Week 4 Flashcards
Thoracic cage: what is it how how is it defined?
Bony structute with a conical shape which is more narrow at the top
- sternum, 12 pairs of ribs and 12 thoracic vertebrae
Diaphragm
Flood the of thoracic cage, a musculotendinous septum that separates thoracic cavity from abdomen
Describe the different types of ribs
First 7 ribs are attached to sternum by costal cartilages
Rubs 8-10 are attached to costal cartilage above
Ribs 11 and 12 are “floating” with free palpable tips
Costochondral junctions
Points at which ribs join their cartilages; they are not palpable
Suprasternal notch
Hollow U-shaped depression just above sternum between clavicles.
Sternum
“Breastbone” has 3 parts — manubrium, body and xiphoid process
Manubriosternal angle
“Angle of Luis” at articulation of manubrium and sternum, and continuous with second rib
Each intercostal space is numbered by what
Each intercostal space is numbered by rib above it
What does the Angle of Louis mark?
The site of tracheal bifurcation into right and left main bronchi; corresponds with upper border of atria of the heart and it lies above 4th thoracic vertebra on back
Costal angle
The right and left costal margins form an angle where they meet at the xiphoid process
— usually 90 degrees or less, increases when rib cage is chronically overinflated, as in emphysema
What are reference lines you can imagine on your patient when they are facing anteriorly?
Anterior axillary line, midclavicular line, midsternal line (lateral to medial)
What are lines you can imagine on your patient when they are facing you posteriorly?
Scapular line, vertebral line (lateral to medial)
What are lines you can imagine on your patient when you are looking at them from the side?
Posterior axillary line, mid axillary line, anterior axillary line
Anterior axillary line
Extends down from anterior axillary fold where pectoral is major muscle inserts
Posterior axillary line
Continues down from posterior axillary fold where latissimus Doris muscle inserts
Midaxillary line
Runs down from apex of axilla and lies between anterior and posterior axillary lines
Mediastinum
Middle section of thoracic cavity containing esophagus, trachea, heart and great vessels
Right and left pleural cavities
Encase lungs
Lung borders
In anterior chest, apex of lung tissue is 3 of 4 cm above inner third of clavicles
Laterally, the lung tissue extends from apex of axilla down to that
7th or 8th rib
Posteriorly, the location of C7 marks what?
Apex of lung tissue, and T10 usually corresponds to base
— deep inspiration expands lungs, and their lower border drops to level of T12
Why is the right lung shorter than the left
Because liver is under it
Why is the left lung more narrow then the right
Heart bulges to the left
How many lobes does each lung have?
Right = 3 Left = 2
What is the most remarkable point about posterior chest?
It is almost all lower lobe
Upper lobes occupy a smaller band of tissue from their apices at what part of posterior chest?
T1 down to T3 to T4
Lobes of the lung, lateral chest:
Lung tissue extends from apex of axilla down to 7th or 8th rib
— right upper lobe extends from apex of axilla down to horizontal fissures at 5th rib
— right middle lobe extends from horizontal fissure down and forward to 6th rib at midclavicular line
— right lower lobe continues from 5th rib to 8th rib in midaxillary line
Lobes of left lung: the 2 lobes of the left lung are seen where?
Laterally as two triangular areas separated by oblique fissue
Lobes of the left lung, things to keep in mind
Left lung has no middle lobe
Anterior chest contains mostly upper and middle lobe with very little lower lobe
Posterior chest contains almost all lower lobe
Pleurae
Thin, slippery pleurae form envelope between lungs and chest wall
Visceral pleura
Lines outside of lungs, dipping down into fissures
Parietal pleura
Lining inside chest wall and diaphragm
Pleural cavity is a potential space, meaning what
Filled only with few mL of lubricating fluid
Pleural cavity normal has a vacuum, or negative pressure, which does what
Holds lungs tightly against chest wall
Trachea
Lies anterior to esophagus and is 10 to 11 cm long in the adult
— begins at level of cricoid cartilage in next and bifurcated just below sternal angle into right and left main bronchi
Where is the trachea bifurcation posteriorly
T4 or T5
Describe the anatomy of right main bronchus
Shorter, wider, and more vertical then the left main bronchus
Trachea and bronchus role
Transport gases between the environment and lung parenchyma
Bronchi are lined with goblet cells and cilia, which do what
Secrete mucus that entraps particles
— also lined with cilia, which sweep particles upward where they can be swallowed or expelled
Acinus
A functional respiratory unit that consists of bronchioles, alveolar ducts, alveolar sacs and the alveoli
4 major functions of respiratory system
A. Supply o2 to the body for energy production
B. Remove CO2 as a waste product of energy reactions
C. Maintain pH balance for homeostasis
D. Maintaining health exchange
How to the lungs help maintain balance by adjusting level of CO2 through respiration
A. Hypoventilation causes CO2 to build up in blood
B. Hyperventilation causes CO2 to be blown off
Normal stimulus to breath for most of us?
Increase in CO2 in blood (hypercapnia)
Describe the development of an infants respiratory system
Infants body systems all develop in utero, but the respiratory system alone does not function until birth; birth demands its instant performance
— during the first 5 weeks, primitive lung bud emerges
— respiratory development continues throughout childhood
Conditions associated with environmental tobacco smoke in infants and children
Sudden infant death syndrome, negative behavioral and cognitive functioning, increased rates of adolescent smoking
Prenatal and postnatal exposure to second hand smoke increase the child’s risk for what
Low birth weight
Chronic otitis media
Obesity
Enlarging uterus elevates diaphragm how much during pregnancy
4 cm
— decreases vertical diameter of thoracic cage, but this decrease is compensated for by an increase in horizontal diameter
— increase in estrogen level relaxes chest cage ligaments
Aging adults and costal cartilages
Become calcified which produce less mobile thorax
Why is aging lung harder to inflate
More rigid in structure
Why is there less surface area available for gas exchange in the aging lung
Histologic changes (gradual loss of intra-alveolar septa and a decreased number of alveoli)
Why does the aging lung base become less ventilated
As a result of closing off a number of airways
Histologic complications increase the older persons risk of what
Postoperative pulmonary complications
Subjective data collection for respiratory system
History of present health concern (COLDSPA)
Past health history
Family history
Lifestyle and health practices
Objective data preparation for collecting data on respiratory system
Provide respect and comfort while allowing for access of examination techniques
Tripod position seen in COPD: what is it?
Client leans forward
Uses arms to support weight
Lifts chest to increase breathing capacity
Inspection: respiration’s
Observe quality and pattern
Breathing characteristics (rate, rhythm, depth)
Labored and noisy (could indicated asthma or bronchitis)
What actions to you perform for respiratory system
Inspection, palpation, percussion, auscultation
Inspection: thoracic cage
Note shape and configuration of chest wall
Spinous process should appear in a straight line; thorax is symmetric, in an elliptical shape, with downward slopping ribs, about 45 degrees relative to spine; scapulae are placed symmetrically in each hemithorax
Symmetric expansion: confirm
Confirm symmetric expansion by placing your warmed hands on posterolateral chest wall with thumbs at level of T9 and T10
Symmetric expansion: slide
Slide hands medically to pinch up small fold of skin between your thumbs; ask person to take a deep breaths
Symmetric expansion: note
Your hands serve as mechanical amplifiers; as a person inhales deeply, your thumbs should move apart symmetrically; note any lag in expansion
Tactile fremitus
Palpable vibration
- sounds generation from larynx are transmitted through bronchi and through lung parenchyma to chest wall, where you feel vibrations
Use palmer base of fingers or ulnar edge of one hand and touch persons chest while they say a phrase
Percussion: posterior chest — lung fields
Determine predominant note over lung feilds; start at apices and percussion band of normally resonant tissue across tops of both shoulders
Then, percussing in interspaces, made side-to-side comparison all the way down lung region
Percussion posterior chest - how many cm between each percussion
5 cm intervals - avoid damping effect of scapulae and ribs
Resonance
Low-pitched, clear, hollow sound that predominates in healthy lung tissue
— relative term and has no constant standard
Percussion posterior chest: what must be yielded to note an abdominal percussion note
Abnormal findings must be 2-3 cm wide to yield an abnormal percussion note; lesions smaller than that are not detectable by percussion
You should expect to hear three types of normal breath sounds in an adult or older child - what are they?
Bronchial
Bronchovesicular
Vesicular
These are found on the chest wall of adult and older child
Adventitious sounds
Added sounds that are not normally heard in lungs
Adventitious sounds: cause
Moving air colliding with secretions in tracheobronchial passageways or by popping open of previously deflated airways
Palpation of anterior chest: palpate symmetric chest expansion
Place your hands on anterolateral wall with thumbs along costal margins and pointing towards xiphoid processes
Why is limitation of thoracic expansion easier to detect on anterior chest
Because greater range of motion exists with breathing
Auscultation breath sounds: auscultation
Auscultation lung fields over anterior chest from apices in supraclavicular areas down to 6th rib
Auscultation breath sounds: progress
Progress from side to side as you move downward, and listen to one full respiration in each location
Auscultation breath sounds: use
Use sequence indicated for percussion; do not place stethoscope directly over female breast; displace breast and listen directly over chest wall
Auscultation breath sounds: evaluate
Evaluate normal breath sounds, noting any abnormal breath sounds and any adventitious sounds
Auscultation breath sounds: assess
If situation warrants, assess voice sounds
Breast surface anatomy contains
Nipple, areola, montgomery glands (elevated subcutaneous glands)
What are the 4 groups of lymph nodes that drain impurities from the breast
Central axillary nodes
Pectoral (anterior)
Sub-scapular (posterior)
Lateral
Where does drainage flow from the central axillary nodes
Up to the infraclavicular and supraclavicular nodes
Anterior nodes drain what
They drain the anterior chest wall and breast.
The posterior nodes drain what
Posterior chest wall and part of the arms
The lateral nodes drain what
Most of the arms
The central nodes receive drainage from what
Anterior, posterior and lateral lymph nodes
Describe the drainage from the nipples to the lymph nodes
Drain from nipple - up
What is the most common area for tumors to grow on the breast?
Tail of Spence
What quadrants is the breast divided into
Upper inner quadrant
Upper outer quadrant
Lower outer quadrant
Lower inner quadrant
When does estrogen stimulate breast changes
Puberty
Beginning of breast development process menarche about ____ years
2
When do breast begin to occur during pregnancy?
2nd month of pregnancy
Colostrum
Thick yellow fluid that is a precursor for milk, containing some amount of protein and lactose, but practically no fat
— rich with antibodies to protect newborn against infections, so breast feeding is important
When is colostrum present
May be expressed about month 4 of pregnancy
— breast produce colostrum for first few days after delivery
Developmental Competence: Aging women (5)
- After menopause, ovarian secretion of estrogen and progesterone decreases, causing breast glandular tissue to atrophy
- Decreased breast size; makes inner structures more prominent
- A breast lump may have been present for years, but is suddenly palpable
- Around nipple, the lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification
- Axillary hair decrease
Gynecomastia
During adolescence it is common for breast tissue to temporarily enlarge
— may appear in aging males due to lowered testosterone
What women are at an increased risk for developing breast cancer
Women who inherit mutations of BRCA-1 and BRCA-2 on one or both sides of the family
When should females start getting mammograms
Age 40
Breast cancer lifestyle risk factors
Alcohol has dose dependent effect
Continuation of physical exercise during aging helps reduce risk
Post menopausal weight gain negates effects of physical exercise
Factors contributing to breast health care access
Low income, lack of health insurance, geographic, cultural, and language barriers and racial bias
“Alcohol/Western” dietary pattern and breast cancer
“Alcohol/Wester” dietary pattern linked to increased risk of breast cancer, especially with estrogen or progesterone + tumors
“Mediterranean” diet and breast cancer
Linked to a modest protective affect against breast cancer
Second major cause of death from cancer in women
Breast cancer
Supernumerary nipple
An extra nipple along embryonic “milk line” on thorax or abdomen
- congenital
- normal variation
What does breast tissue feel like in nulliparous women vs after pregnancy
Nulliparous - firm, smooth, elastic
After pregnancy - softer and looser
Characteristics of lump of mass: location
Describe distance in cm from nipple; or diagram breast in woman’s record and mark location of lump
Characteristics of lump or mass: size
Judge in cm by width, length, depth
Characteristics of lump or mass: shape
State whether lump is oval, round, lobulated, or indistinct
Characteristics of lump or mass: consistency
State if lump is soft, firm or hard
Characteristics of lump or mass: movability
Is lump freely moveable or fixed when you try to slide it over chest wall?
Characteristics of lump or mass: distinctness
is lump solitary or multiple?
Characteristics of lump or mass: nipple
is it displaced or retracted
Characteristics of lump or mass: skin over lump
is it erythromatous, dimpled, or retracted?
Characteristics of lump or mass: tenderness
is lump tender to palpation?
Characteristics of lump or mass: lymphadenopathy
are any regional lymph nodes palpable?
why do premenopausal women who are mid-cycle make it hard to detect lesions?
they have tissue edema and mastalgia (pain) that make it difficult
Subjective questioning related to breast assessment (normal vs abnormal)
v
normal vs. abnormal breast changes
g
positioning for breast exam
g
Correct techniques used for breat assessment (inspection)
v
correct techniques for breast assessment (palpation)
v
Assessment findings associated associated with breast cancer
f
breast self-exam teaching and assessment of patient outcomes
g
