HA 9_17 Thorax and Lungs.pdf

The right lung has three lobes The left lung has two lobes Separated by fissures Mediastinum in the middle Trachea - bifurcates into the two main bronchi Microorganisms or aspiration are common on the right side of the lung because of the anatomy Aveloi- exchange of oxygen and CO2 People who smoke...

The right lung has three lobes The left lung has two lobes Separated by fissures Mediastinum in the middle Trachea - bifurcates into the two main bronchi Microorganisms or aspiration are common on the right side of the lung because of the anatomy Aveloi- exchange of oxygen and CO2 People who smoke destroy cilia because that cilia is used to get rid of microorganisms The tip of the lungs is above the clavicle Pleural Membranes Visceral Membrane Lines the outer surface of each lung Parietal Membrane Lines the thoracic wall and upper surface of the diaphragm serous fluid- prevents friction from occurring, negative pressure- if there is a puncture it sucks in air, prevents the lung from expanding( pneumothorax) Landmarks help understand the location and what is underneath them Bony structures: vertical and horizontal lines Sternum Vertebrae Clavicle Ribs Sternum The angle of Louis- when we feel that, that is where the 2nd rib connects Find the sternal angle to find where the trachea bifurcates Underneath is top part of atria Area where ribs open is the coastal angle, less than 90 degrees if healthy respiroty, to make sure expeling all air Angle widens, sign of emphasimea, can not expel air Posterior Thorax Use vertebrae and scapulae as locators C7/TI are prominent with flexed neck Lower border of scapula is usually at the 7th or 8th rib 12th rib bottom of cage Scapula sticks out most on scapular line Psterier trache biforceartes at T4 Respiratory System/With Age Decreased efficiency Lungs lose elasticity Skeletal muscles weaken Costal cartilage becomes calcified Decreases depth of respirations Diameters of thoracic cavity change Barrel chest AP=T Antier postier = transverse if they have barrel chest Retenation of air, can not expel air, retain co2 Kyphosis Curverd thoraci spine Decreased ability to inflate lungs Less O2 for body Increased retention of CO2 Increased risk for DOE, Postop Complications, Pnemunia Respiratory System/Cultural Considerations Increased incidence of respiratory disease in poor, rural, urban, and recent immigrant groups asthma TB Increased incidence Travel, immunosuppression Patients should be fully disrobed cultural prohibition of removing clothing same sex examiner Environmental concerns--Occupational Asbestos Asbestosis Air conditioning/Heating systems Increased respiratory infections Environmental concerns--Home Secondhand smoke- get more carcinogens Pet dander Dust Molds Subjective Examination/Health History Questions Are you having any problems with the respiratory system Trouble breathing while Exercise Lying down orthopnea Cough Description: expectoration (mucus) Mucous How much Color Consistency Blood Odor Chest Pain: frequent coughing and effect on serous fluid Shortness of breath (Dyspnea) Compared with the patient’s norm What brings it on Related to position Time of day Wheezing Musical respiratory sound Weight loss: work so hard to cough, increase your metabolic rate, and prevent from eating food  History of Respiratory Disorders Infections Bronchitis Pneumonia TB Chronic Disorders Emphysema Asthma Colds Frequency Environmental exposure Dust/allergens Workplace Self-care behaviors Pneumococcal Vaccine 65 or older Influenza Immunization Covid Vaccine Tobacco is the leading cause of preventable death in the United States Do you smoke cigarettes or cigars How many packs/day for how many years Exposure to 2nd hand smoke Objective Inspection Inspect for any signs of respiratory difficulty Dyspnea Assess the patient’s color (lips and nail beds) Listen to the patient’s breathing Inspect the patient’s neck, and use neck muscles to breathe Facial expression Level of Consciousness, confusion Inspection of the Posterior Chest Shape and Configuration AP: T Diameter- NORMAL 1:2 Muscles Skin Palpation of the Posterior Chest Symmetric Chest Expansion Inspection of the Anterior Chest Shape and Configuration Costal Angle Ribs Deformity Symmetry Respirations and chest Observe the rate, rhythm, depth, and effort of breathing Palpation of Anterior Chest Usually supine Tenderness- inflammation Crepitus- air escapes the lungs into the subcutaneous tissues (chest tube) Palpate for chest expansion Symmetry of chest movement Asymmetry/or decreased expansion Pain Pneumothorax Fibrotic changes Tactile Fremitus Palpable vibrations with speaking Diminished vibrations with obstruction Increased vibrations with increased density pneumonia “99” Sounds of Percussion of Anterior Chest Resonance Hyperressonance Over inflated lungs/COPD Dullness Organs Heart ,Liver Tympany Stomach Flat Bones, muscles Auscultation of Anterior Chest Apices of lungs down to 6th intercostal space Listen with the diaphragm of a stethoscope/Patient should breathe deeply with mouth open  Listen to at least one full breath in each location Trachea and 1st & 2nd intercostal space next to sternum in addition to percussion locations Normal Breath Sounds Bronchial (Tracheal) louder and higher in pitch over the trachea and larynx Inspiration < Expiration Bronchovesicular moderate sound and pitch over major bronchi, adjacent to manubrium, between scapulae Inspiration = Expiration Vesicular soft sound and low pitch over smaller bronchioles and alveoli, peripheral lung fields Inspiration > Expiration Voice Sounds Auscultated over anterior and posterior chest wall in same areas as tactile fremitus. Bronchophony 99, muffled (normal) if you hear it clear that is abnormal Egophony eeeeee , hear e (normal), hear a (abnormal) Whispered Pectoriloquy 1,2,3, hear nothing (normal), if you hear it clear that is abnormal Palpation of Posterior Chest Palpate for tenderness, masses, abnormalities Palpate ribs and intercostal spaces Respiratory Expansion Fremitus Percussion of Posterior Chest Begin at apices Percuss over interspaces Progress side-to-side Avoid scapulae and ribs Abnormal Findings Barrel Chest AP = T Horizontal Ribs Normal Aging COPD Abnormal Findings Adventitious Lung Sounds Fine Crackles High pitched short, crackling, popping Inspiration (mostly) Do not clear with cough Collapsed or fluid filled alveoli pop open Ex. pneumonia Course Crackles Loud, moist low pitched bubbling Inspiration and/or Expiration Clears with cough or suctioning Air collides with secretions Collapsed or fluid filled alveoli open Pleural Friction Rub Low pitched grating Inspiration and expiration Pleural surfaces rubbing together Wheeze (sibilant) High-pitched, musical Mostly expiration Air passing through very narrow passageways Abnormal Findings Respiratory patterns Tachypnea Rapid respirations >24 breaths/min Fever, exercise, pleuritic pain, pneumonia Bradypnea Slow, regular