Health Assessment Thorax And Lungs: Thoracic Cage And Sternum PDF

Preview

Summary

Lecture Notes and overview break down of the course before midterm...

Description

Health Assessment Thorax and Lungs Thoracic Cage and Sternum  12 pairs ribs, 12 thoracic vertebrae The first seven ribs attach directly to the sternum, ribs 8, 9,10 attach to the costal cartilage above ribs 11 and 12. Attached by cartilage to allow for their movement when we breathe. • True Ribs: 7 pairs = pairs 1 to 7 called vertebrosternal because they connect anteriorly to the sternum and posteriorly to the thoracic vertebrae 3 pairs of • False Ribs: 3 pairs = pairs 8 to 10 are called vertebrocostal, because they connect to the costal cartilage of the superior rib and to the thoracic vertebrae. • Floating Ribs: 2 pairs = pairs 11 and 12, with no anterior attachment to the sternum. Reference: Colbert, Ankney & Lee (2015)

Surface Landmarks that Help Localize a Finding and Communicate those Findings to Others Anterior Thoracic Landmarks

Posterior Thoracic Landmarks

Suprasternal Notch: U shaped depression above sternum, between the clavicles.

Vertebra Prominens: Flex head-feel the prominent bony spur protruding at the base of the neck at C7 (the prominent one) then T1.

Sternum or Breastbone: a) manubrium b) body c) xiphoid process

Spinous Processes: Count to T4 to from the spinal column, then angle downward. Inferior Border of the Scapula: Lower tip, 7th or 8th rib.

Sternal Angle: “Angle of Louis” is continuous with the second(2nd) rib and helps to localize respiratory findings. Is also the site of the tracheal bifurcation of the right and left main bronchi. Costal Angle: 90 degrees and is the right and left costal margin that forms an angle that meets at the xiphoid.

Twelfth Rib: Palpate midway between the spine and the person’s side to feel the free tip.

Lung Borders  Anterior Chest: The apex, or highest point, of the lung tissue is 3 or 4 cm above the inner third of the clavicles. The base, or lower border, rests on the diaphragm at about the sixth rib in the midclavicular line.  Posterior Chest: The location of C7 marks the apex of lung tissue, and T10 usually corresponds to the base.  Lateral Chest: Lung tissue extends from the apex to the axilla down to the 7th or 8th rib. Lobes of the Lungs  Anterior Lobes of the Lungs: Right lung is shorter due to the liver, has 3 lobes versus the left lung is more narrow as heart bulges on that side and has only 2 lobes (no middle lobe). Lungs separated by fissures (p. 435). Fissures on anterior side of right lung are the oblique fissure and horizontal fissure and on the left lung is the left oblique fissure only. The anterior chest contains primarily upper and middle lobes.  Posterior Lobes of the Lungs: The upper lung lobe goes to T1-T3 or T4. The posterior lobe reaches T10 on expiration and T12 on inspiration. Posterior aspect is almost all lower lobe.  Lateral Lobes of the Lungs: Extends from the apex of the axilla to the 7th or 8th rib. Reference Lines for Chest  Anterior Aspect of Chest = Midsternal line – midclavicular - anterior axillary line  Posterior Aspect of Chest = Vertical line - scapula line  Lateral Aspect of Chest = Midaxillary - posterior axillary - anterior axillary

Objective Physical Chest Assessment through IPA

Inspection

Shape, symmetry of chest wall, presence of artificial veins, costal angle, respirations (respiratory patterns), intercostal spaces and skin colour. Shape of Chest Wall: Normal Anterior/posterior diameter of chest is less than the transverse-ratio AP to T is from 1:2 to 5:7

Abnormal: AP to T = 2:2 (Equal) COPD (i.e., Emphysema) = Hyper-inflated Lungs Normal: AP to T = 1:2 Abnormal: AP to T = 2:2 Inspection of Respiratory Patterns Rate: 10 to 20 breaths per minute Normal Adult Depth: 500 mL to 800 mL Pattern: Even The ratio of pulse to respirations is fairly constant, about 4:1. Both values increase as a normal response to exercise, fear, or fever. Depth: Air moving in and out with each respiration. Occasional sighs punctuate the normal breathing pattern and are purposeful to Sigh expand alveoli. Frequent sighs may indicate emotional dysfunction. Frequent sighs also may lead to hyperventilation and dizziness. Tachypnea

Rapid shallow breathing. Increased rate >24 per minute. This is a normal response to fever, fear, or exercise. Rate also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons.

Hyperventilation

Increase in both rate and depth. Normally occurs with extreme exertion, fear, or anxiety. Also occurs with diabetic ketoacidosis (Kussmaul's respirations), hepatic coma, salicylate overdose (producing a respiratory alkalosis to compensate for the metabolic acidosis), lesions of the midbrain, and alteration in blood gas concentration (either an increase in carbon dioxide or decrease in oxygen). Hyperventilation blows off carbon dioxide, causing a decreased level in the blood (alkalosis). Slow breathing. A decreased but regular rate (less than 10 per minute), as in drug-induced depression of the respiratory centre in the medulla, increased intracranial pressure, and diabetic coma.

Bradypnea

Hypoventilation

An irregular shallow pattern caused by an overdose of narcotics or anaesthetics. May also occur with prolonged bed rest or conscious splinting of the chest to avoid respiratory pain.

Cheyne-Stokes Respiration

A cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. The breathing periods last 30 to 45 seconds, with periods of apnea (20 seconds) alternating the cycle. The most common cause is severe heart failure; other causes are renal failure, meningitis, drug overdose, and increased intracranial pressure. Occurs normally in infants and aging persons during sleep. Similar to Cheyne-Stokes respiration, except that the pattern is irregular. A series of normal respirations (three to four) is followed by a period of apnea. The cycle length is variable, lasting anywhere from 10 seconds to 1 minute. Seen with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis. Normal inspiration and prolonged expiration to overcome increased airway resistance. In a person with chronic obstructive lung disease, any situation calling for increased heart rate (exercise) may lead to dyspneic episode (air trapping) because then the person does not have enough time for full expiration.

Biot’s Respiration

Chronic Obstructive Breathing

Palpation

Chest Expansion Posterior: Symmetrical chest expansion by placing warmed hands on the posteriorly at T9-T10 and, hands should move symmetrically. Abnormal Findings: Unequal chest expansion occurs with marked atelectasis or pneumonia; with thoracic trauma such as fractured ribs; or with pneumothorax. Anterior: Place your hands on the anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process to palpate chest expansion. Abnormal Findings: A lag in expansion occurs with atelectasis, pneumonia, and postoperative guarding. Tactile Fremitus Assess tactile fremitus (vocal) which is a palpable vibration generated from the larynx and transmitted to the bronchi to chest wall. Use finger ball or ulnar edge of hand and ask patient to state “blue moon, or 99”. Posterior: Between the scapulae, fremitus may feel stronger on the right side than on the left side because the right side is closer to the bronchial bifurcation. Avoid palpating over the scapulae because bone damps sound transmission. Anterior: Start over the lung apices, and palpate from one side to another. Note. Fremitus normally decreases as you progress down because more and more tissue impedes sound transmission.

Abnormal Findings: Increased Tactile Fremitus: Occurs with conditions that increase the density of lung tissue (solid tissue), thereby making a better conducting medium for vibrations (e.g., compression or consolidation such as pneumonia). There must be a patent bronchus, and consolidation must extend to lung surface for increased fremitus to be apparent.

Decreased Tactile Fremitus: Occurs when anything obstructs transmission of vibrations (e.g., an obstructed bronchus, pleural effusion or thickening, pneumothorax, and emphysema). Any barrier (exudate is external to alveoli and acts as a blockade) and obese patients (those with large chest walls) that gets in the way of the sound and your palpating hand decreases fremitus.

Auscultation Normal Breath Sounds Breath Sounds Bronchial (B)

Normal Location Anteriorly over the trachea; not normally heard over the lung tissue

Duration Inspiration < Expiration

Pitch and Intensity High pitched Harsh, hollow and tubular

Bronchovesicular (BV)

Between the scapulae and lateral to the sternum at the first and second intercostal spaces Over peripheral lung; best heard at the base of the lungs

Inspiration = Expiration

Moderate pitch Mixed

Inspiration > Expiration

Low pitch Rustling, like the sound of the wind in the trees “Gentle-sighing”

Vesicular (V)

BV

Vesicular

Vesicular

Bronchial

BV

Adventitious Breath Sounds DISCONTINUOUS ADVENTITIOUS CONTINUOUS ADVENTITIOUS BREATH SOUNDS (CRACKLES) BREATH SOUNDS (WHEEZES) Fine Crackles (Rales) Sibilant Wheeze  Discontinuous  High-pitched and musical squeaking sounds that sound polyphonic (multiple notes as in musical chords)  High-pitched  Heard on expiration  Short crackling Example: Resulting sound is similar to that from a vibrating reed.  Popping sounds heard during inspiration  Not cleared with coughing Example: Sounds like rolling a strand of hair between the fingers near the ear. Coarse Crackles (Coarse Rales) Sonorous Wheeze (Gurgles or Rhonchi)  Loud and low-pitched  Low-pitched and snoring  Bubbling and gurgling sounds that start early  Moaning sounds inspiration  Heard throughout the cycle but more prominent on Example: Sounds like opening a Velcro fastener. expiration Atelectatic Crackles Stridor  Sounds like fine crackles in axillae and bases  High-pitched and heard on inspiration  Are not pathological  Louder in the neck than over the chest wall  Disappear after the first few breaths Example: “Crowing” or “seal” sound. Pleural Friction Rub  Creaking and/or grating sound  Heard on both inspiration and expiration Example: Sounds like two pieces of dry leather rubbing against one another and causes pain. Voice Sounds: Auscultation is done if an abnormality is heard during general auscultation or palpation. Choose one, as they parallel tactile fremitus. Voice sounds are heard loudest over the trachea and softest in lung periphery. Diseases that increase lung density (pneumonia/tumour) increase transmission of voice sounds or decrease (asthma/pneumothorax) due to airway constriction .

Bronchophony “99” Normal = Muffled Abnormal = Clear

Egophony “eeeeeeee” Normal = “eeeeeeee” Abnormal = “aaaaa”

Whispered Pectoriloquy “1,2,3” Normal = Faint and distinct Abnormal = Clear and distinct Increased Voice Sounds (Pneumonia)

Decreased Voice Sounds (Asthma)

CRITICAL THINKING YOUR WAY THROUGH AN ASSESSMENT Read slowly and carefully through the following example: 

Symptom # 1: Audible (direct auscultation = heard by the ear and without a stethoscope) wheezing to the left lower lobe (LLL) o What could it be? o System = Respiratory Disease 1. COPD 2. Asthma 3. Pneumonia 4. Atelectasis

When there is an abnormal finding: Determine what you know about a finding and what could be the cause behind it (here is where your pathophysiology comes into play). For example, if there is wheezing...why? Is that the only symptom? Not in this case…here is your second symptom: 

Symptom # 2: Fever = 38.4°C o Is there a fever, if so then you would look towards pneumonia or atelectasis versus asthma. ASSESSMENT

What do you need to do to determine what the issue is and therefore, provide the proper nursing interventions? PULL IT APART = DEDUCTIVE THINKING If wheezing and elevated temperature are not conclusive enough then consider needing to use IPA to find out why the patient is wheezing and has a fever. Inspection of the chest wall...is there a pull of the trachea to the affected side. If yes, based on deductive thinking conclude that it is atelectasis and the lung is significantly collapsed. If no, do not rule out the atelectasis yet...Palpate, tactile fremitus would be increased if pneumonia and decreased with atelectasis. If one side of the chest was not symmetrical you’re your focus is still deciding between pneumonia and atelectasis. Finally, Auscultate and you should note air entry, which is decreased to the left lower lobe there are crackles in addition to the wheezing so it is still between pneumonia versus atelectasis. Now auscultate using the Voice Sounds Tests (Bronchophony, Egophony and Whispered Pectoriloquy). The voice tests would be increased with pneumonia and decreased/absent with atelectasis. Outcomes of this Assessment:  Elevated temperature  Audible wheezing (with and without the use of a stethoscope)  I: No tracheal shift upon inspection  P: Decreased tactile fremitus upon palpation  A: Crackles and wheezing (audible by indirect auscultation = heard with the use of a stethoscope) and decreased findings with the Voice Sounds Tests PIECE IT BACK TOGETHER = INDUCTIVE THINKING The two differences between the conditions are decreased tactile fremitus and decreased findings with the Voice Tests, therefore it would be atelectasis. Why is it atelectasis when all the symptoms and assessment findings are all so similar except for one? Put your pathophysiology to work!!! What do you know about atelectasis and pneumonia that leads you to select atelectasis over pneumonia?  Atelectasis = Collapsed shrunken section of the alveoli or the entire lung.  Pneumonia = Decreased surface area of the respiratory membrane due to increased fluids that replace alveolar air. If the lung is collapsed, then there would be no air moving through the lung. Air helps with vibrations from the voice so it would result in a decrease or absent findings when implementing Tactile Fremitus and Voice Sounds Tests. If the findings had of been the opposite, an increase in tactile fremitus and louder voice sounds then you would know based on knowing what happens (increased secretions) with pneumonia that when a client with pneumonia speaks, the vibrations from the voice would vibrate the secretions within the affected lobe(s). THEREFORE…THE CLIENT IN THIS EXAMPLE WOULD HAVE ATELECTASIS Remember: Nurses pull it apart (deductive) and put it all back together (inductive) to find out the why. CRITICAL THINKING = DEDUCTIVE AND INDUCTIVE THINKING CAN YOU NOW SEE WHY KNOWING YOUR PATHOPHYSIOLOGY IS SO IMPORTANT!!!...