Thorax and Lungs Exam Notes PDF

THORAX AND LUNGS Anatomy -thoracic cage: bony structure -sternum -12 pairs of ribs -thoracic vertebrae -diaphragm -costochondral junction Sternum -sternum -manubrium (top) -body -xiphoid -manubriosternal angle -sternal angle, where manubrium and body of sternum meet -costal angle -ma...

THORAX AND LUNGS Anatomy -thoracic cage: bony structure -sternum -12 pairs of ribs -thoracic vertebrae -diaphragm -costochondral junction Sternum -sternum -manubrium (top) -body -xiphoid -manubriosternal angle -sternal angle, where manubrium and body of sternum meet -costal angle -margins meet at xiphoid Anterior landmarks -suprasternal notch: hollow area by clavicle -sternum -manubriosternal angle -costal angle Posterior landmarks -vertebra prominens: C7 -spinous process -scapula -C7 marks apex of lung tissue and T10 usually corresponds to base -deep inspiration expands lungs, and their lower border drops to level of T12 Anatomical landmarks -you will use anatomical landmarks to document the location of respiratory assessment findings -the angle of Louis (sternal angle) is a useful place to start counting ribs, which helps localize a respiratory finding horizontally Lungs -lungs are paired but not precisely symmetric structures -right lung has 3 lobes -left lung has 2 lobes -right lung shorter than the left because the liver is under it -left lung narrower than right because heart bulges to the left. Anatomical reference points -thoracic cavity -mediastinum -pleural cavities -lung borders -anterior: apex 3-4 cm above inner third of clavicle; base-lower border at diaphragm- 6th rib midclavicular line -lateral: apex at axilla; base-7-8th rib -posterior: apex at C7: base T10, T12 with deep inspiration Respirations -inspiration -chest size increases, diaphragm contracts, drops lower, creates a slightly negative pressure- air flows in. -expiration -passive-diaphragm relaxes- becomes dome-like. Air flows out Personal health history -prior respiratory problems -asthma, covid, pneumonia -when was the last time -do you still have symptoms -ask no matter the age and whenever they had it -thoracic surgery, biopsy, trauma? -Any allergies? -meds? Inhaler? -chest X-ray, TB skin test, flu, vaccines, pulmonary studies? -ever been exposed to TB -Recent travel outside the US? Family history -history of lung disease? Pulmonary disorders? -any family smoking while you grew up? -ever smoked? If yes how much? When did you quit? -second hand smoke? Lifestyle and health practices -usual dietary intake? -poor nutritional status seen in clients with COPD, predictor of mortality -smoking? -environmental exposure? -ADLs -what kind of stress are you experiencing? Does it affect your breathing? -herbal meds? Alternative therapies? Health promotion opportunities -vaccines -smoking cessation -environmental exposure and protection -weight maintenance -exercise Inspection -facial expressions -pursed lips, nasal flaring -LOC -drowsiness, restlessness -skin color -lips, nail beds, clubbing -respirations -quality, effort, even -use of accessory muscles -retractions -shape and configuration -spinous process straight -downward sloping ribs -90 degree costal angle -sitting position: tripod? Palpation -tenderness -sensation, temperature -crepitus: sounds like rice cakes, means fluid -masses -chest expansion -tactile fremitus: ABNORMAL!! Feel on back and tell the pt to say "99". Vibration will feel different if there\'s consolidation. Could be infection, inflammation. Assess if there any areas that have fluid, mass, pneumonia Percussion -lung fields: not predominant tone -left to right for symmetry -resonance: normal, low pitched, clear, hollow sound heard over normal lung tissue -hyperresonance: lower pitched, booming sound heard when too much air is present. Ex: emphysema -dull: Soft, muffled thud heard with density in lungs. Ex: pneumonia, atelectasis, tumor, pleural effusion, consolidation Auscultation -use diaphragm of stethoscope -atleast 6-8 points (side to side, top to bottom) -apex and base of lungs -listen anteriorly, posteriorly and laterally -IF YOU HEAR SOMETHING MAKE THEM COUGH -9 spots in the back to hear -5 in front Lung sounds -bronchial (top) -loud, high pitched sounds -bronchovesicular (middle) -medium pitched sounds -vesicular -soft, low pitched sounds -entirety of lung fields Additional pulmonary assessment -voice sounds (auscultation) -only if pathology is suspected -occurs with diseases that increase lung density -bronchophony -normal: "99" sounds muffled -abnormal: "99" sounds clear -egophony -normal: long "eee" sounds like "eee" -abnormal: "eee" sounds like "aaa" -whispered pectoriloquy -normal: hear faint, muffled "123" -abnormal: whispered "123" heard clearly -respiratory rate -pulse ox -ABG: not routine, taken from artery Pediatric lifespan considerations -inspection -rounded thorax until age 6 -chest circumference less than head until age 2 -first respiratory assessment at birth-APGAR -nose breathers until 3 months -uses diaphragm to breathe (retraction) -periods of apnea are common -palpation: encircle thorax with both hands -percussion: limited use -auscultation: bronchovesicular in peripheral lung fields until age 5-6 Pregnant considerations -thoracic cage may appear wider -deeper respirations -thoracic breathing -faster respiration rate, SOB in late pregnancy -clients with history of asthma have increased risk of certain conditions Geriatric considerations -chest cage commonly shows and increased anteroposterior diameter, giving a round barrel shape and kyphosis or an outward curvature of T spine -chest expansion may be somewhat decreased, although still symmetric -cant take deep symmetrical breaths, still have normal lung sounds -tend to tire easily during auscultation when deep mouth breathing is required Abnormal findings -barrel chest -chest pops out -scoliosis -kyphosis -hunch back -pectus excavatum -from birth -cosmetic except if theres problems -corrected with surgery -chest goes in -pectus carinatum -sternum bulges -take clothes off to inspect -more in young men Adventitious breath sounds -abnormal lung sounds -often first sign of illness -wheezing: continuous high pitched musical sound on expiration or inspiration. Result of narrowed airways -asthma, emphysema, anaphylaxis, foreign body in the mainstem bronchus, or a fixed lesion such as a tumor -rhonchi: characterized by low pitched sounds heard on inspiration and expiration. Lower pitched variant of the wheeze. It has a snowing, gurgling or rattle like quality -rhonchi, unlike wheezes, may disappear after coughing, which suggests that secretions play a role -crackles/rales: described as fine (soft, high pitched) or coarse (louder, low pitched) -suggest the presence intra alveolar fluid as seen with congestive Heart failure, pneumonia and interstitial lung disease -stridor: a high pitched musical breath sounds resulting from turbulent air flow in the larynx or lower in the bronchial tree -often intense and can be heard without a stethoscope stridor usually requires immediate intervention -inspiratory stridor suggests obstruction above the vocal cords (i.e angioedema, epiglottis, foreign body) -expiratory or mixed inspiratory/expiratory stridor suggests obstruction below the vocal cords (i.e croup, tumor, foreign body, bacterial tracheitis) -diminished breath sounds can be caused by anything that prevents air from entering the lungs -atelectasis, severe COPD, severe asthma, pneumothorax, tension pneumothorax, and extrinsic bronchial compression from tumor Respiratory patterns -kussmaul -ketoacidosis -diabetes -fruityacetone breath -cheyne stokes -near death -has a lot of stops -tachypnea -fast, over 30=pathologic -bradypnea -slow -below 12 -anesthesia might cause this -blote -irregular HEART AND NECK VESSELS Landmarks -precordium: anterior chest overlying heart and great vessels -mediastinum -extends from 2nd to 5th intercostal space, right border of sternum to left midclavicular line -base at top of the heart -apex at bottom of heart -right: anterior -left: posterior Thoracic cavity -left pleural cavity (left lung) -right pleural cavity (right lung) -mediastinum is the space between the 2 pleural cavities Superior mediastinum -borders: first rib (superior)to T4 (inferior) -content -thymus, trachea, esophagus, thoracic duct, aortic arch, veins (SVC, brachiocephalic, left superior intercostal), nerves (vagus, phrenic, left recurrent laryngeal), lymphatics, other small arteries and veins -mnemonic -try to eat toast and vitamins now little oliver Anterior inferior mediastinum -borders: T4 (superior) to T9 (inferior); sternum (anterior) to pericardium (posterior) -content: remnants of the thymus, lymph nodes Middle inferior mediastinum -borders: T4 (superior) to T9 (inferior); anterior aspect of pericardium (anterior) to posterior aspect of pericardium -content: phrenic nerve, heart, pericardium, ascending aorta, pulmonary trunk, SVC pericardiacophrenic artery Posterior inferior mediastinum -borders: T4 (superior) to T12 (inferior); posterior aspect of pericardium (Anterior) to spine (posterior) -content: descending thoracic aorta, azygos veins, hemiazygos veins, accessory hemiazygos veins, thoracic duct, cisterna chyli, esophagus, esophageal plexus vagus nerve, greater, lesser and least splanchnic nerves, lymphatics -mnemonics -on the DATE vivian slapped larry Anatomy of the heart -3 layers of tissue -pericardium -protects heart, doubled walled sac -outermost -myocardium -muscular wall: specialized cardiac muscle cells provide bulk of contractive heart muscle -endocardium -innermost wall is thin and includes 3 layers with smooth endothelial cells lining heart chambers and great vessels -4 chambers -2 atria (left and right): thin walled reservoir, hold blood -2 ventricles: muscular pumping chamber -left and right separated by interventricular septum -4 chambers separated by valves -valves control the blood flow between the heart chambers and between the ventricles and the corresponding great vessels, promoting unidirectional flow (only opens one way) -open and close passively in response to pressure gradients moving in blood -main purpose is to prevent backflow of blood -no valves are present between vena cava and right atrium or between pulmonary veins and left atrium -four valves in the heart -the valves that separate the atria from the ventricles are the atrioventricular (AV) valves: -each valve has 3 cusps that look like half moons -two AV valves -valves are attached by the chordae tendineae that anchor the flaps of the valves to papillary muscles in the ventricular walls to keep the flaps closed as the heart contracts, preventing retrograde blood flow -ventricles and the corresponding great vessels (pulmonary arteries, aorta) connect by the semilunar valves, with the pulmonic valve connecting the right ventricle with the pulmonary arteries and the aortic valve connecting the left ventricle with the aorta Circulation of blood -SVC and IVC -\> right atrium -\> tricuspid valve -\> right ventricle -\> pulmonary valve -\> pulmonary artery -\> lungs -\> left atrium -\> left ventricle -\> aorta -\> body -right atrium receives deoxygenated venous blood return from the body via SVC, IVC and coronary sinus (blood from the heart) -pulmonary arteries are the only arteries that carry deoxygenated blood to the body - it is then oxygenated as it flows through to pulmonary vascular bed of lungs and carbon dioxide is removed -right side of the heart is a low pressure system (protects pulmonary capillary bed) -abnormally high pressure in right side of the heart shows in the neck veins and abdomen -jugular distended, abdomen enlarged, hard and fluid filled -left side of heart is a high pressure system (to provide adequate pressure to support blood flow throughout body) -abnormally high pressure in left side of heart gives a person symptoms of pulmonary congestion -cant breath while sleeping, make them sleep up right -due to this pressure difference, walls of myocardium in the left side of the heart are thicker than the right side of the heart Cardiac cycle (BP) -diastole -heart filling phase- Av valves open to allow ventricles to relax and fill with blood and allow blood to be ejected from the heart -LUB -systole -heart pumping phase- AV valves close, to prevent regurgitation of blood back up into atria -DUB Cardiac cycle: blood through the heart -⅓ systole -ventricles contract -pump blood -AV valves closed -S1 -aortic/pulmonic valves open -blood fills pulmonary and systemic arteries -high Oxygen use -⅔ diastole -ventricles relax -fill with blood -AV valves open -aortic/pulmonic valves closed -S2 -oxygen delivery Normal heart sounds -S1: closure of AV valves, signals beginning of systole -mitral and tricuspid fuse as one sound and heard loudest at the apex -softer at base louder at apex -S2: closure of semilunar valves, signals end of systole -aortic and pulmonic closure heard louder at the base Abnormal heart sounds -extra heart sounds -S3: ventricular filling creates vibrations, occurs after S2 (LUBDUBDEE) -S4: occurs at the end of diastole, before S1 (stiff ventricles) -easier to hear abnormal sounds when laying on left -murmurs -increased blood flow velocity: exercise -viscosity of blood decreased: anemia -structural defects in valves, narrowing, incompetence or unusual opening Carotid artery -central artery -groove between trachea and sternomastoid muscle; medial to and along side that muscle -close to the heart, timing closely coincides with ventricular systole (S1) -grade pulse -never palpate both at the same time because it blocks blood flow -note characteristics of its waveform -smooth rapid upstroke -summit rounded and smooth -downstroke more gradual and has a dicrotic notch caused by closure of aortic valve Jugular veins -2 jugular veins present in each side of the neck -larger internal jugular lies deep and medial to sternomastoid muscle -usually not visible when upright, although diffuse pulsations may be seen in sternal notch when the patient is supine -external jugular vein is more superficial; lies lateral to sternomastoid muscle, above clavicle -empty deoxygenated blood into SVC -because no cardiac valve exists to separate SVC from right atrium, jugular veins reflects activity of right side of the heart; specifically reflect filling pressure and volume changes -volume and pressure increased when right side of the heart fails to pump efficiently History of present illness -chest pain -tachycardia -palpitations -fatigue -dizziness -nocturia -edema -pyrosis (heartburn) -dyspnea, orthopnea, cough Personal health history -heart defect? -murmur? -rheumatic fever? -heart surgery/procedure? -ECG, EKG? If yes, what were the results -cholesterol -meds -self assessment/monitoring Family health history -make sure to ask them what age each person was diagnosed and what the relation is -Hypertension? -myocardial infarction? -coronary heart disease? -hyperlipidemia? -diabetes mellitus? -stroke? -black and mexicans have a increased risk -asians have a decreased risk Lifestyle and health practices -smoking? -stress? Coping strategies? -24 hour dietary recall -alcohol -exercise -activity tolerance -effects of heart disease on sexual activity? -sleep/rest? -self image? Neck vessels: inspection and palpation -carotid -palpate: one side at a time -asculatate: use bell; assess for bruits (whooshy abnormal sounds) -tell patient to hold breath -shouldn\'t hear anything -jugular -internal: see pulsation in suprasternal notch if supine Heart: inspection and palpation -precordium: across the chest -inspect for pulsations -palpation -auscultation -sounds produced by valves may be heard all over precordium -concentrate and listen selectively to one second at a time -inch your stethoscope in a rough Z pattern -listen with both bell and diaphragm -heart sounds are low frequency -diaphragm is for relatively higher pitched sounds -bell is for relatively lower pitched sounds (bruits, murmur) Auscultation of cardiac valves -aortic valve area: right 2 -pulmonic valve area: left 2 -Erb\'s point: left 3rd intercostal space where S2 is best auscultated -tricuspid valve: left lower sternal border, 4th ICS -mitral valve: left 5th ICS at left apex Heart: auscultation -listen for S1 and S2 -assess rhythm, rate, and sound of valve closure -listen for extra heart sounds -listen for murmurs (whish wish sound) -timing: systolic/diastolic -systolic: may occur with or without heart disease -diastolic: indicates heart disease -sinus arrhythmias: rhythm varies with breathing -pulse deficit: indicates weak ventricular contraction Grades of murmur intensity -grade 1: heard by a expert in optimum conditions -grade 2: heard by a non expert in optimum conditions -grade 3: easily heard, no thrill (vibration) -grade 4: loud murmur, palpable thrill -grade 5: very loud, often heard over a wide area, palpable thrill -grade 6: extremely loud, heard without a stethoscope Newborn and infant considerations -heartbeats at 3 weeks gestation -heart positioned horizontal, apex at 4th left intercostal space -reaches adult position age 7 -moms health during pregnancy -smoking, chronic conditions, teratogenic drugs -cyanosis with nursing, crying -fetal heart of valve defect -check pulse ox in first 24 hours of birth -growth -activity -fatigue with activity, tires when feeding Children and adolescent considerations -growth -activity -joint pain, unexplained fever -headaches/nosebleeds -frequent URIs -family history -heart rate can increase with inspiration and with expiration Pregnant considerations -blood volume increases by 30-40% so workload increases -pulse rate increases by 10-15 beats -BP decreases/fluctuates due to peripheral vasodilation -history of high BP: associated symptoms -faintness/dizziness -looking for pre pregnancy baseline -then we can assess changes from that baseline Older adult considerations -interrelated with lifestyle, habits and disease: smoking, alcohol use, diet, lack of exercise -systolic BP increases -additional increases with arteriosclerosis -left ventricular wall thickness increases -dysrhythmia: irregular heart failure increases related to conduction changes. -heart/lung disease -CHF, COPD, A fib -meds -environment: ADLs -changes in vital signs -increase in systolic BP -stiffer arteries, less elastic -systolic HTN -orthostatic HTN -exercise tolerance/stress test -respiratory rate generally the same -resting Heart rate has no change Congenital heart defects -acyanotic defects -ventricular septal defect -atrial septal defect -patent ductus arteriosus -coarctation -cyanotic defects -tetralogy -transposition -truncus arteriosus -total anomalous pulmonary venous return -hypoplastic left heart syndrome Pulmonary edema -fluid in the lungs -tired, SOB -bilateral edema in legs and ankles -ascites -heart pumps weaker Angina -temporary chest pain, pressure or discomfort -narrowed artery -ischemia -heart muscle isn\'t receiving enough oxygen due to narrowed coronary artery PERIPHERAL VASCULAR SYSTEM Anatomy -head and neck -temporal -carotid -arteries in the arm -brachial -ulnar -radial -arteries in the leg -femoral -popliteal -posteriortibial -dorsal pedis -veins in the arm -superficial (where the iV goes) -deep -veins in the leg -femoral -popliteal -great and small saphenous Peripheral vascular: arteries -high pressure system delivers oxygenated blood to body systems -to the entire body -strong, tough walls withstand high pressure -elastic fibers: allow walls to stretch with systole and recoil with diastole -muscle fibers (vascular smooth muscle, VSM) control amount of blood delivered to tissue -VSM contracts/dilates: diameter of arteries change -heartbeat creates pressure wave: pulse -arteries function is to supply oxygen and nutrients to tissues Peripheral vascular: veins -drain deoxygenated blood from tissues and return to heart -veins with one way valves -venous return depends on pressure gradient caused by: -breathing -capacitance vessels (veins) -stretch and hold more blood with volume increases -reduce stress on heart Lymphatic system -separate vessel system -retrieves fluid from the interstitial space and returns it to the blood system -without lymphatics, edema occurs -function: -conserve fluid and plasma that leaks out of capillaries -form part of the immune system that defend against disease or infection -absorb lipids from the intestinal tract -lymph flow propelled by -contracting skeletal muscle -pressure change secondary to breathing -contraction of vessel walls -lymph nodes -clumps of lymphatic tissue, bead like at intervals along vessel s -cervical: drains head and neck -axillary: drains breast and upper arm -epitrochlear: hand and lower arm -inguinal: lower extremity, external genitalia, anterior abdominal wall (groin) -lymph vessel coverage into two main trunks empty into the venous system at the subclavian veins -right lymphatic duct: drains right side of head and neck, right arm, right side of thorax, right lung and pleura, right side of heart and upper section of liver -thoracic duct: drains the rest of the body History of present illness -changes in skin: color, temperature, texture -pain/cramping in legs? -when do you feel it, were you able to do it before -aching in legs? -contoured, bulging veins -sores/open wounds in legs? -edema in bilateral lower extremities -swollen glands or lymph nodes? -difficulty achieving or maintaining an erection? (bad flow to the area) Personal health history -issues with peripheral circulation (blood clots, ulcers, coldness, numbness, edema, poor healing, hair loss) -treatment/surgeries on blood vessels Family history/personal -deep vein thrombosis (DVT)? -diabetes -HTN? -coronary heart disease -intermittent claudication? -intermittent pain from the lack of blood flow -hyperlipidemia Lifestyle and health practices -smoking? Tobacco? -exercise? -oral or transdermal contraceptive use? -stress? -circulatory problems interfering with ability to function? -self image -meds -compression socks Health promotion opportunities -smoking cessation -exercise -compression socks -foot care -look for modifiable risks: those that can be changed to promote health Health promotion: take care of your feet -look at your feet daily -use a mirror to see bottom of your feet -look for red spots or sensitive areas, changes in color or nails -trim nails straight across, not too short -remove polish when it chips to see changes -chest blood flow -exercise regularly -put your feet up when sitting -gentle massage, wiggle toes -don\'t cross legs for long periods of time -quit smoking -birth control can cause clots -wear comfortable shoes that fit -get measured for fit -try new shoes on later in the day when feet are largest -buy shoes that are shaped like your foot -make sure shoes don\'t slide/rub when walking -leave room between toe and shoe -practice good skin care -keep skin on feet soft, smooth, use lighter layer of lotion -wash feet daily with mild soap. Dry thoroughly especially between toes 9 common pulse points in the body -temporal artery -radial artery -carotid artery -apical pulse -brachial artery -femoral artery -popliteal artery -dorsalis pedis -posterior tibial Objective date: inspect and palpate arms -skin -color -temperature -texture -turgor -lesions (venous patterns) -edema -nailbeds -capillary refill -clubbing -epitrochlear lymph node -location: inner elbow -brachial, radial, ulnar pulse -rate, rhythm, force -symmetry (arm size) -temperature -capillary refill Allen test -ask patient to open and close hand several times -compress radial and ulnar arteries when patient hand is in a fist -tell patient to open hand then let go of one artery -hand should pink up -bad if positive -repeat with each artery Objective data: inspect and palpate legs -inspect -patient should be supine -symmetry -color of skin -texture -lesions -calf muscle (DVT) -leg veins (shouldnt see any) -edema (if there is, measure it and check for pitting) -palpate -temperature -turgor -pulses Objective data: legs -palpate inguinal nodes -pulse points -femoral artery -popliteal artery -dorsalis pedis -posterior tibial Hormans sign -discomfort in the calf muscle on forced dorsiflexion of the foot with the knee straight -positive means there DVT Objective data: legs -edema: pretibial or medial malleolus -not pitting -grade of pitting (none of them are normal) -1+= mild pitting, slight indentation, no noticeable swelling of leg -2+= moderate pitting, indentation subsides rapidly -3+= deep pitting, indentation remains short time, leg looks swollen -4+= very deep pitting, indentation lasts long time, leg is very swollen -bilateral edema usually means problem with the heart Abnormal findings -raynaud\'s phenomenon -circulation issue -fingers white due to inadequate blood flow -blue as oxygen is depleted into the tissues -lymphedema -chronic -axillary nodes removed -hard to get rid of -arterial insufficiency -trophic skin changes and preulcerative changes seen in severe peripheral arterial disease -venous insufficiency -improper functioning of the vein valves in the leg, causing swelling and skin changes -blood pools in legs -may cause ulcers -reddish blue to skin -thick skin -deep vein thrombus (DVT) -blood clot in a deep vein Newborn considerations -acrocyanosis (blue hands and feet), cyanosis -temperature in periphery -lymphatic system established at birth Children considerations -cyanosis/coldness in extremities? -pulse force same upper/lower, normal, symmetric -lymphatic system established by age 6 -palpable lymph nodes often occur Pregnancy considerations -bilateral pitting edema in lower extremities by end of the day, third trimester -vasodilation -venous pressure increased: edema, hemorrhoids, varicosities Aging adult considerations -dorsalis pedis and posterior tibial difficult to locate -trophic changes with arterial insufficiency -arteriosclerosis Eupnea: normal relaxed breathing ### Clear Sputum - - ### White or Gray Sputum - - ### Yellow Sputum - - ### Green Sputum - - ### Brown or Rust-Colored Sputum - - ### Pink or Blood-Tinged Sputum - - ### Red (Bloody) Sputum (Hemoptysis) - - Normal changes in aging in the cardiovascular system -stiffening of heart valves. Cardiac conductivity altered -increased risk for conduction disturbances and tachydysrhythmias, decreased heart rate in response to stress -decreased renin, angiotensin and aldosterone production -arterial stiffening contributes to decline in peripheral and vital organ perfusion. Some peripheral pulses may not be palpable -decreased baroreceptor sensitivity with potential for postural hypotension -loss of arterial elasticity with potential for isolated systolic hypertension and left ventricular hypertrophy -resting cardiac output maintained -increased risk for "silent" myocardial infarction -veins thicken, valvular reflux contributes to varicosities and dependent edema can occur with long periods of sitting without evaluating feet Arterial insufficiency -reduced blood flow through one or more of your arteries. It happens when your artery becomes narrowed or blocked. Atherosclerosis (plaque buildup) is the most common cause. Your arteries are the blood vessels that carry oxygen-rich blood from your heart to the rest of your body.