N113 Thorax Assessment Spring 2024 PDF

N113: THORAX Assessment SPRING 2024 Breast, Lungs & Thorax Assessment T H ERESA A N TONIO, M SN N 1 13 I NTRO TO M ED/SURG 1 Required Reading: Taylor, C., Lynn, P., Bartlett, J. L., ◦ ◦ ◦ ◦ Chapter 27, pp. 798-801, 805-807; Chapter 27, pp. 800 Table 27-2; Chapter 27, pp. 801 Table 27-3; Chapter 40,...

N113: THORAX Assessment SPRING 2024 Breast, Lungs & Thorax Assessment T H ERESA A N TONIO, M SN N 1 13 I NTRO TO M ED/SURG 1 Required Reading: Taylor, C., Lynn, P., Bartlett, J. L., ◦ ◦ ◦ ◦ Chapter 27, pp. 798-801, 805-807; Chapter 27, pp. 800 Table 27-2; Chapter 27, pp. 801 Table 27-3; Chapter 40, pp. 1585-1590, 1593-1618 Hinkle, J.L., Cheever, K.H., & Overbaugh, K.J., ◦ Chapter 17, pp. 462-465; 470-483; ◦ Chapter 52, pp. 1708-1718. OBJECTIVES 2 Explain the significance of selected findings in the thorax, lungs, and breast: Identify questions during thorax, lungs, and breast assessment Methods of assessment Characteristics associated with thorax, lungs, and breast Cultural variations Age variations Health promotion Patient/family teaching 3 N113: THORAX Assessment SPRING 2024 HEALTH ASSESSMENT Obtain HISTORY ◦ Family history ◦ Occupational history ◦ Country of origin ◦ Exposure 4 The RESPIRATORY System 5 Chest Landmarks Accurate localization and count First rib First intercostal space Second rib Second intercostal space 6 Medical & Surgical History ◦ Trauma or surgery ◦ Chest pain with deep breathing ◦ Cough ◦ Smoking ◦ Allergies ◦ Environmental exposures ◦ Lung disease ◦ Respiratory infections ◦ Pillow use N113: THORAX Assessment SPRING 2024 7 Anterior view of the viscera of thorax shows the various parts of the heart, lungs and ribs. 8 Apex: where the upper lobe begins Base: broad, concave, and rests upon the convex surface of the diaphragm Three (3) lobes to the right Two (2) lobes to the left 9 N113: THORAX Assessment SPRING 2024 Thoracic/Chest Landmark 10 Methods and Order of Chest Assessment General Inspection & Patient history Inspection 11 GENERAL INSPECTION and OBSERVATION Count respiratory rate for a full minute – longer if there’s any abnormalities Normal respiratory rate: 12 to 20 BPM for adults Observe the rhythm, depth, and effort of breathing Respiratory pattern should be even, coordinated, and regular Inspiration to expiration ratio: 1:2 12 Palpation Percussion Auscultation N113: THORAX Assessment SPRING 2024 13 ◦ Color ◦ Shape & symmetry ◦ Spinal alignment ◦ Three normal curvatures ◦ Cervical ◦ Thoracic ◦ Lumbar 14 Tracheal position Respiratory Rate Rhythm Depth Chest movements Respiratory efforts of breathing Chest excursion Skin color Anxious vs. calm Neck vein distension Clubbing of nailbeds 15 N113: THORAX Assessment SPRING 2024 16 17 Chest Shape and Size Normal chest = OVAL shape Anterior-Posterior (AP) Diameter is half the transverse diameter = 1:2 Increased in AP Diameter = chronic conditions where the AP diameter is equal to the transverse diameter 18 N113: THORAX Assessment SPRING 2024 Palpation (Posterior Thorax) ◦ Normal findings ◦ Skin intact ◦ Uniform temperature ◦ Use the back of hands ◦ No tenderness ◦ No masses ◦ No pain 19 Palpation (Posterior Thorax) ◦ Normal Findings: ◦ Full & symmetric chest expansion Normal – thumbs should separate 1 ½ to 2 inches during inspiration Abnormal Findings Asymmetric and or decreased chest expansion 20 Palpation (Posterior Thorax) ◦ Tactile Fremitus ◦ Definition: the faintly perceptible vibration felt through the chest wall when the client speaks ◦ Procedure ◦ Place palm on landmarks ◦ Have client repeat “ninety-nine” ◦ Normal finding ◦ Bilaterally symmetrical 21 N113: THORAX Assessment SPRING 2024 Percussion A method of medical diagnosis in which various areas of the body, especially the chest, back, and abdomen, are tapped to determine by resonance the condition of internal organs. INTERPRETING PERCUSSION SOUNDS Percussion Sound Normal lung tissue (Long, loud, low-pitched, hollow sound) (May be present in bronchitis) Hyperresonance Lung hyperinflation COPD, Pneumothorax Tympany Gastric air bubble Large Pneumothorax (Very loud, low-pitched sound) (Loud, high-pitched, moderate in length, musical, drum-like) Dullness (medium intensity, pitch and length, thud-like) Flatness (Short, high-pitched extremely dull sound) 22 23 Using your stethoscope Use the bell of the stethoscope to detect low-pitched sounds Use the diaphragm of the stethoscope to detect high-pitched sounds (such as normal heart sounds, breath sounds, and bowel sounds). 24 Significance of finding Resonance Lobar Pneumonia Atelectasis Extensive Pleural Effusion N113: THORAX Assessment SPRING 2024 Auscultation Use flat disc of diaphragm Best: high-frequency sounds Use systematic side to side approach Ask client to take slow, deep breaths, through mouth 25 26 Normal Breath Sounds 27 N113: THORAX Assessment SPRING 2024 Normal Breath Sounds 28 Normal Breath Sounds  Vesicular  Bronchovesicular  Bronchial 29 Normal Breath Sounds 30 N113: THORAX Assessment SPRING 2024 Vesicular Breath Sounds Description ◦ Soft-intensity ◦ Low pitched (gentle sighing) ◦ Heard over most lung fields Best Location ◦ Peripheral lung ◦ Base of lung 31 Bronchovesicular Breath Sound Description ◦ Moderate intensity & pitch ◦ “blowing” sound created by air movement through larger airway Location ◦ Between scapulae and lateral to sternum ◦ First and second intercostal spaces 32 High pitched, loud, harsh sounds ◦ Created by air moving through trachea Location ◦ Over trachea Not normally heard over lung tissue 33 N113: THORAX Assessment SPRING 2024 34 Chest Deformities Barrel Chest ◦ Ratio of AP to transverse diameter is 1:1 ◦ Increased AP diameter is normal for COPD patients ◦ Caused by chronic lung diseases (emphysema) 35 35 36 N113: THORAX Assessment SPRING 2024 Lateral curvature or deviation of the spine Scoliosis in adults caused:  trauma  present since birth  idiopathic scoliosis, which has no identifiable cause 37 37 38 Kyphosis 39 N113: THORAX Assessment SPRING 2024 Excessive curve in lumbar spine Slack tummy muscles Protruding buttocks 40 Clear (mucoid): COPD Yellow (mucopurulent): acute lower respiratory tract infection/asthma. Green (purulent): current infection – acute disease or exacerbation of chronic disease, such as COPD. Red/brown (rusty): pneumococcal pneumonia Pink (serous/frothy): acute pulmonary edema 41 PRIORITY PATIENT PROBLEMS: Impaired Gas Exchange due to decreased functional lung tissue Impaired Airway Clearance Dyspnea due to chronic airflow limitations Fatigue due to inefficient breathing pattern Disturbed body image Activity Intolerance For thoracic deformities: Pain Potential for ◦ Aspiration ◦ Infection ◦ Self-Care Deficit 42 Rusty red sputum (Pneumococcal Pneumonia) Mucous Plug (Asthma) N113: THORAX Assessment SPRING 2024 Abnormal Breath Sounds 43 Adventitious Breath Sounds Crackles (rales) Wheezes Pleural friction rubs Rhonchi (gurgles) Stridor 44 Adventitious Breath Sounds ◦Auscultation of any adventitious breath sounds in one or both lungs means patient condition is not improved ◦ABSENT BREATH SOUND ◦ Pneumothorax (collapsed lungs)- in trauma patients ◦ Lobectomy 45 N113: THORAX Assessment SPRING 2024 Can be fine or coarse Inspiration Expiration High-pitched, intermittent, cracking, popping sound FINE CRACKLES (RALES) Common cause: Air passing through fluid Commonly heard at the bases on inspiration Disease process: Bronchitis, Pneumonia, Emphysema, Heart Failure Inspiration Expiration COARSE CRACKLES (RALES) 46 Priority Patient Problem: Decreased Gas Exchange due to fluid in the lungs at the alveolar-capillary membrane For more information, Chapter 22 All-In-One 47 Continuous, low-pitched, coarse, harsh sounds “Snoring quality” May disappear or decrease with coughing Occurs when air passes through narrowed air passages due to secretions, swelling or tumors Predominantly heard over trachea and bronchi 48 N113: THORAX Assessment SPRING 2024 Priority Patient Problem: Decreased Gas Exchange due to alveolar-capillary membrane changes occurring with inflammatory process and exudate in the lungs Insufficient Airway Clearance due to the presence of excessive tracheobronchial secretions occurring with infection For more information: Chapter 12 All-In-One 49 Continuous, high-pitched, squeaky musical sounds Happens when airflow is blocked Occurs because of airway inflammation or narrowing (asthma or infection) Can also occur because of airway obstruction related to tumor or foreign body Not cleared by coughing Inspiration Expiration 50 Priority Patient Problem: Dyspnea due to bronchial inflammation Fatigue due to hypoxia and/or increased work of breathing For more information: Chapter 76 All-In-One 51 N113: THORAX Assessment SPRING 2024 Friction Rub Superficial grating or creaking sounds Occurs when visceral and parietal pleural surfaces become damaged and are unable to glide silently over each other during breathing Commonly heard over areas of greater thoracic expansion (e.g., lower anterior and lateral chest) May not be audible if fluid accumulates Priority Patient Problem: Decreased Gas Exchange due to decreased blood flow with pulmonary capillary vasoconstriction Acute Pain due to inflammation of pleural surfaces For more information: Chapter 76 All-In-One 52 Connective tissue disease-associated interstitial lung disease (CTD-ILD) 53 Abnormal Breath Sound 54 N113: THORAX Assessment SPRING 2024 Loud, high-pitched crowing sound or harsh honking wheeze with severe broncholaryngeal spasm Can be heard loudest over the neck, usually without a stethoscope, when a patient inhales Caused by an upper airway obstruction REQUIRES IMMEDIATE ATTENTION Inspiration Expiration 55 56 ↓ lung elasticity ↓ small airway caliber ↓ chest wall compliance ↓ respiratory muscle strength ↓ expiratory flow ↑ dynamic airway collapse 57 ◦ Alveoli losses elasticity (become fibrotic) decreasing exertional capacity and respiratory excursion ◦ ↓ number and effectiveness of cilia (↓mucous removal) ◦ Greater risk for pulmonary infection ↓ gas exchange ◦ Thoracic curvature may be accentuated (Kyphosis) because of osteoporosis ◦ Anteroposterior diameter widens (barrel-chested appearance) N113: THORAX Assessment SPRING 2024 Health Promotion  Promotion of health screening, health maintenance, and self-care teaching Health promotion plans need to be developed according to the needs, desires, and priorities of the client  The client decides on the health promotional goals  Early detection and vaccinations 58 Health Promotion Review and summarize data from assessment Reinforce the strength and competencies of the client Identify health goals and behavior-change options Identify health outcomes Develop a behavior change plan Reiterate the benefits of change 59 BREAST ASSESSMENT 60 N113: THORAX Assessment SPRING 2024 Breast Location & Assessment Location ◦ Between the 2nd and 6th ribs between the sternal edge and mid-axillary line Methods of breast assessment ◦ Inspection ◦ Palpation 61 Breast Assessment Divided into four quadrants, using the “clock” for abnormality position 62 62 Breast Assessment Tail of Spence: ◦ Contains largest portion of glandular tissue ◦ Most common site for female breast cancer 63 63 N113: THORAX Assessment SPRING 2024 64 Women ages 40 to 44 Women ages 45-54 Women ages 55 and older Choice to start annual breast cancer screening with mammograms Should get mammograms yearly Should switch to mammograms ever 2 years and have a choice for annual screening (American Cancer Society 2015-2016) 65 Breast Assessment Preparation Introduce self Include your professional title Verify/identify client Use two identifiers Assess allergy status Explain Procedure Reason for examination Provide privacy Door Curtain Sheet Expose ONLY the part that needs to be assessed Wash and warm hands 66 N113: THORAX Assessment SPRING 2024 Assessment of the Breast Observe and Inspect ◦ Size/Symmetry ◦ Shape ◦ Skin discoloration ◦ Nipple discharge, integrity, and retraction ◦ Tenderness and masses, dimpling Females: Rounded shape, slightly unequal size, generally symmetric Males: Breasts even with chest wall If obese breast may be similar to females Skin uniform in color (back or abdomen) Skin smooth and intact 67 Palpation of the Breast Palpation is done by using the flat surface of the middle three fingertips (held together) making gentle rotating motion on the breast Position of Choice ◦ Client supine ◦ Breasts flatten evenly against the chest wall ◦ High risk patients examine in both supine and sitting position 68 Breast Examination 69 N113: THORAX Assessment SPRING 2024  Recent change in breast size, swelling, and marked asymmetry  Localized discoloration or hyper-pigmentation Localized unilateral hyper-vascular areas Indicates increased blood flow  Nipple retraction or breast dimpling Swelling or edema  Orange peel (exaggeration of the pores) Presence of discharge, crusts, or cracks  Recent inversion of one or both nipples (If present since puberty, then it’s a normal finding)  FYI- some medications cause nipple discharge (oral contraceptives, steroids, digitalis, and diuretics) Tenderness, masses, or nodules 70 71 Nipple Retraction, Ulceration, Dimpling 72 N113: THORAX Assessment SPRING 2024 If mass is detected (document): Location Quadrant Hour Size Shape Regular Irregular Consistency Hard Soft Mobility Skin over mass Reddened? Dimpled? Tenderness 73 73 Genetic Abnormalities Only 5-10% of cancers are due to a genetic abnormality inherited Approx. 90% of Breast Cancer are due to genetic abnormalities that happen as a result of the aging process & “wear and tear” of life Breastcancer.org 2012 74 Lifespan Considerations Elderly 75 General breast size remains the same Breasts change in shape Become flaccid, lack firmness  Connective tissue Glandular tissue atrophies Fat tissue increases in most women N113: THORAX Assessment SPRING 2024 New Breast Cancer by Race and Ethnicity (CDC, 2023) Rate per 100,000 people 76 Any Questions? [email protected] 77