Chapter 18 Thorax Lungs Notes PDF

Preview

Summary

lecture notes...

Description

Jarvis Assessement Ch. 18 Thorax and Lungs NR 414 Nursing Assessment UNIT OBJECTIVES: Upon completion of this unit the student will be prepared to: Identify the components of the thoracic cage. Describe the surface landmarks on the thorax. List the contents of the mediastinum. Describe the borders and lobes of the lung. Explain the pleurae and their function. Discuss the location and functions of the trachea and bronchial tree. Summarize the mechanics of respiration. Discuss developmental care associated with the thoracic cavity. Differentiate adventitious sounds. Identify characteristics of normal breath sounds. Demonstrate appropriate gathering of subjective data of the respiratory system. Demonstrate general techniques of objective assessment of the respiratory system. Incorporate health promotion concepts and screenings when performing an assessment of the respiratory system. Correctly identify variations in health in the assessment of the respiratory system. Demonstrate documentation of subjective and objective data of the respiratory system. Structure and Function of the Thorax (chest bones) Anterior Thoracic Landmarks:  Sternum-breastbone, consists of manubrium (top), sternum body, and xiphoid process (cartilage at the bottom)  Suprasternal Notch-depression in the top of the sternum, on the manubrium between the two clavicle bones  Manubriosternal Angle/ Angle of Louis/ Sternal Angle Of Louis–It marks the joint between Manubrium and sternum- Manubriosternal joint. It lies at the level of 2nd costal cartilage anteriorly and between T4-5 vertebra posteriorly. Surface landmark- It is felt 5 cm below the suprasternal notch as a tranverse prominence.  Costal Angle- angle beneath the sternum (the inverted v of the ribs) that should be about 90 degrees. Barrel chests will have wider angle, which suggests lung disease Posterior Thoracic Landmarks • Vertebra Prominens- the prominent bones in the neck, the 7 th cervical vertibra is the most prominent. the most prominently detectable spinous process in most people • Spinous Processes- bony projections off the posterior of each vertebra that correlate with each rib • Inferior border of Scapula- lowest point of the scapula/shoulder blade. Know that breath sounds won’t be heard behind the scapula • Twelfth rib- bottom most rib, shortest rib, one of two floating ribs. 1-7 are attached to sternum, 8-10 are attached to cartilage, 11-12 float.

Anterior Reference Lines:  Midsternal line  Midclavicular line Posterior Reference Lines:  Vertebral (midspinal) line  Scapular line Lateral Reference Lines:  Anterior axillary line  Posterior axillary line  Midaxillary lines The Thoracic Cavity:  Mediastinum is the middle section of thoracic cavity o Contains esophagus, trachea, heart, & great vessels o Right & Left pleural cavities contain lungs o Lung Borders  Anterior:  Apex is 3-4cm above inner third of clavicle  Base rests on diaphragm o 6th rib in midclavicular line  Lateral: apex of axilla to 7-8th rib  Posterior: C7 apex, T10 base Lobes of the Lung: Anterior

  

Posterior

Right lung is shorter because of underlying liver and has three lobes, remember tri Left lung has two lobes Lobes are separated by fissures

Lobes of the Lung Left Lateral

Right Lateral

Pleura:  Serous membranes that form an envelope between lungs and chest wall  Visceral Pleura- lines outside of lungs, dipping into fissures  Parietal Pleura- lines inside of chest wall and diaphragm  Pleural cavity- inside of envelope, potential space, filled with only few ml of lubricating fluid, vacuum (neg. pressure)  Costodiaphragmatic recess- pleurae extend 3 cm below level of lungs, this is a “potential space” o Potential space exists for expansion, but it has fluid sitting in it so it has potential for infection. Trachea and Bronchial Tree:  Trachea is anterior to esophagus. Begins at cricoid cartilage and bifurcates below sternal angle into right and left bronchi o Right main bronchis is shorter, wider and more vertical than left main bronchus  Function to transport gases to and from lung parenchyma  They constitute dead space (of about 150 ml), no gas exchange occurs  Acinus is functional respiratory unit o Consists of bronchioles, alveolar ducts, alveolar sacs, alveoli Mechanics of Respiration Respiration involves ventilation, diffusion, and perfusion. Ventilation (or breathing) is movement of gases in and out of the lungs; inspiration (or inhalation) is the act of breathing in, and expiration (or exhalation) is the act of breathing out. Unlike heart rate, which is controlled by the autonomic nervous system, ventilation has both autonomic and voluntary control. Diffusion is the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood. Perfusion is the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells. Four major functions of respiratory system:

1. 2. 3. 4.

Supply O2 to body for energy production Remove CO2 as a waste product of energy reactions Maintain homeostasis of actions- Acid-Base Balance Maintain heat exchange

Control of Respirations  Humoral regulation: mostly influenced by the need to expire CO 2 and maintain H+ ion levels in body.  Hypercapnia is main stimulus to breathe. Changing chest size  Inspiration-active process, takes more energy; creates slightly negative pressure; forced inspiration  Expiration- passive process; creates relatively positive pressure; forced expiration Structure and Function: Infants and Children  Surfactant isn’t present in prenatal lungs until 32 weeks, so premature lungs collapse Structure and Function: Aging Adult  As vital capacity decreases vs. elasticity/mobility o vital capacity is the maximum amount the lungs can contain and expel in a breath  DOE, dyspnea on exertion- trouble breathing with activity o = increased risk of infection  Thorax becomes more rounded  Kyphosis common  Lung assessment may cause dizziness, faintness so take time Structure and Function: Cultural Competence  Incidence of TB in US declined; foreign-born and racial/ethnic minorities larger burden of TB disease  Asthma- 5% to 12% of US population o Most common chronic disease in childhood with a prevalence rate of 9.5% in children ages 0 to 17 years. More common in urban areas Subjective Data 1. Cough (Characteristics, +/- Hemoptysis, +/- sputum) a. Hemoptysis- coughing up blood b. Remember PQRSTU if cough: Precipitates or Palliative, Quality, Region or Radiating, Severity, Time, What do You think causes this? 2. SOB! (Shortness of Breath) 3. Chest pain with breathing 4. Past history of respiratory infections/Disease (more lower lung serious than upper) 5. Smoking history – pack years (years x ppd) 6. Environmental exposure 7. Self-care behaviors a. Exercise, protection from inhalants and smoke, proper inhaler use Additional history for aging adult  Have you noticed any shortness of breath or fatigue with your daily activities?  Tell me about your usual amount of physical activity

   

(For those with a history of chronic obstructive pulmonary disease, lung cancer, or tuberculosis): How are you getting along each day? Any weight change in last 3 months? How much? How is your energy level? Do you tire more easily? How does your illness affect you at home and at work? Do you have any chest pain with breathing? Do you have any chest pain after a bout of coughing or after a fall?

Additional history for infants and children  Has the child had any frequent or very severe colds?  Is there any history of allergy in family?  (For child under 2 years of age): At what age were new foods introduced? Was child breastfed or bottle-fed?  Does child have a cough or seem congested? Does child have noisy breathing or wheezing?  What measures have you taken to child-proof your home and yard? Is there any possibility of child inhaling or swallowing toxic substances?  Has anyone taught you emergency care measures in case of accidental choking or a hardbreathing spell?  Are any smokers in home or in car with child? Objective Data: The Exam  Preparation o Position-start at back o Draping o Timing during a complete examination (just after neck, thyroid, lymph) o Posterior and then anterior o Cleaning stethoscope end piece  Equipment Needed o Stethoscope o Small ruler, marked in centimeters o Marking pen o Alcohol swab https://www.nursingcenter.com/cearticle?an=01845097-201509000-00003 Objective Data: Posterior Chest– Inspect  Thoracic Cage o Shape and configuration of chest wall  Anteroposterior: Transverse diameter- (front to back vs side to side) o Normal is 1:2 or 5:7. o Barrel chest 1:1  Note position of person while breathingo Sitting upright with relaxed posture is normal o Tripod position- leaning forward while seated, indicates distressed breathing o Orthopneic position- in bed, leaning over with arms over pillows, helps w/ breathing o Also look for retracting (lungs pulling up), flared nostrils, pursed lips or grimace  Skin color and condition o Nail clubbing is a sign of poor perfusion Objective Data: Posterior Chest- Palpate  Confirm Symmetric Expansion- To assess the symmetry of chest expansion during breathing, stand behind the person, and place your hands with fingers spread apart beneath

his or her arms, on the sides of the chest, about 2 inches below the axilla. Your fingers should be pointing toward the anterior chest - this will let you feel the chest rising and falling on inspiration and expiration. Ask the person to breathe out completely – observe your hands and thumbs to see that they have moved equally on both sides.  Palpate the entire chest wall – o Tenderness, temperature, moisture, lumps or masses, crepitus  Assess for Tactile (or vocal) fremitus- a palpable vibration o Technique- To assess for tactile fremitus, ask the patient to say “ 99” or “blue moon”. While the patient is speaking, palpate the chest from one side to the other with ulnar/palm of hand. Tactile fremitus is normally found over the main stem bronchi near the clavicles in the front or between the scapulae in the back. As you move your hands downward and outward, fremitus should decrease. (9 positions on each side) o Decreased fremitus in areas where fremitus is normally expected indicates obstruction, pneumothorax, or emphysema. o Increased fremitus may indicate compression or consolidation of lung tissue, as occurs in pneumonia. o Factors that affect normal intensity of tactile fremitus  Position of bronchi to chest wall  Chest wall thickness  Pitch and intensity of voice Objective Data: Posterior Chest– Percuss  Determine the predominant note over the lung fields o Resonance: Low-pitched, clear, hollow sound; predominant note over lung fields  Determine the Diaphragmatic Excursion- percuss to locate lower border in both inspiration and expiration Ask patient to “exhale and hold it” briefly while percussing down scapular line until sound changes from resonant to dull. Then ask patient to “inhale and hold it” and measure from first mark down. Sample Charting for Normal findings on palpation include: normal chest size and shape, warm, dry skin, no tender spots, symmetrical chest expansion, and tactile fremitus over the mainstem bronchi in front and between the scapulae in the back of the chest. Objective Data: Posterior Chest-Auscultate  Breath Sounds- should be clear and present  Technique- use diaphragm, use side to side comparison  As you listen, think o What am I hearing over this spot? o What should I expect to be hearing?  Breath Sounds: o Bronchial breath sounds: High pitch o Bronchovesicular breath sounds: Moderate pitch o Vesicular breath sounds: Low pitch Objective Data: Anterior Chest– Inspect  Shape and configuration of chest wall  Facial expression  Assess LOC (Level of consciousness)  Skin color and condition-lips, nails  Nail shape, nail beds  Work of breathing (WOB) o Quality of respirations o Rib interspaces- Retractions? o Accessory neck muscles

Objective Data: Anterior Chest– Palpate  Symmetric Chest Expansion- easier to detect limitation in thoracic expansion with greater ROM here  Tactile (vocal) fremitus  Palpate the anterior chest wall Objective Data: Anterior Chest-Percuss  Predominant note over lung fields  Start with apices in supraclavicular areas and then interspaces  Expected Percussion Notes, fig. 18-24, p. 433  Borders of cardiac dullness Objective Data: Anterior Chest– Auscultate- apices in supraclavicular area down to 6 th rib  Breath sounds – normal (https://www.practicalclinicalskills.com/) o Bronchial- loud, hollow, and high pitch o Bronchovesicular- medium pitch sounds heard over the main bronchi. o Vesicular- soft, low pitched; heard in all lung areas except the major bronchi o What may cause abnormal breath sounds?  Decreased: COPD, mucous, pleurisy, pneumothorax  Increased: pneumonia  Listed for Adventitious Sounds o Wheeze expiratory wheeze is common in asthma o Rhonchi are low pitched wheezes, have a snoring, gurgling or rattle like quality o Crackles in outer lungs indicate the sacks with fluid in them, know that bra sounds and hairy chests can sound crackly too. o Pleural rubs are louder than crackles, has more of a rubbing sound  Measurement of Pulmonary Function Statuso Forced Expiratory Time seconds it takes for person to exhale total lung capacity to residual volume. Measures for airflow obstruction o Pulse Oximeter is noninvasive measure of arterial oxygen saturation o 6-minute walk test- Distance in 6 minutes > 300 meters suggests engagement in ADLs Objective Data: Anterior Chest (not typically part of exam)  Voice Sounds o Bronchophony o Egophony o Whispered Pectoriloquy Samples Objective Data: The chest wall is symmetric, without deformity, and is atraumatic in appearance. No tenderness is appreciated upon palpation of the chest wall. The patient does not exhibit signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is normal upon percussion of all lung fields. Respirations 18/ minute, relaxed and even. Anteroposterior less than transverse diameter. Chest expansion symmetric. No retraction or bulging of interspaces. No pain or tenderness on palpation. Tactile fremitus symmetric. Percussion tones resonant over all lung fields. Vesicular breath sounds auscultated over lung fields. No adventitious sounds present. Objective Data:Developmental Competence Infants and Children:

 

 

Apgar at birth: heart rate, respiratory effort, muscle tone, reflex irritability, color o Score of 2 in each category is good, total of 7- 10 is good. Infant has a rounded thorax with an equal anteroposterior-to-transverse chest diameter. o Count respiratory rate for 1 full minute; normal rates for newborn are 30 to 40 breaths per minute but may spike up to 60 breaths per minute. Newborn fine crackles are ok. By age 6 years, thorax reaches adult ratio of 1:2. Chest wall is thin with little musculature. o Breath sounds are louder and harsher than adults.

Objective Data:Developmental Competence Aging adult:  Chest cage commonly shows increased AP:T diameter (round barrel shape) & kyphosis (outward curvature of T spine)  Compensates by holding head extended and tilted back  May palpate marked bony prominences because of reduced subcutaneous fat  Chest expansion may be somewhat decreased, should still by symmetric  Costal cartilages become calcified with aging resulting in less mobile thorax  May fatigue easily, especially during auscultation when deep mouth breathing is required Abnormal Configurations of the Thorax:  Normal Adult vs. o Barrel chest- AP to transverse close to equal, ribs are more horizontal than sloped. Associated with aging as well as chronic emphysema and asthma. o Pectus excavatum- sunken sternum. Congenital. o Pectus carinatum- bird chest, prominent sternum. Congenital. o Scoliosis- S curved spine o Kyphosis- exaggerated posterior curvature of the spine (humpback)  Neonate o Barrel-chested o Nose-breather  Elderly o Kyphosis o Decreased but symmetrical chest expansion Breathing Patterns:  Sigh- extra deep breath  Tachypnea- fast breathing  Bradypnea- slow breathing  Hypoventilation- underventilating will cause respiratory acidosis- too much CO2 in body  Hyperventilation – overventilating will cause respiratory alkalosis  Chronic obstructive breathing- normal inspiration with exaggerated expiration  Cheyne-Stokes-pause then rapid- common near death  Biot’s respiration- similar to cheyne-stokes with more irregular pattern; common in head injury Abnormal Findings: Adventitious Lung Sounds  Discontinuous Sounds o Crackles  Bubbling, crackling, popping  Low- to high-pitched, discontinuous sounds  Auscultated during inspiration and expiration  Opening of deflated small airways and alveoli; air passing through fluid in the airways



o Fine crackles- discontinuous, high-pitched, short crackling, popping sounds heard on inspiration, not cleared with coughing o Atelectatic crackles- fine crackles that disappear w/cough or breaths; not pathologic. o Pleural Friction Rub Continuous Sounds o Wheeze (Sibilant)  Musical or squeaking  High-pitched, continuous sounds  Auscultated during inspiration and expiration  Air passing through narrowed airways  Diffuse airway obstruction from acute asthma or chronic emphysema o Rhonchi (Sonorous Wheeze)  Sonorous or coarse; snoring quality  Low-pitched, continuous sounds  Auscultated during inspiration and expiration  Coughing may clear the sound somewhat  Air passing through or around secretions  Common in bronchitis o Stridor  Harsh, loud, high-pitched  Crowding sound, louder in neck.  Auscultated mainly on inspiration  Narrowing of upper airway (larynx or trachea); obstruction-presence of foreign body in airway

Abnormal Findings: Abnormal Tactile Fremitus Decreased fremitus in areas where fremitus is normally expected indicates obstruction, pneumothorax, or emphysema. Increased fremitus may indicate compression or consolidation of lung tissue, as occurs in pneumonia. Rhonchi fremitus- vibrations felt when inhaled air passes secretions in large bronchi Pleural friction fremitus/rubs are low-pitched, grating, or creaking sounds that occur when inflamed pleural surfaces rub together during respiration. More often heard on inspiration than expiration, the pleural friction rub is easy to confuse with a pericardial friction rub. To determine whether the sound is a pleural friction rub or a pericardial friction rub, ask the patient to hold his breath briefly. If the rubbing sound continues, its a pericardial friction rub because the inflamed pericardial layers continue rubbing together with each heart beat - a pleural rub stops when breathing stops. Abnormal Findings: Respiratory Conditions Atelectasis (collapse) -result of airway obstruction, compression on the lungs, and lack of surfactant -cough, lag on expansion on affected side -increased respiration and pulse -breath sounds decreased -possible cyanosis Lobar pneumonia -infection of lung leaves alveolar membrane edematous and porous -RBC and WBC pass from blood to alveoli -alveoli fill up, decreases surface area of respiratory membrane.... hypoxemia -fever, cough with pleuritic chest pain, blood-tinged sputum, chills, SOB, fatigue

-increased respirations -chest expansion unilaterally decreased -tachycardia Acute bronchitis -acute infection of trachea and larger bronchi -cough, lasting up to 3 weeks -most cases viral -epithelium of bronchi inflamed and damaged -sore throat, low grade fever, postnasal drip, fatigue, substernal aching Chronic bronchitis -proliferation of mucus glands in the passageways, resulting in excessive mucus secretion -inflammation of bronchi -hacking, rasping cough -chronic: dyspnea, fatigue, cyanosis, possible clubbing -crackles over deflated areas Emphysema is a chronic respiratory disease where there is over-inflation of the air sacs (alveoli) in the lungs, causing a decrease in lung function, and often, breathlessness. The small passageways (bronchioles) leading to the alveoli collapse, trapping ...