head and feel for most prominent bony spur
Spinous processes
number correlates with rib number, angle downward from their vertebral body (T1, T2, etc.)
Anterior Chest Reference Lines (2)
midsternal line and midclavicular line
Lateral Chest Reference Lines (3)
anterior axillary, posterior axillary, and midaxillary
Posterior Chest Reference Lines (2)
vertebral (midspinal) line and scapular line
Mediastinum
middle section of thoracic cavity containing the esophagus, trachea, heart and great vessels
Pleural cavities
right and left, contains the lungs
Apex of the lung
3-4 cm above clavicle
Base of the lung
lower border, rests on the diaphragm
Right Lung v. Left Lung: Right
• shorter than the left
• has three lobes
• lobes are separated by fissures (oblique lines)
Right Lung v. Left Lung: Left
• longer than the right
• narrower than the right (heart bulges to the left)
• two lobes separated by oblique lines
What are pleurae and what are the 2 types?
serous membranes that form an envelope between the lungs and the chest wall; visceral and parietal
Visceral pleura
lines the outside of the lungs
Parietal pleura
lines the inside of the chest wall and diaphragm
Pleural cavity- Inside the envelope
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
Costodiaphragmatic recess
pleural space beneath the lungs; potential space for abnormal fill with fluid or air which compromises lung expansion
Bronchia components for protection (2)
• goblet cells
• cilia
Goblet cells
secrete mucous to entrap particles
Cilia
sweep particles upward to be expelled/swallowed
Acinus (functional respiratory unit) Components (4)
• bronchioles
• alveolar ducts
• alveolar sacs
• alveoli
GAS EXCHANGE OCCURS HERE
4 major functions of the respiratory system
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
Control of Respirations MAJOR FEEDBACK LOOP includes…(3)
• 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
Inspiration
air rushes into lungs
• diaphragm contracts, descends, and flattens
• FORCED inspiration due to exercise or chronic disease uses accessory neck muscle
Expiration
chest recoil, air is expelled and diaphragm relaxes
• FORCED expiration uses abdominal muscles to assist diaphragm
Vertical diameter of thoracic during respirations
downward/upward movement of diaphragm
Anteroposterior (AP) diameter of thoracic during respirations
elevation or depression of the ribs; increases or decreases
Developmental Considerations: Pregnant Women
• increased O2 demand from fetus
• enlarged uterus displaces diaphragm
• increased estrogen levels relax chest cage ligaments, allowing costal angle widening
Developmental Considerations: The Aging Adult
• 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)
Subjective Data: Respiratory System (13)
• 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?)
Orthopnea
difficulty breathing when supine
Paroxysmal Nocturnal Dyspnea
awakening from sleep with SOB (shortness of breath)
Tripod position
respiratory distress; leaning forward with elbows on knees
Objective Data: Inspection
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°)
Signs and Symptoms of Hypoxia (11)
• RESTLESSNESS!!!!
• agitation, behavior changes
• decreased LOC
• apprehension and anxiety
• disorientation
• increased fatigue, HR, BP, and RR
• dyspnea
• arrhythmias
• pallor
• cyanosis (late)
• clubbing (chronic)
Normal Adult Thorax
• elliptical shaped chest
• transverse diameter is 2x the AP diameter (AP:T= 1:2)
Barrel Chest
• transverse diameter is same as AP diameter
• older adults, COPD
Pectus Excavatum: Sunken Sternum/Funnel Chest
• present at birth
• sternum grows inward, causing chest wall to sink, can cause pressure on lungs and heart
Pectus Carinatum: Forward protrusion of the sternum
• can increase during growth spurts
• braces or surgery can be done if it becomes painful, otherwise left alone
Objective Data: Palpation for Anterior Chest
examine thoracic expansion (place hands along aterolateral wall with the thumbs pointing along costal margins toward xiphoid process)
A lag in thoracic expansion may indicate…
atelectasis, pneumonia, and postoperative guarding
A palpable grating sensation with breathing may indicate…
pleural friction fremitus
Crepitus
air in the tissues
Objective Data: Palpating Posterior Chest
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)
Lung consolidation
occurs when normally air filled lung is engorged with fluid or tissue and fremitus becomes more pronounced; pneumonia
Pleural effusion
collects in space between lung and chest wall, displacing lung upward; fremitus is decreased
Objective Data: Palpating Tactile Fremitus
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
Objective Data: Percussion
• indirect, percuss over intercostal spaces in GREEK KEY PATTERN
• start with apices and progress in symmetrical fashion
Resonant
healthy lung and bronchitis; clear, long low-pitched sound
Dull
heard over fluid/masses in lungs; short, high-pitched, thudding sound that vibrates weirdly
Hyperresonant
heard with air trapping and emphysema; a louder and longer, lower-pitched sound
Objective Data: Auscultation
use diaphragm, patient breathing through MOUTH deeper than normal; start at apices, Greek key
Breath sounds are produced by…
turbulent air flow
Tracheal Breath Sound
normal; I<E; harsh, high-pitched
Bronchial Breath Sound
normal; next to trachea; E>I; loud, high-pitched
Bronchovesicular Breath Sounds
normal; sternal border between scapula; I=E; medium loudness and pitch
Vesicular Breath Sounds
normal; heard over most lung fields; I>E; soft, low-pitched
Decreased breath sounds occurs if… (4)
• fluid/pus has accumulated in pleural space
• secretions or foreign body obstructs bronchi
• lungs are hyperinflated
• shallow breathing
Adventitious Breath Sounds
added sounds that are heard in addition to usual breath sounds
Discontinuous sounds
crackles
Continuous sounds
rhonchi, wheeze
Crackles (rales)
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
Rhonchi
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
Wheeze
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
Stridor
inspiration wheeze associated with upper airway obstruction
Sighing
frequently interspersed deeper breathing
Atelectasis
partial or complete collapse of a lung or lobe
• alveoli become deflated
• could occur due to fluid in lung, lung tumors, and chest injuries
Atelectasis Complications (6)
• cyanosis
• cough
• increased RR and HR
• dull percussion
• breath sounds decreased or absent
• occasional fine crackles
Acute Bronchitis
infection of the trachea and larger bronchi; cough greater than 3 weeks; large airways are narrowed; smokers, aging adults, children and winter
Acute Bronchitis Complications (3)
• increased mucous production
• loss of cilia function
• swelling of epithelium
Chronic Bronchitis
cigarette smoking; crackles over deflated areas and may have wheeze
Chronic Bronchitis Complications (4)
• dyspnea
• fatigue
• cyanosis
• possible clubbing of fingers
Emphysema
hyperinflated lungs and destruction of pulmonary connective tissue; permanent enlargement of alveoli with destruction of septa (alveolar walls); increases airway resistance especially on expiration
Emphysema Complications (5)
• decreased breath sounds at auscultation
• prolonged expiration
• hyperresonance at percussion
• increased AP diameter
• accessory muscle use
Pleurisy
lining of the lung becomes inflamed due to pulmonary infections; idiopathic
Pleural Effusion
excessive fluid in pleural space with decreased or absent sounds; crackles, pleural rub; INCREASED RESPIRATIONS, DYSPNEA
• congestive heart failure, fluid overload or infection
Pneumonia
inflammatory response to an infective agent; alveoli congested with WBC and bacteria causing consolidation; rhonchi or gurgles over affected area
Pneumothorax
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
Asthma
bronchospasm and inflammation; WHEEZING, DYSPNEA AND CHEST TIGHTNESS
• raised concern if absent breath sounds
Incentive Spirometer
prevents lung consolidation and pneumonia
• useful for surgical and bedbound patients
• instruct patients to inhale fully at a steady pace NOT EXHALE!!!
Peak Flow Meter
used to monitor pulmonary function in asthma patients; patient must cooperate, ask them to inhale deeply and the exhale as fast as possible
Ineffective Airway Clearance: Priority Nursing Diagnosis
• impaired cough
• incisional pain
• decreased LOC
• excessive tenacious secretions
Impaired Gas Exchange: Priority Nursing Diagnosis
• decreased lung expansion
• prescence of pulmonary secretions
• inadequate O2 intake
Ineffective Breathing Pattern: Priority Nursing Diagnosis
• depressed ventilation
• neuromuscular damage
• airway obstruction
Risk for Infection: Priority Nursing Diagnosis
stasis of pulmonary secretions
General Patient Goals for Respiratory Insufficiency (6)
• 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
