Thorax & Lungs- Ch. 18 Flashcards
Structure and function
- ventilation
- regulate acid/base balance of blood
- regulate O2/CO2
- always listen to lung and heart sounds
Subjective data: health history questions
Cough
SOB
Chest pain while breathing
History of respiratory infections: pneumonia, TB, copd, lung surgery
Smoking history
Environmental exposure: work hazards
Self control behaviors: x-Ray, vaccines(pneumonia), TB, exercise, dental hygiene
Subjective-cough
Cough?: productive? What are you coughing up? Sputum?
Subjective- shortness of breath
activity, laying, sitting, how long?
COPD-has SOB very easily when doing simple things
*proximal nocturnal dyspnea- sob at night, CHF, pulmonary edema
Subjective: Chest pain when breathing
pneumonia, bronchitis- painful to palpate, jpainful to breathe in,
- muscle pain-reproducible
- chest pain cardiac related is non reproducible(angina)
Subjective- smoking history
Usually always have chronic adventitious sounds-crackles
Objective data: the physical exam
Prep: good positioning decreases position changes/⬇️SOB
Draping-support modesty
Inspect 👀
-posterior thorax
Thoracic cage- shape and configuration, position, skin color, spinal alignment (scoliosis, kyphosis), tripod position (copd)
Palpate ✋🏻
-posterior
-symmetrical expansion (chest expansion)- place thumbs at T9-10 and watch for hands to rise symmetrically
Tactile fremitus: sound/vibration generates thru the larynx-patent bronchi-chest wall. Place palms beginning with Apices (c7)
“99, blue moon”
* is it symmetrical ??
What would cause ⬆️ fremitus?
Pneumonia
What would cause ⬇️ tactile fremitus?
Obstruction, pneumothorax, emphysema, asthma
Anteroposterior-Transverse diameter
Front to back of thoracic cage
Transverse is 2x the size of ant/post
Normal 1:2*
Percussion 👆🏻
Posterior thorax
Begin with Apices (c7), listen and compare to other side (RtoL), is it symmetrical?
- L to R-compare
- resonance should be heard over lungs during percussion
- bone sounds flat
- organ sounds dull
Pleural friction fremitus
Inflammation in lung tissue
-sounds like “sand paper”
Auscultation 👂🏻
Listen for breath sounds in all fields
Posterior thorax
1) bronchovesicular sounds
2) vesicular sounds
Apices- will sound diminished
Feel for 1st intercostal
Bronchovesicular sounds
-Posterior
On sides of spine
⬆️-moderate pitch
Heard on inspiration and expiration
Vesicular sounds
-posterior
Along medial scapular border and down and around Ribs
⬇️ pitch
Heard on inspiration more than ex.
Adventitious sounds: any sound that is abnormal (not suppose to be heard in the lungs)
1- crackles: “rales”, snap, crackle, pop, when alveoli are not fully inflated with air * heard on inspiration
2- wheeze: “rhonchi”, heard mainly over explorations, asthma, emphysema
3- stridor: sounds like a wheeze buy more coarse, affiliated with allergic response, airway pushing air thru a constructed tube “snore”
Anterior thorax
👀 Inspect
Check skin, posture, LOC, quality of respirations (rr), intercostal spaces, accessory muscles (abdomen)?
*pigeon chest: indebted ant wall
Anterior thorax
Palpate ✋🏻
Completed posteriorly
Palpate for the ❤️
Sitting in upright position
Anterior thorax
Percussion 👆🏻
Resonance heard over lungs
We percuss posteriorly
Anterior thorax
👂🏻 Auscultation
*use diaphragm
Listen for breath sounds, adventitious sounds, 1 full cycle (in and out), listen L to R then compare
Anterior thorax
3 auscultation areas
1) Bronchial (tracheal): ⬆️ pitch, inspiration
2) bronchovesicular-⬆️ pitch, inspiration and expiration
3) vesicular- ⬇️ pitch, inspiration
Measurement of pulmonary function status:
Forced expiratory time
Pulse Ox
6- minute distance walk
Abnormal shapes of the thorax
barrel chest- A=P
pectus excavatum- inverted anterior chest wall
Pectus carinatum- protrusion of chest outward “pigeon chest”
Congenital
scoliosis, kyphosis
Common respiratory conditions
Lobar pneumonia CHF ARDS Emphysema Asthma
Sputum
Pink/frothy r/t pulmonary edema (life threatening)
Bloody sputum-hemoptysis
-viral infection: clear/white
-bacterial: yellow/green/rust
Anatomy
Posterior: vetebral prominens (sp of C7), sp of T3, clavicle, scapula (inferior angle), 12th rib
Anterior: suprasternal notch, manubrium of sternum, sternum, manubriosternal angle (angle of Louis), costal angle
Reference lines
Anterior
Mid sternal line: ⬇️ middle of sternum (angina pain)
Mid clavicar line: bisects each clavicle halfway between sternoclavicular and acromian joints
Reference lines
Posterior
Scapular line: extends thru the inferior angle of the scapula/arms at sides of body
Vetebral line: follows the spine
Lobes of the lungs
Right lung: 3 lobes (upper, middle, lower)
Ant-all
Post-mostly lower
Lat-all3
Left lung: 2 lobes (upper, lower)
Ant- both
Post- mostly lower
Lat-both
Reference lines
Lateral
Anterior axillary: extends ⬇️ from anterior axillary folds where the pec major inserts
Mid-axillary line: line extends ⬇️ from the apex of the axilla and lies between and parallel to the other 2
Posterior axillary line: line extends down from the posterior fold where the latissimus dorsi inserts
Lobes of lung
Anterior
Right- U-M-L
Left- U-L
Lobes of lung
Posterior
Right- U-L
Left- U-L
Lobes of the lung
Lateral
Right: U-M-L
Left: U-L
When we listen to lungs posteriorly which lobes do we listen to most of the time??
Lower lobes
Tactile fremitus would be increased when…?
The patient has an advanced case of pneumonia
Tactile fremitus would be decreased when…?
The patient has pleural effusion and when the patient has a blocker bronchus
True statement about percussion?
Percussion is helpful only in identifying surface alterations of lung tissue
