Thorax, Lungs, and Respiratory System PDF

Thorax, Lungs, and Respiratory Giddens (2017) Concepts Homeostasis and Regulation ◦ Gas Exchange ◦ Ventilation ◦ Oxygenation ◦ Transport ◦ Perfusion Respiratory Assessment Vital Signs...

Thorax, Lungs, and Respiratory Giddens (2017) Concepts Homeostasis and Regulation ◦ Gas Exchange ◦ Ventilation ◦ Oxygenation ◦ Transport ◦ Perfusion Respiratory Assessment Vital Signs Skin, hair and nails Head, Neck, CNS (PNS) Mouth Nose Throat Thorax and Lungs CVS/PVS… Video of Gas Exchange https://www.youtube.com/watch?v=WzrN6sJ1i_g Inspiration vs Expiration Inspiration is triggered by rise in blood CO2: ◦ Inspiratory muscles contract ◦ Lung fields descend by 2 rib spaces ◦ 500-800 mL of air intake ◦ Expiration longer (2x) & passive Respiratory Anatomy Thoracic cage : Clavicles Manubrium (sternal angle at 2nd rib “Angle of Louis”) Sternum, 12 pairs of ribs, 12 vertebra posteriorly Count rib spaces starting BELOW the first rib Costal margin=inferior rib border The Thoracic Cavity Heart Lungs Thymus = gland of immune system, shrinks post puberty, T-cell production), Trachea Esophagus Aorta & Great vessels Pleura & Pleural Space Visceral pleura lines lungs Parietal pleura lines thoracic wall Mediastinum Diaphragm Pleural space Trauma can cause lung collapse (eg. pneumothorax, http://www.knowyourbody.net/wp-content/uploads/2012/04/Parietal-pleura- hemothorax) Image.jpg Respiratory muscles Inspiration: ◦ Intercostal Muscles ◦ Diaphragm ◦ (innervated by Phrenic nerve C3-C5, & CN X) Expiration: ◦ Passive https://www.physio-pedia.com/Muscles_of_Respiration Internal structures Trachea bifurcates ◦ sternal angle anteriorly ◦ T4 posteriorly Right main bronchus ◦ shorter, wider, more vertical than left ◦ Risk for foreign body aspiration Alveoli = gas exchange http://img.tfd.com/dorland/thumbs/bronchus.jpg Landmarking Lungs: Anterior Lung Fields ◦ Supraclavicular – 6th rib midclavicular line ◦ 8th rib midaxillary line RUL & LUL ◦ RUL apex 2.5 cm higher than LUL apex RML ◦ 4th-6th rib at sternum, gives way to RLL at anterior axillary line Size: RUL + RML = LUL RLL size & position = LLL size & position Lung Fields on Inspiration Lungs: Lateral Lungs: Posterior Excellent assessment of upper & lower lobes bilaterally  General Survey https://www.dailymail.co.uk/news/article-2183262/Olympics-2012-The-Muslim-women-overcame-odds-m https://www.pearsonhighered.com/assets/samplechapter/0/1/3/5/013 ake-London.html 5030439.pdf Health History Respiratory specific: ◦ Sleep apnea ◦ Pleuritic Pain ◦ Cough ◦ Sputum (Mucoid? Purulent? Tenacious?...colour, quality, quantity)/Hemoptysis ◦ Dyspnea ◦ Short of breath ◦ Wheezing ◦ Stridor ◦ Infections ◦ Occupational Exposure/Environmental Exposure ◦ Deep vein thrombosis/pulmonary embolism ◦ Tachypnea ◦ Asthma ◦ Bronchitis ◦ COPD ◦ TB http:// photos2.demandstudios.com Vital Signs Thorax, Lungs, & Respiration: IPPA 1. Inspection ◦ Level of Consciousness ◦ Facial Expression ◦ Posture ◦ Shape of thorax ◦ Respiratory Movement and Effort ◦ Rate, Rhythm, Depth, Quality of Breathing (VITAL SIGNS!) 2. Palpation 3. Percussion 4. Auscultation Inspection of the Skin Central vs Peripheral Cyanosis http://www.medicalzone.net/uploads/1/2/7/3/12737542/7986947.jpg Cyanosis – You will Learn In Pathophysiology! http://epomedicine.com/wp-content/uploads/2013/12/cyanosis.gif Inspection: Thorax Shape Anterior-posterior (AP or sagittal) Diameter should be less than Transverse Ratio of AP : Transverse Expected ◦ 1:2 – 5:7 Barrel Chest ◦ 1:1 ◦ COPD Palpation Superior to inferior ◦ 1,2,3,4,5, pattern ◦ Left and right sides consecutively ◦ Anterior & Posterior assessment Note tenderness, masses, lesions, crepitus ◦ Crepitus = bubble wrap sensation = air trapping Tactile fremitus ◦ Ulnar surface of hand ◦ Patient Repeats “99” ◦ Variations in findings usually reduced at the bases ◦ Used when there are concerns about lung disease Palpation: Chest Expansion Assessed when there are concerns about lung volume: ◦ Muscle weakness, fracture, infection, respiratory disease ◦ Combine with percussion for diaphragmatic excursion Posterior ◦ Place hands at level of T9 & T10 posteriorly ◦ Slide thumbs medially to raise a skin fold between ◦ Ask the patient to inhale deeply ◦ Skin fold should expand/disappear ◦ Note symmetry Anterior ◦ Hands at costal margin Low/asymmetrical = abnormal Percussion Percuss from lung apex to lung base (avoid the clavicle and ribs) Compare side to side Anterior and posterior assessment ◦ Expected finding: Resonance Throughout ◦ Abnormal: Hyper resonance (air trapping, e.g. COPD) Dullness (e.g. fluid) Percussion: Diaphragmatic excursion Test when there are concerns with chest expansion ◦ Instruct to exhale and hold ◦ Percuss down mid-scapular line intercostal spaces ◦ Mark change to dullness ◦ Break (breath normally) ◦ Instruct to inhale and hold ◦ Percuss from first line down ◦ Should be at least 1-2 rib spaces (3-5 cm) ◦ Repeat on other side  Auscultation Assess ◦ Intensity and Pitch ◦ Quality ◦ Duration ◦ Adventitious Sounds Tips: ◦ Not over clothing ◦ Diaphragm of stethoscope Remind clients to tell you if they get dizzy! ◦ Ask the patient to breath a little more deeply than normal, through their mouth ◦ Listen to one full breath per location ◦ Move side to side to compare symmetry Auscultation Reminder: Lower Lobes Lower Lobes: Auscultate Laterally and Posterior NOT Anterior – Why? Auscultation – Don’t! https://meded.ucsd.edu/clinicalmed/lung.htm Auscultation – Do! https://meded.ucsd.edu/clinicalmed/lung.htm Breath Sounds Tracheal ◦ Heard over Trachea (See bronchial sounds) Bronchial ◦ Heard over Sternum (I:E = 1:2 or 1:3) ◦ https://www.youtube.com/watch?v=WfkWMfE9 VTY Broncho vesicular (I=E) ◦ Heard 1st & 2nd intercostal space anterior chest ◦ https://www.youtube.com/watch?v=E9iNwFF6R 1Y Vesicular (I:E = 3:1 or 4:1) ◦ Heard over most lung fields ◦ https://www.youtube.com/watch?v=VtnMRG0O RLs https://s-media-cache-ak0.pinimg.com/736x/99/bf/df/99bfdf410ed7b885cb0a2cca8d6d4fb3.jpg Adventitious Lung Sounds Wheeze ◦ Continuous sounds (high or low). Usually more pronounced on expiration. ◦ https://www.easyauscultation.com/cases?coursecaseorder=4&courseid=201 Crackles ◦ Discontinuous brief popping sounds. More common during inspiration ◦ Coarse vs Fine ◦ https://www.easyauscultation.com/cases?coursecaseorder=2&courseid=201 ◦ https://www.easyauscultation.com/cases?coursecaseorder=3&courseid=201 Stridor ◦ You don’t need a stethoscope for stridor! ◦ https://www.easyauscultation.com/cases?coursecaseorder=13&courseid=202 If you have any trouble with these links, google easy auscultation for the home site Red Flag: Respiratory Distress Short sentences, few words Irritability ◦ Unable to focus ◦ LOC alterations Positioning ◦ Leaning forward https://www.youtube.com/watch?v=oGwCfZW9Xiw ◦ Standing ◦ Sitting leaning forward, tripod Work of breathing ◦ Mouth breathing ◦ Pursed lips ◦ Nasal flaring ◦ Accessory muscle use: neck & intercostal References Giddens, J.F. (2017). Concepts for nursing practice: Second edition. St. Louis, MS: Elsevier. Stephen, T.C., & Skillen, D. L., (2021). Canadian nursing health assessment: A best practice approach – enhanced reprint. Philadelphia: Lippincott, Williams, & Wilkins. *Links to other resources provided in slides