Health Assessment BSN 201 Week 7 Lecture 11, 12 Thorax and Lungs PDF

Health Assessment BSN 201 Week 7 Lecture 11, 12 Thorax and Lungs  Learning Objectives After you have successfully completed this lecture, you will be able to  Identify the structure and function of the thorax and lungs  Identify pertinent respiratory history questions  Obtain a respirat...

Health Assessment BSN 201 Week 7 Lecture 11, 12 Thorax and Lungs  Learning Objectives After you have successfully completed this lecture, you will be able to  Identify the structure and function of the thorax and lungs  Identify pertinent respiratory history questions  Obtain a respiratory history  Perform a respiratory physical assessment  Differentiate between normal and abnormal findings  Document respiratory findings  Position and Surface Landmarks  Thoracic cage is a bony structure with conical shape, it is defined by sternum, 12 pairs of ribs and 12 thoracic vertebrae  “floor” is diaphragm, that separates thoracic cavity from abdomen Position and Surface Landmarks (Cont….)  First seven ribs attach directly to sternum via their costal cartilages  Ribs 8, 9, and 10 attach to costal cartilage above  Ribs 11 and 12 are “floating,” with free palpable tips  Costochondral junctions are the points at which ribs join their cartilages  Anterior Thoracic Landmarks 1) Suprasternal notch (U-shaped depression just above sternum between clavicles) 2) Sternum “breastbone” (three parts: manubrium, body & xiphoid process) 3) Sternum angle “angle of Louis’’ (articulation of manubrium &body of sternum, continuous with 2nd rib) 4) Costal angle (right &left costal margins form an angle where they meet at xiphoid process ;usually 90 degrees or less)  Posterior Thoracic Landmarks 1) Vertebral prominence 2) Spinous process 3) Inferior border of the scapula 4) Twelfth rib  Reference Lines  Anterior  Posterior  Lateral  Lung Borders 8  Anteriorly  Posteriorly  Apex (highest point of lung  Location of C7 marks the apex tissue), is 3 to 4 cm above inner of lung tissue & T10 usually third of clavicles corresponds to the base  Base (lower border), rests on  Deep inspiration expands lungs diaphragm at about 6th rib in to level of T12 midclavicular line Laterally  Laterally extends from apex of axilla down to 7th or 8th rib  Lobes of the Lungs 9 Right lung is shorter than Left lung is narrower Right lung has three left lung ?????? than right lung ?????? lobes left lung has two lobes  Anterior  Lobes of the Lungs (Cont….) 10  Posterior  Lobes of the Lungs (Cont….) 11  Lateral  Pleurae  Serous membranes that form an envelope between lungs & chest wall i. Visceral pleura (outside of lungs) ii. Parietal pleura (lining inside of the chest wall and diaphragm)  Respiratory Patterns 1) Rate 2) Depth 3) Hypoventilation 4) Hyperventilation 5) Kussmaul respirations 6) Cheyne-Stokes Respiration Subjective Data 1) Cough 2) Shortness of breath 3) Chest pain with breathing 4) History of respiratory infections 5) Smoking history 6) Environmental exposure  Subjective Data 1- Cough  Do you have a cough?  When did it start? Timing:  Gradual or sudden?  Early morning: chronic bronchial inflammation of  How often do you cough? smokers  At any special time of day?  Afternoon / evening: exposure to  Is cough wake you up at night? irritants  Night: Sinusitis  Throughout the day: respiratory tract infection  Subjective Data (Cont….) 1- Cough (Cont….)  Type: (dry or productive)  Characteristics of sputum: Characteristic of sputum: What color, how much, does it contain blood or have foul odor  White/clear: cold, bronchitis, or viral infection  Yellow/green: bacterial infection Sputum containing blood=  Rust colored: TB, pneumonia Hemoptysis  Pink/frothy: pulmonary edema  Subjective Data (Cont….) 1- Cough (Cont….)  Quality: How would you describe your cough?  Hacking: pneumonia  Dry: early heart failure, asthma  Barking: Croup syndrome  Congested (Wet): bronchitis  Subjective Data (Cont….) 2- Shortness of Breath (SOB)  Orthopnea: difficult breathing  Ever had any SOB? when supine  What brings it on?  Paroxysmal nocturnal dyspnea:  How severe is it? awakening from sleep with SOB,  Is it affected by any position? needing to be upright  Occur at any specific time?  Is there any activity precipitate SOB 18  Subjective Data (Cont….) 2- Shortness of Breath (Cont….)  Does the SOB episodes associated with any factors, such as night sweat, cough, chest pain, wheezing sound?  Is it related to food, pollens, dust, animals, season, or emotions? Cyanosis: is a bluish color around lips and/or nails Cyanosis signals hypoxia  Subjective Data (Cont….) 3-Chest Pain with Breathing Any chest pain with breathing? When did it start? Describe the pain: burning, stabbing? Is it brought on by respiratory infection, coughing, or trauma?  Is it associated with fever, deep breathing, unequal chest inflation? What have you done to treat it?  Subjective Data (Cont….) 4- History of Respiratory Infections Past History of breathing trouble or lung diseases such as Bronchitis, Pneumonia, Atelectasis, Pleural Effusion, Asthma  Any unusual frequent or severe colds  Any family history of TB, Asthma, Allergies  Subjective Data (Cont….) 5- Smoking History  Type: Do you smoke cigarette or cigar  At what age did you start?  Amount: How many packs per day  Quitting attempts: Have you ever tried to quit Passive smoking: Do you live with someone else who smoke?  Subjective Data (Cont….) 6- Environmental Exposure Are there any environmental conditions that may affect the breathing? Where do you work? At a factory, chemical plant, farming, in heavy traffic area Do you do wear masks or have the ventilator system checked  Objective Data Preparation Equipment Stethoscope  Ask the client to sit upright Alcohol swap  Warm room, diaphragm endpiece, private room with no interruption  Perform Inspect- palpate- percuss- auscultate on posterior chest, then move to face & repeat same maneuver on anterior chest  Objective Data (Cont….)  Inspect the posterior chest 1) Shape and configuration  Spinous processes should appear in a straight line  Thorax is symmetric, in an elliptical (oval) shape  Scapulae are placed symmetrically  Note configuration of thorax: Anteroposterior (AP) diameter should be less than transverse diameter  Objective Data (Cont….) 2) Note the position the client takes to breathe Relaxed posture with arms comfortably at the sides Inspection the posterior chest 3) Skin color and condition (Cont….) Should be consistent with person's genetic background No cyanosis or pallor should be present Note any lesions  Objective Data (Cont….)  Palpation the posterior chest 1) General  Skin temperature and moisture  Tenderness  Superficial lumps or masses or lesions  Objective Data (Cont….)  Palpation the posterior chest (Cont….) 2) Symmetric expansion i. Placing your warmed hands sideways on posterolateral chest wall with thumbs pointing together at level of T9 or T10 ii. Ask client to take a deep breath then inhales deeply iii. Note any lag in expansion  Unequal chest expansion occurs with pneumonia, trauma, or fractured ribs  Objective Data (Cont….) Palpation the posterior chest (Cont….) Fremitus is a palpable 3) Tactile (vocal) fremitus vibration generated from larynx & transmitted through bronchi and lung i. Use either palmar base (ball) of fingers to chest wall or ulnar edge of one hand ii. Touch client 's chest while he / she repeats words “ninety-nine” or “blue moon” iii. Start over lung apices and palpate from one side to other  Objective Data (Cont….) Palpation the posterior chest (Cont….) 3) Tactile (vocal) fremitus (Cont…..)  Normally, vibration is same in all areas  Objective Data (Cont….) Percuss the posterior chest 1) Lung fields (determine predominant note over lung fields) i. Start at apices and percuss across the tops of both shoulders ii. Then in the interspace iii. Make side to side comparison all the way down the lung field  Objective Data (Cont….) Percuss the posterior chest (Cont….) 1) Lung fields (Cont….)  Normally, resonance sound (healthy lung)  Hyper-resonance (emphysema)  Dullness (tumor, atelectasis, pleural effusion, pneumonia)  Objective Data (Cont….)  Auscultate the posterior chest 1) Breath sounds (use diaphragm of stethoscope) i. Listen to lung areas from apices at C7 to bases T10, laterally from axilla down to 7th & 8th rib ii. Side to side comparison iii. Listen to at least one full respiration in each location  Normally, hear normal breath sounds  Objective Data (Cont….)  Normal breath sounds (posterior chest) Bronchovesicular (BV): between scapulae, inspiration equal expiration, moderate pitch and intensity Vesicular (V): over lung field, inspiration longer than expiration, low pitch and soft, like sound of wind in tree  Objective Data (Cont….)  Inspect of the anterior chest 1) General  Shape and configuration  Ribs are sloping downward with symmetric interspaces; costal angle is within 90 degrees  Facial expression  Should be relaxed and indicating unconscious effort of breathing  Color and condition  Lips & nails free of cyanosis or pallor  Explore any skin lesions  Objective Data (Cont….) Inspect of the anterior chest (Cont….) 2) Quality of respiration  Relaxed breathing is effortless, regular and even, produces no noise  Chest expands symmetrically with each inspiration  Normally accessory muscles are not used to augment respiratory effort  Respiratory rate should be within normal range (Eupnea) ; and pattern of breathing is regular  Objective Data (Cont….) Palpate of the anterior chest 1) General  Skin temperature and moisture  Skin mobility and turgor  Tenderness  Detect any superficial lumps or masses  Objective Data (Cont….) Palpate of the anterior chest (Cont….) 2) Symmetric chest expansion i. Place hands over the anterolateral wall with thumb along costal margin pointing xiphoid process ii. Ask client to take a deep breath iii. Watch your thumb move symmetrically & chest expansion with your fingers  Objective Data (Cont….) Palpate of the anterior chest (Cont….) 3)Tactile Fremitus i. Palpate over the lung apices in the supraclavicular areas ii. Compare vibrations from one side to the other as client repeats “ninety-nine” or “blue moon”  Normally, vibration is same in all areas  Objective Data (Cont….) Percuss the anterior chest 1) Lung fields (determine predominant note over lung fields) i. Begin percussing apices in supraclavicular areas ii. Then percussing interspaces iii. Comparing one side with the other iv. Move down the anterior chest  Objective Data (Cont….) Percuss the anterior chest (Cont….) 1) Lung fields (Cont….)  Normally, resonance sound  Hyper-resonance (emphysema)  Dullness (tumor, atelectasis, pleural effusion, pneumonia)  Objective Data (Cont….)  Auscultate of the anterior chest 1) Breath sounds (use diaphragm of stethoscope)  Auscultate from apices at supraclavicular area down to 6th rib, compare from side to side  Normally, hear normal breath sounds  Normal Breath Sounds (Anterior Chest) Normal location Quality Duration Pitch & Amplitude Trachea & larynx Harsh hollow Inspiration < High & loud Bronchial (B) tubular expiration Around upper Mixed Inspiration = Moderate Bronchovesicular sternum in 1 & 2 st nd expiration (BV) intercostal spaces Over lung fields Sound of Inspiration > Low & soft Vesicular (V) wind in trees expiration Abnormal Findings: Configurations of Thorax 2) Scoliosis 3) Kyphosis 1) Barrel chest Lateral S- shape Posterior curvature of Equal anteroposterior- curvature of thoracic thoracic spine to-transverse diameter and lumbar spine (humpback) Abnormal Findings: Configurations of Thorax (Cont….) 4) Pectus Excavatum 5) Pectus Carinatum Sunken sternum and adjacent A forward protrusion of the cartilages (funnel chest) sternum  Abnormal Findings: Tactile Fremitus Increased Tactile Fremitus Decreased Tactile Fremitus  Occurs with conditions that increase the density of lung  Occurs when anything tissue (e.g., compression or obstructs transmission of consolidation [pneumonia]) vibrations (e.g., pleural effusion, pneumothorax, and emphysema)  Adventitious Lung Sounds Adventitious sounds are not normally heard in the lungs Crackles Wheeze Stridor  Bubbling and  Musical sound  Crowing sound; gurgling sounds louder in neck than over chest wall  Start in early  Predominate in  Heard during inspiration and expiration but may inspiration may be present in occur in both expiration expiration and inspiration  Pneumonia  Asthma  Foreign inhalation  Sample Charting: Subjective Data No cough, shortness of breath, or chest pain with breathing. No history of respiratory diseases. Has“one” colds per year. Has never smoked. Works in well- ventilated office on a smoke-free campus. Last TB skin test 4 years, negative. Never had chest x-ray Sample Charting: Objective Data  Inspection: Resp 16/min, relaxed and even  Palpation: Chest expansion symmetric. Tactile fremitus equal bilaterally. No tenderness to palpation. No lumps or lesions  Percussion: Resonant to percussion over lung fields  Auscultation: Vesicular breath sounds clear over lung fields and = bilaterally. Loud, low-pitched, gurgling crackles over anterior sternum at 4th and 5th interspace