WEEK 4- LUNG AND THORAX Flashcards
Inspection
Assess thoracic cage
Measure respirations
Assess skin colour and condition
Evaluate patient’s position
Observe patient’s facial expression
Assess level of consciousness
Palpation
Confirm symmetrical expansion
Assess tactile fremitus
Detect any lumps, masses, tenderness
Percussion
Percuss over lung fields
Estimate diaphragmatic excursion
Auscultation
Assess normal breath sounds
Note any abnormal breath sounds
If breath sounds are abnormal, perform bronchophony,
whispered pectoriloquy, and egophony
Note any adventitious sounds
TACTILE FREMITUS
the vibration of the chest wall that results from sound vibrations created by speech or other vocal sounds.
A man’s reason for seeking care is difficulty breathing. When you auscultate his lower lung fields, you hear bronchial sounds in his right and left lower lobes. What would this assessment indicate?
abnormal variation
What is the most accurate way to auscultate the lungs?
Ask patient to breathe through the mouth, deeper than usual and out
a normal variation
Upon inspection of Mr. Z, you note that his anteroposterior to transverse diameter ratio is 1:1. What would this indicate?
What changes would you expect in an aging adult?
less distensible lungs
Which is true regarding the auscultation? Select all that apply.
The stethoscope does not magnify sounds
The bell is best used for low-pitched sounds
The nurse cannot hear resonance when auscultating
Expected assessment findings in the normal adult lung include the presence of
muffled voice sounds and symmetrical tactile fremitus
Unequal chest expansion occurs when:
part of the lung is obstructed or collapsed
The assessment of the lateral chest wall is:
Referred to as the forgotten lobe
Auscultation of breath sounds is an important component of respiratory assessment. An accurate description of this part of the examination
Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons
When examining for tactile fremitus it is important to:
palpate the chest symmetrically
thoracic landmarks
Suprasternal notch
Sternal angle (angle of Louis/ manubriosternal angle)
Sternum, ribs & xiphoid process
Diaphragm
Costal angle
Intercostal spaces
posterior thoracic cage
Vertebra prominens
C7 & T1
Spinous processes
Inferior border of scapula
Twelfth rib
reference lines: anterior and posterior
Anterior (arms at side)
Midsternal line
Midclavicular line
Bisects center of each clavicle
Posterior (arms at side)
Vertebral line (midspinal)
Scapular line
Extends through inferior angle of scapula
reference lines: lateral
Lateral (pt’s arm 90°)
Midaxillary line
Anterior axillary line
Posterior axillary line
the lungs
Apex & base
Lobes
Trachea & bronchi
Acinus
Visceral & parietal pleurae
Pleural cavity
Potential space
approach the client:
- maintain and provide privacy/hygiene
- curtain, draping, hand washing before and hand, clean equipment
communicating w client
introduce yourself, first, last name, designation
- questions
general survey
physical appearance,
body structure
mobility
behavior
subjective data
Cough
Shortness of breath
Chest pain with breathing
History of respiratory infections
Smoking history
Environmental exposure
Self-care behaviors
objective data
Preparation
Sitting upright
Draping
Clean stethoscope
Posterior, then Anterior
Inspection, Palpation, Percussion, & Auscultation
inspection-posterior
Position person takes to breathe
Skin colour & condition
Shape & configuration of chest wall
Spinous processes
Thorax & scapula
Neck & trapezius muscles
Anteroposterior diameter to transverse diameter
palpation- posterior
Palpate chest wall
Tenderness, temperature, moisture & masses/lumps
Explore lesions noted upon inspection
Symmetrical expansion
Thumbs at T9/T10
Tactile fremitus
Palpable vibration that should be symmetrical
Ask client to say “99”
percussion-posterior
Underlying structures
Characteristic sounds
How?
Start at apices
shoulders
Interspaces
Bilaterally
Notes
Resonance, hyperresonance and dull notes
auscultation-posterior
-Position of client
-Stethoscope
-Client instructions
-Full breath
Findings
Presence of air entry
Lobes & bilateral
Quality of air entry
Clear (any adventitious sounds)
Location of bronchial, bronchovesicular & vesicular breath sounds heard
“Air entry clear in all lobes & equal bilaterally, no adventitious sounds” (also, important to note where bronchial, bronchovesicular & vesicular breath sounds heard)
normal breath sounds: 3
bronchial, bronchovesicular, vesicular
bronchial breath sound
harsh, hollow, tubular, high, loud
bronchovesicular breath sound
mixed, moderate
vesicular breath sound
wind in the trees, rustling, low
adventitious breath sound
Crackles
Pneumonia, heart failure, pulmonary edema, bronchitis, asthma or emphysema
Wheezes/ronchi
Obstructed airways (e.g., asthma, emphysema or bronchitis, tumour)
Stridor
High pitched inspiratory sound in upper airways
Croup, obstructed airway or epiglottitis
Pleural fiction rub
Superficial, course & low pitched sound (grating)
crackles
Pneumonia, heart failure, pulmonary edema, bronchitis, asthma or emphysema
wheezing
Obstructed airways (e.g., asthma, emphysema or bronchitis, tumour)
stridor
High pitched inspiratory sound in upper airways
Croup, obstructed airway or epiglottitis
pleural fiction rub
Superficial, course & low pitched sound (grating)
inspection- anterior
facial expression and LOC
quality of respiration
skin colour/condition
lips, nail beds, lesions
interspaces and accessory muscle
shape and configuration wall
palpation- anterior
Tenderness, temperature, moisture, skin mobility/turgour & masses
Symmetrical chest expansion
Tactile fremitus
percussion-anterior
Notes
Resonance
Hyperresonance
Dull notes
How
Start at apices
supraclavicular
Interspaces
Bilaterally
auscultation- anterior
Findings
Presence of air entry
Lobes and bilateral
Quality of air entry
Clear (any adventitious sounds)
Location of bronchial, bronchovesicular & vesicular breath sounds heard
“Air entry clear in all lobes and equal bilaterally, no adventitious sounds” (also, important to note where bronchial, bronchovesicular & vesicular breath sounds heard)
abnormal findings
respiration less than 93%,
Rate
Tachypnea
Bradypnea
Rate and depth
Hyperventilation
Hypoventilation
Cheyne-Stokes respiration
developmental considerations- pregnancy
costal angle wides, increase in transverse diameter of thoracic cage
infant lungs:
normal RR new born 30-40, lungs do not work untill birth
developmental considerations- adult
calcification of cartilage
lung becomes rigid (decrease in vital capacity and increase residual volume)
- increase risk for shortness of breath
cultural/social considerations
tuberculosis
asthma and resp diseases
COPD and women
health promotion
cut off tobacco
- stop smoking
- Identify the location of the apex & base of the lung anteriorly & posteriorly & locate landmarks for each lobe.
- Identify anterior & posterior landmarks where the trachea bifurcates
- Differentiate between the following percussion notes: dullness, resonance, hyperresonance & tympany.
- Identify locations of bronchial, bronchovesicular & vesicular on the posterior & anterior thorax.
equipment
- Outline abnormal assessment findings. Barrel chest, pectus excavatum, pectus carinatum, scoliosis, kyphosis, tachypnea, bradypnea, hyperventilation, hypoventilation
Barrel Chest: This refers to a rounded, bulging chest shape that resembles the shape of a barrel. It’s often associated with chronic obstructive pulmonary disease (COPD) or emphysema.
Pectus Excavatum: Also known as “sunken chest,” this is a deformity of the chest wall where the sternum and rib cage grow abnormally, causing a caved-in appearance of the chest.
Pectus Carinatum: This is the opposite of pectus excavatum, where the sternum protrudes outward, creating a “pigeon chest” appearance.
Scoliosis: This is a sideways curvature of the spine, which can vary in severity. It may cause the shoulders or waist to appear uneven.
Kyphosis: This refers to an excessive outward curvature of the spine, causing a rounded upper back, often termed “hunchback” or “hunching.”
Tachypnea: This is an increased respiratory rate, meaning the person is breathing faster than normal. It can be a sign of various medical conditions such as respiratory distress, fever, anxiety, or metabolic acidosis.
Bradypnea: Conversely, bradypnea is a slower than normal respiratory rate. It can be a sign of respiratory depression, neurological problems, or certain medications.
Hyperventilation: This occurs when a person breathes at a faster rate or deeper than necessary, leading to decreased levels of carbon dioxide in the blood. It can be caused by anxiety, panic attacks, or medical conditions such as diabetic ketoacidosis.
Hypoventilation: This is the opposite of hyperventilation, where breathing is too shallow or slow, leading to inadequate exchange of oxygen and carbon dioxide in the lungs. It can occur in conditions like sleep apnea, respiratory muscle weakness, or drug overdose.
These abnormalities can indicate various underlying health conditions and may require further evaluation and management by healthcare professionals.
