Ch 18 - NUR 314 - Health Assessment

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Ch 18 - Thorax and Lungs

Ch 18:

Normal anatomy of the lungs and landmarks

The toracic cavity: The mediastinum is the middle section of the thoracic cavity containing the esophagus, trachea, heart and great vessels. The right and left pleural cavities, on either side of the mediastinum contains the lungs.

Lung borders: in the anterior chest, the apex or highest point of lung tissue is 3 to 4 cm above the inner third of the clavicles. The base or lowerborder rests on the diaprhagm at about the sixth rib in the midclavicular line. Laterally, lung tissue extends from the apex of the axilla down to the seventh or eigth rib. Posteriorly, the location of C7 makrs the apex of lung tissue, and T10 usually corresponds to the base. Deep inspiration expands the lungs, and their lower border drops to the level of T12.

Lobes of the lungs: the lungs are paired but not precisely symmetric structures. The right lugn is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The right lung has three lobes, and the left lung has two lobes. These lobes are not arranged in horizontal bands like desert layers in a parfait glass. Rather they stack in diagnonal sloping segments and are separated by fissurs that run obliquely through the chest.

Anterior: on the anterior chest, the oblique (the major or diagonal) fissure crosses the fifth rib in the midaxillary line and terminates at the sixth rib in the midclaviular line. Ther right lung also contains the horizontal (minor) fissure, which divides the right upper and middle lobes. This fisssure extends from the fifth rib in the right midasillary line to the third intercostal space or fourth rib and the right sternal border.

Posterior: the most remarkable point about the posterior chest is that it is alost all lower lobe. The upper lobes occupy a smaller band of tissue from their apices at T1 down to T3 or T4. At this level, the lower lobes begin expiration and to T12 on inspiration> note that the right middle lobe does not project onto the posterior chest at all. If the prson abducts the aprms and places their hands on the back of the head, the division between the upper and lower lobes corresponds to the medial borderder of the scapulae.

Lateral: Laterally, tung tissue extends from the apex of the axilla down to the seventh or eigth rib. The right upper lobe extends from the apex of the axilal down to the horizontal fissure at the fifth rib. The righ tmiddle lobe extends from the horizontal fissure down and forward to the sixth rib at th emidclavicular line. Ther right lower lobe continues from the firth rib to the eigth rib in the midaxillary line.
The left lung contains only two lobes, upper and lower. These are seen laterally as two triangular areas seperated by the oblique fissure. The left upper lobe extends from the apex of the axilla down to the fifth rib at the midaxillary line. The left lower lobe continues down to the eigth rib in the midaxillary line.

Using these landmarks take a marker and try tracing the outline of each lobe on a willing partner. Take special note fo the three main points that commonly confuse beginning examiners:
- The left lung has no middle lobe
- The anterior chest contains mostly upper and middle lobe with very little lower lobe
- The posterior chest contains almost all lower lobe.

Ch 18:

Normal muscles for respiration along with accessory muscles in respiratory difficulty

Changing chest size: Respiration is the physical act of breathing air rushes into the lungs and the chest size increases (inspiration) and is expelled from the lungs as the chest recoils (expiration). The mechanical expansion and contraction of the chest cavity alters the size of the thoracic container in two dimensions; 1. the vertical diameter lengthens or shortens, which is accomplished by downward or upwward movment of the diaphragm and 2. the anterorposterior diameter decreases which is accomplied by elevation or depression of the ribs.

In inpsiration, increasing the size of the htoracic container creates a slightly negative pressure in relation to the atmosphere, so air rushes to fillt he partial vacuum. The major muscle responsible for this increase is the diaprhagm. During inspiration, contraction fo the bell shaped diaphragm causes it to descend and flatten. This lengthens the vertical diameter. Intercostal muscles lift the sternum and elvate the ribs making them more horizontal, this increases the anteroposterior diameter.

Expiration is primarily passive . As the diaphragm relaxes, elastic forces within the lungs, chest cage and abdomen cause it to dome up.A ll this squeezing creates a relatively positive pressure within the alveoli and the air flows out.
Forced inspiration, such as the after heavy exercise or occurring pathologically with respiratory distress, commands the use of the accessory neck muscles to heave up the sternum and rib cage. These neck msucles are the sternomastoids, the scaleni, and the trapezii. In forced expiration, the abdominal msucles contract powerfully to push the abdominal viscera forcefully in and up against the diaphragm, making it dome upward and makiing it squeeze against the lungs.

Ch 18:

Tactile femitus - what is it - what does it mean clinically, and how to you evaluate it.

Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and through the lung parenchyma to the chest wall, where you feel them as vibrations. Using either the palmar base (the ball) of the fingers or the ulnar ede of one hand, and tough the person chest while he or she repeats the words "ninety nine" or "blue moon" these are resonant phrases that vgenerate stong vibrations. Start over the lung apices and palpate rom ne side to another. Fremitus varies among persons, but symmetry is most important; the vibrations should feel the same int the corresponding area on each side. However, just between the scapulae, femitis may feel stronger on the right side than on the left side because the right side is closer to the bronchial bifurcation. Avoid palapting over the scapulae because bond damps out sound transmittion.
The following factors affect normal intensity of tactile fremitis;
Relative location of braonchi to the chest wall
Normally fremitis is most prominent between the scpulae and around the sternum, sites where the major bronchi are closest to the chest wall. Fremitis normally decreases as you progress down because more and more tissue impedes sound transmission.

Thickness of the chest wall: Fremitus feels greater over a thin chest wall than over an obese or heavily muscular one where thick tissue damps the vibration

Pitch and intensity: A loud low pitched voice generates more fremitus than a soft, high pitched one.
Note any areas of abnormal fremitus. Sound is conducted better through a uniformly dense structure than through a porous one, which change sin shape and solidity (as does the lung tissue durin gnormal respiration). Thus conditions that increase the density of lung tissue makes a better conducting medium for sound vibratios and increase tactile fremitus.

Decreased fremitus: occurs when anything obstructs transmission of vibrations (eg. Obstructed broncus, pleural effusion or thickening, pneumothroax or emphysema). Any barrier that comes between the sound and your palpating hand will decrease fremitus

Increased fremitis: Occurs with compression or consolidation of lung tisssues (eg. Lobar pneumonia). This is present only when bronchus is patent and when the consolidation extends to the lung surface. Note that only gross changes increase fremitus. Small areas of early pneumonia do not significantly affect fremitus.

Rhoncheal fremitus: is palpable with thick bronchial secretions
Pleural friction fremitus is palpable with inflammation of the pleura

Crepitus: is a coarse crackin sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

Ch 18:

Techniques for inspection, auscultation, palpation, and percussion of the lungs and significant findings.

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Ch 18:

Inspect posterior chest

Thoracic cage: Note the shape and configuration of the chest wall. The spinous processes should appear in a straight lien. The thorax is symmetric, in an elliptical shape, with downward sloping ribs about 45 degrees relative to the spine. The scapulae are placed symmetrically in each hemithroax.
The anteroposterior diameter whoudl be less than the transverse diameter. The ratio fo anteroposterior to transverse diameter is from 1:2 to 5:7
The neck muscles and trapezius msucles should be developed normally for the age and occupation.
Note the position The person takes to breathe. This includes a relaxed posture and the ability to support one's own weight with arms fomfortably at the sides or in the lap.
Assess the skin color and condition. Color should be consistent with person's genetic background, with allowance for sun exposed areas on the chest and the back. No cyanosis or pallow should be present. Note any lesions. Inquires as to any change in nevus on the back, for example where the person may have difficulty monitoring.
Skeletal deformities may limit thoracic cage excursion; scoliosis, kyphosis, configuration of the thorax.
AP= transverse diameter or barrel chest. Ribs are horizontal, chest appears as if held in continuous inepiration>t his occurs in chonic emphysema from hyperinflation fo the lungs.
Neck muscles are hypertrophied in COPD from adiing in forced respiration.
People with COPD often sit in a tripod position, leaning forward with arms braced against thir kknees, chair or bed. This gives them leverage so that therir retus abdominis, intercostal and accessory neck muscles can aid in inspiration.
Cyansois occurs with tissue hypoxia.

Ch 18:

Palpate the posterior chest

Systemic expansion: confirm symmetric chest expansion by palacing your warmed hands on the posterolateral chest wall with thumbs at the level of T9 or T1-0. Slide your hands medially to pinch up a small fold of skin between yoru thumbs.
Unequal chest expansion occurs with marked atelectasis, lobar pleumonia, pleural effusion with thoracic trauma, such as fractured ribs, or with pneumothorax.
Pain accompanies deep breathing when the pleurae are infamed.
Ask the person to take a deep breath. Your hands serve as mechanical amplifiers, as the person inhales deeply, your thumbe should move appart symmetrically. Note any lag in expansion.
Assess tactile (or vocal) fremeritus. Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and through the lung parenchyma to the chest wall, where you feel them as vibrations.
Using either the palmar bas (the ball) of the fingers or the ulnar ede of one hand, and tough the person chest whle he or she repeats the words "ninety nine" or "blue moon" these are resonant phrases that vgenerate stong vibrations. Start over the lung apices and palpate rom ne side to another.
Fremitis varies among persons, but symmerty is most important; the vibrations should feel the same int the corresponding area on each side. However, just between the scapulae, femitis may feel stronger on the right side than on the left side because the right side is closer to the bronchial bifurcation. Avoid palapting over the scapulae because bond damps out sound transmittion.
The following factors affect normal intensity of tactile fremitis;
Relative location of braonchi to the chest wall
Normally fremitis is most prominent between the scpulae and around the sternum, sites where the major bronchi are closest to the chest wall. Fremitis normally decreases as you progress down because more and more tissue impedes sound transmission.
Thickness of the chest wall: Fremitus feels greater over a thin chest wall than over an obese or heavily muscular one where thick tissue damps the vibration
Pitch and intensity: A loud low pitched voice generates more fremitus than a soft, high pitched one.
Note any areas of abnormal fremitus. Sound is conducted better through a uniformly dense structure than through a porous one, which change sin shape and solidity (as does the lung tissue durin gnormal respiration). Thus conditions that increase the density of lung tissue makes a better conducting medium for sound vibratios and increase tactile fremitus.
Decreased fremitus: occurs when anything obstructs transmission of vibrations (eg. Obstructed broncus, pleural effusion or thickening, pneumothroax or emphysema). Any barrier that comes between the sound and your palpating hand will decrease fremitus
Increased fremitis: Occurs with compression or consolidation of lung tisssues (eg. Lobar pneumonia). This is present only when bronchus is patent and when the consolidation extends to the lung surface. Note that only gross changes increase fremitus. Small areas of early pneumonia do not significantly affect fremitus.
Rhoncheal fremitus: is palpable with thick bronchial secretions
Pleural friction: fremitus is palpable with inflammation of the pleura
Crepitus: is a coarse crackin sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

Ch 18:

Percuss Posterior chest

Lung fields; Determine the predominant note over the lung fields. Start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders. Then, percussing in the interspace, make a side to side comparison all the way down the lung region. Percuss at 5 cm intervals. Avoid the damping effect of the scapulae and ribs.
Resonance is the low piched, clear, hollow, sound that predominants in healthy lung tissue in the adult. However resonance is a relative term and has no constant standard. The resonant note may be modified somewhat in the athleete with a heavily msuclular chest wall and in the heavily obese adult in whom subcutaneous fat produes scattered dullness.The depth of penetration of percussion has limits. Percussion sets into motion only the outer 5 to 7 cm of tissue. It will not penetrate to reveal any change in density deeper than that. Also an abnormal finding msuct be 2 to 3 cm wide to yeild an abnormal percussion note. Lesions smaller than that are not detectable by percussion.
Hyperreonance is a lower piched booming sound found when too much air is present, such as in emphysema or pneumothroax.
A dull note (Soft muccled thud) signals abnormal density in the lungs as with pneumonia, pleural effusion, atelectasis or tumor.
Diaphragmatic excursion: Determine diaphragmatic excursion. Percuss to map out the lower lung border, both in expiration and in inspiration. First, ask the person to "exhale and hold it" briefly while you perfuss don the scapular line until the should changes from resonant to dull on each side. This estimates the level of the diaphragm seperating the lungs from the abdominal viscera. It may be somewhat higher on the right side (about 1 to 2 cm) because of the presenc of the liver. Mark the spot.
Now ask te person to take a deep breath and hold it" . Continue percussing down from your first mark and mark the level where the sound changes to dull on this deep inspiration> measure the difference. This deaphragmatic excursion should be equal bilaterally and measure about 3 to 5 cm in the adults, althouth it ay be up to 7 to 8 cm in well conditioned people.
When youa re a beginning examiner you become so involved in the subtle differences of percussion notes that you extend the patient's limits of breath holding. Always hold your own breath when you ask your parent to. When you run out of air, the other person surely has too, especially if the person has a respriatory problem.
Note an abnormally high level of dullness and absense of excursion. These occur with pleural effusion (fluid in the space between the visceral and parietal pleura) or atelectasis of the lower lobes)

Ch 18:

Ascultate the posterior chest

The passage of air through the trachobronchial tree creates a characteristic set of noises that are sudible through the chest wall. These nosies also may be modified by obstruction within the respiratory passages or by changes in the lung parenchyma, the pleura or the chest wall.
Breath sounds: evaluate the presence and quality of normal brath sounds. The person is sitting, leaning forward sligtly with arms resting comfortably across the lap. Instruct the person to breathe throught he mouth a little bit deeper than usual but to sto if he or she feels dizzy. Be careful to monitor the breathign throughout the examination and offer times for the person to rest and breate normally. The person is usuallyw illing to comply with your instructions in an effort to please you and be a good patient. Watch that he or she does not hyperventialte to the point of fainting.
Clean the flat diaphragm endpiece of the stethoscope and hold it firmly on the sperson's chest wall. Llisten to at least one full respiration in each location, side to side comparison is most important.
Do not confuse background noise with lung sounds. Become familiar with these extraneous noises that may be confused with lung pathology if not recognize.
1. Examiner's breathing on stethoscope tubing
2. Stethoscope tubng bumping together
3. Patient shivering
4. Patient's hair chest: movment of hairs under stethoscope sound like crackles (rales) minimze this by pressing harder or by wetting the hair with a damp clothh
5. Rusting of paper grown or paper drapes
While standing behind the person listen to the following lugn areas--posterior from the apeices at C7 to the bases (aroudn T10), and laterally from the axilal down to the seventh or eigth rib.
Continue to visualize approximate locations of the lobes of each lugn so that you correlate your findings to anatomical areas. As you listen think 1 what am I hearing over this spot and 2 what should I expect to be hearing? You shuould expect to hear three types of normal breath sound sin the adult and older child: bronchial, sometimes called tracheal or tubular), bronchovesicular, and vesicular. Crackles are abnormal lung sounds.
Note the normal location of the three types of breath sounds on the chest wall of the adult and older child.
Decreased or absent breath sounds occur:
When the bronchial tree is obstructed at some point by secretions, mucus plug or a foreign body.
In emphysema as a result of loss of elasticity in the lung fibers and ecreased force of inspiraed air; also the lugnsa are already hyperinflated so the inaled air does not make as much noise
When anything obstructs transmission of sound between the lung and your stethoscope, such as pleurisy or plerual thickening or air (pneumothroax) or fluid (pleural effusion) in the pleural space.
A silent chest means no air is moing in or out, which is an ominous sign.
Increased breath sounds: mean that sounds are louder than they should be (eg. Bronchial sounds are abdominal when they are heard over the abdominal location, the peripheral lung fields)> they have a high pitched, tubular quailty, with a prolonged expiratory phase and a distinct pause between inspiration and expiration> They sound very close to your stethoscope, as if they were right in the tubing close to your ear. They occur when consolidation (eg pneumonia) or fcompression 9eg fluid in the intraplerual space) yeilds a dense lung area that enhances the transmission of sound from the bronchi When the inspired air reaches the alveoi it hits solid lung tissue that conducts sound more efficiently to the surface.
Adventitious sounds: note any adventitious sound.s These are added sounds that are not normally heard in the lugs. If present, they are heard as being superimposed on the breath sounds. They are caused by moving air colliding with secretions in the trachobronchial passageway or by poppign open of previously deflated airways. Sources differ as to the classification and nomenclature of these sounds, but crackles (or rales) and wheeze (or rhonchi) are the terms most common ly used by examiners
One type of adventitious sound, atelecatatic crackles, it is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoi are not fully aerated 9as in people awho are asleep or in older adults), they deflate sligtly and accumulate secretions. Crackles are heard when these secretions are expanded by a few deep braths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lugns and disappear after the first few breath or after a cough.
In the past persons were asked to "take a deep rbeath and blow it out hard" to screen for the presence of wheezing. However, this manuver is futile because evidence hsows wheezing may occur on maximal forced exhalation in healthy people.
During normal tidal flow, high pitched wheeze occurs with asthma.
Voice sounds: Determine the quailty of voice sounds or vocal resonance. The spoken voice can be ausculated over the chest wall just as it can be felt in tactile fremitus described earlier. Ask the person to repeat a phrase such as "nignety nine" while you listen over the chest wall. Normal voice transmission is soft, muffled and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said. Pathology that increases lung density enhanses transmission of voice sounds.
Eliciting the voice sound is not done routinely. Rather these are supplemental manuvers performed if you suspect lung pathology on the basis of earlier data. Whn they are performed you are testing formt te possibel presence of bronchophony, egophony and whispered pectoriloquy.
Consolidation or compression of lung tissue will enhance the voice sounds, making the words more distinct.

Ch 18:

Inspect Anterior chest

Note the shape and configuration of the chest wall. The ribs are sloping downward with symmetric interspaces. The costal angle is within 90 degrees. Development of abdominal muscles is as expected for the person's age, weight and athletic condition
Note the person's facial expression. The facila expression should be relaxed and benign, indicating an unconsicious effort of breathing.Assess the level of consciousness. The level of consciousness should be alert and cooperativeNote skin color and condition. The lips and nail beds are free of cyanosis or unusual pallor. The nales are of nomal configuration. Explore any skin lesions.
Assess the quality of respirations. Normal relaxed breathing is automiatic and effortless, regular and even, and produces no noise. The chest expands symmetrically with each inspirations. Note any localized lag on inspiration.
No retraction or bulging of the interspaces should occur on ispiration.
Normally, accessory mucles are not used to augment respiratory effort. However, with very heavy exercise, the accessory neck muscles (scalene, stenomastoid, trapezuis) are used momentarily to enhance inspiration.
The respriatory rate is within noral lmits for the person's age and the pattern of breathing is regular. Occasional sighs normally puntuate breathing.
Barrel chest has horizonatl ribs and costal angle >90 degrees
Hypertrophy of abnormal muscles occurs in chonic emphysema
Tense, strained, tired facies accompany COPD
The person with COPD may purse the lips in a whilstling position. By exhaling slowly and against a narrow opening, the pressur e in the bronchial tree remains positive and fewer airways collapse.
Cerebral hypoxia may be reflected by excessive drowsiness or by anxiety, restlessenss and irritability.
The respriatory rate is within noral lmits for the person's age and the pattern of breathing is regular. Occasional sighs normally puntuate breathing.
Clubbing of distal phalynx occurs with chonic respiratory disease.
Cutaneous anginomas (spider nevi) associated with liver disease of portal hypernsion may be evident on the chest.
Noisy breathng occurs with severe asthma or chonic bronchitis.
Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia or when gaurding to aoid postoperative incisional pain or pleurisy pain.
Refraction suggests obstruction of respiratoy tract or increased inspiratory effort is needed, as with atelectasis. Bulging indicates trapped air as in the forced experiation associated with emphesma or asthma.
Accessory muscles are used in acute airway obstructiona nd massive atelectasis.
Rectus abdominis and internal intercostal msucles are used to force expiration in COPD
Tachypnea and hypervntialtion, bradypnea and hypoventilatiion, periodic breathing.

Ch 18:

Palpate the anterior chest

Palpate the symmetric chest expansion. Place you hand on the anterolateral wall with the thumbs along the constal margins and pointing toward the xiphoid process.
Ask the person to take a deep berath. Watch your thumbs move apart symmetrically, and note smooth chest expansion with your fingers. Any lmitation in thoracic expansion is easier to detect on anterior chest because greater range of motion exists with breathing here.
Assess tactile (Vocal) fremitus. Begin palpating over the lung apices in the supraclavicular areas. Compare vibrations from one side ot the other as the person repeats "ninety nine". Avoid palpating over female breast tissue because bteast tissue normally damps the sounds.
Palpate the anterior chest wall to note any tenderness (normally none is present0 and to detect any superficial lumps or masses (again, normally none are present0. note skin mobility and turgor, and note the skin temperature and moisture.
Abnormally wide costal angle with little inspiritory variation occurs with emphysema.
A lag in expansion occurs with atelectasis, pneumonia and postoperative guarding.
A palpable grating sensation with breathng indicates plerual friction fremitus.
If any lumps are found in the breast tissues, refer the man to a specialist.

Ch 18:

Percuss the anterior chest

Begin percussing the apices in the supraclavicular areas. Then, percussing the interspaces and comparing one side with the other, move down the anterior chest.
Interspaces are easier to palpate the anterior chest than on the back. Do not percuss directly over female breast tissue because this would produce a dull note. nShift the breast tissue over slightly using the edge ofyour stationary hand. In females with large breasts percussion may yeild little useful data.
Note the borders of cardiac dullness normally found on the anterior chest and do not confuse these with suspected lung pathology. In the right hemithorax the upper border of liver dullness is located in the fifth intercostal space in the right midclavicular line. On the left tympany is evident over the gastic space.
Lungs are hyperinflated with chonic emphysema, which result in thyperresonance where you would expect cardiac dullness.
Dullness behind the right breast occurs with right middle lobe pneumonia.

Ch 18:

Ascultate the anterior chest

Breast sounds: auscultate the lung fields over the naterior chest from the apices tin the upraclavicular areas down to the sixth rib. Progress from side to side as you move downward, and listened to one full respriation in each location. Use the sequence indicated for percussion. Do not place you stethoscope directly over the female breast. Displace the breast and listen directly over the chest wall.
Evaluate normal breath sounds, noting any abnormal breath sounds and nay adventitious sounds. If the situtation warrants, assess the voice sounds on the anterior chest.
Measurment of pulmonary function status
The forceed expiratory time is the number of seconds it takes for the person to exhale from total lung capacity to residual volume. It is a screening measure of airflow obstruction> Although the test usually is not performed in the respriatory assessment, it is useful when you wish to screen for pumonary function.
Ask the perosn to inhale the deepest breath possible and then to blow it all out hard, as quickly as possible, with the mouth open. Listen with your stethoscope over the sternum. The normal time for full expiration is 4 seconds or less.
In an ambulatory care setting, a handheld spirometer mesasures lung health in chonic consditions such as asthma. Ask for the patient to inhale deeply and then to exhale into the spirometer as fast as possible until the most air possible is exhaled. The forced vital capcity (FVC) is the toal volue of air exhaled. The forced expiratory volume in one second (FEV1) is the volume exhaled in the first measured second a normal outcome is a FEV1/FVC ratio of 75% or greater meaning no significant obstruction or airflow present.
The pulse oximeter is a noninvasive metod to assess arterial oxygen saturation (SPO2). A healthy person with no lung disease and no anemia normally has an SPo2 of 97% to 98%. However, every SpO2 result must be evaluated in the context of the person's hemoglobin elvel, acid base ablance and ventilatory status.
The 6 minute distance wlak is a safer, simple inexpensive clinical measue of functional status in aging adults. Th 6MD is used as an outcome measure for people in pulmonary rehabilitation because it mirrors conditions that are used in everyday life. Locate a flat surfaced corridor that has little foot traffic, is wide enough to permit comfortable turns, and has a controlled environment. Ensure that the person is wearing comfortable shoes and equip him or her with a pulse oximeieter to monitor oxygen satruatin. Ask the person to set his or her own pace to cover as much ground as possibel in 6 minutes, and assure the person it is all right to slow down or to stop to rest at any time. Use a stopwatch to time the walsk. A person who walks > 300 meters in 6 minutes is more likely to engage in activities of daily living.
A forced expriation of 6 seconds or more occurs with obstructive lung disease. Refer this person for more precise pulmonary function studies.
Mild obstruction of airflow is a FEV1/FVC ratio of 60% to 70%, moderate obstruction is a measure of 50% to 60%, severe obstruction is a ratio of less than 50%.
Ask the person to stop the wak if you measure an SpO2 below 85% to 88% or a extreme breathlessness occurs.

Ch 18:

Impact of COPD on anatomy and assessment of patients.

Bronchitis

Condition: proliferation of mucus glands in the passageways, resultign in excessive mucus secretion. Inflammation of bronchi with partial obstruction of bronchi by secretions or constrictions. Secretions of lung distal to obstruction may be deflated. Bronchitis may be acute or chonic with recurrent productive cough. Chronic bronchitis is usually caused by cigarrette smoking.
Inspection: Hacking, rasping cough productive of thick mucoid sputum, chonic dyspnea, fatigue cyanosis, possible clubbing of fingers.
Palpation: tactile fremitis normal.
Percussion: Resonant
Auscultation: Normal vesicular. Voice sounds normal. Chonic--prolonged expiration.
Adventitious sounds: Crackles over deflated areas. May have wheeze.

Ch 18:

Impact of COPD on anatomy and assessment of patients.

Emphysema

Condition: caused by destruction of pulmonary connective tissue (elastin, collagen); characterized by permanent enlargemnt of air sacs distal to terminal bronchioles and rupture of interalveolar walls. This increases airway resistance, especially on expiration--producing a hyperinflated lung and an increase in lung volume. Cigarette smoking accounts for 80% to 90% of cases of emphysema.
Inspection: increased anteroposterior diameter. Barrel chest. Use of accessory muscles to aid respiration>T ripod position. Shortness of breath, especially on exertion. Respiratory distress tachypnea.
Palpation: decreased tactile fremitus and chest expansion.
Percussion: hyperresonant, decreased diaphragmatic excursion.
Auscultation: decreased breath sounds. May have prolonged expiration. Muffled heart sounds resulting from overdistention of lungs.
Adventitious sounds: usually none; occasionally wheeze.
Asthma (reactive airway Disease)
Condition: an allergic hypersensitivity to certain inhaled allergens (pollen) irritants (tobacco, ozone), microbes, stress, or exercise that produces a complex response characterized by bronchospasm and inflammation, edema in walls of bronchioles, and secretions of highly viscious mucus into airways. These factors greatly increase airway resistance, especially during expiration, and produce the symptoms of wheezing, dyspnea and chest tightness.
Inspection: During severe attack: increased respiratory rate, shortness of breath with audible wheeze, use of accessory neck muscles, cyanosis, apprehension, retraction of intercostal spaces. Expiration labored, prolonged. When chronic may have barrel chest.
Palpation: tactile fremitus, decreased tachycardia.
Percussion: resonant. May be hyperresonant if chronic.
Auscultation; diminished air movement. Breath sounds decreased with prolonged expiration. Voice sounds decreased.
Adventitious sounds: bilateral wheezing on expiration sometimes inspiration and expiratiory wheezing.

Ch 18:

Impact of COPD on anatomy and assessment of patients.

Abnormal findings of Emphysema

Abnormal findings indicatory of COPD: Barrel chest. Ribs are horizontal appear as if held in continous inpiration. Occurs in chronic emphysema from hyperinflation of the lungs.
Neck muscles ar ehypertrophied in COPD from aiding in forces respriations.
People with COPD often sit in a tripod position, leaning forward with arms brackd against their kneew, chair or bed. This gives them leverage so that their rectus abdominis, intercostal and accessory neck muscles can aid in expiration. Cyanosis occurs with tissue hypoxia.
Decreased frmitus: occurs when antyhing obstructs transmission of vibration 9eg. Obstructed bronchitus, pleural effusion or thickening, pneumothroax or emphysema) any barrier that comes between the sound and your palpating had will decrease fremitus.
Crepitus: Coarse, crackling sensation palpable over the skin surface. Occurs in subcutaneous emphysema when air escapes from the lungs and enters the subcutaeneous tissues as after open thoracic injury or surgery.
Hyperresonance is a lower piched, booming sound found when too much air is present, such as inemphysema or pneuomothroax.
Barrel chest has horizontal ribs and costal angles >90 deegrees.
Hypertrophy of abdominal muscles occurs in chonic emphysema.
Tense strained, tired faces accompnay COPD.
The person with COPD may pursue the lips in a whistling position. By exhaling slowly and against a narrow opening the pressure in the bornchial tree remains positive and fewer airways collapse.
Cerebral hypoxia may be reflected by excessive drowsiness or by anxiety,r estlessness or irritability.
Clubbing of diatal phalanx occur with chonic respiratory diseases.
Cutaneous angiomas (spider nevi) associated with liver disease or portal hypertension may be evident on chest.
Noaisy brathing occurs with severe asthma or chonic bronchitis.
Restriction suggests obstruction of respiratory tract or increased inspiratory effort is needed, as with atelectasis. Bulging indicates trapped air as in the forced expiration associated with emphysema or asthma.
Accessory muscles are used in acute airway obstruction and massive atelectesis.
Rectus abdominis and interal intercostal muscles are used to force expiration in COPD.
Abnormally wide costal angle aoccurs with little inspiratory variation occurs with emphysema.
Lungs are hyperinflated with chonic emphysema, which results in hyperresonance where you would expect cardiac dullness.
Note a barrel shaped chest persisting after age 6 years, which may develop with chonic asthma or cystic fibrosis.

Ch 18:

Signs and symptoms of pnuemothorax.

Condition: free air in pleural space causes partial or ocmplete lung collapse. Air in pleural space neutralizes the usual negative pressure present; thus lung collapses. Usually unilateral. Pneumothroax can be 1. spontaneous (air enters pleural space through rupture in lung wall, 2. traumatic (air enters trhough oepning or injury in chest wall) or 3. tension (trapped air in plaural space increases, compressing lungs and shifting mediastinum to the unaffected side).
Inspection: Unequal chest expansion> if large, tachypnea, cyanosis, apprehension, bulging in interspaces.
Palpation; tactile fremitus decreased or absent. Tracheal shift to opposite side (unaffected side0. chest expansion decreased on affected side. Tachycardia, decreased BP.
Percussion. Hyperresonant. Decreased diaphragmatic excursion.
Auscultation: rbeath sounds decreased or absent. Voice sounds decreased or absent.
Adventitious sounds; None.
Abnormal findings: unequal chest expansion occurs with marked atelectasis, lobar pneumia, plural effusion, with thoracic trauma such as fractured ribs, or with pneumothrax.
Decreast fremitus: occurs wen anything obstructs transmission of vibrational (eg. Obstructied bronchus, pleural effusion, or thickening, pneumothroax or emphysema). Any barrier that comes between the sound and your palpating will decrease fremitus.
Asymmetric expansion occurs with diaphragmatic hernia or pneumothoriax.
Diminished breath sounds occur with pneumonia, atelectaisis, pleural effusion or pneumothroax.

Ch 18:

Normal anatomical changes associated with aging.

...

Ch 18:

Clinical evaluation of heart failure with assessment findings.

Condition: pump failure with increasing pressure of cardiac overload causes pumonary congestion or an increased amount of blood present in pumonary capillaries.
Dependent air sacs are deflated. Pulmonary capillaires engorged. Bronchial mucsa may be swollen.
Inspection: Increased respiratory rate, shortness of breath on exertion, orthopena, paroxysmal noctural dyspna, nocturia, ankle edema, pallor in light skinned people.
Palpation: skin moist clammy, tactile fremitus normal.
Percussion: resonant
Ausculation: normal, vesicular, heart sounds include an S2 gallop.
Adventious sounds: craclkes at lung base.

Ch 18:

Review developmental competence pgs 434-437

...

Ch 18:

Angle of Louis

manubriosternal angle, the articulation of the manubrium and body of the sternum, continuous with the second rib

Ch 18:

Apnea

cessation of breathing

Ch 18:

Asthma

Condition: an allergic hypersensitivity to certain inhaled allergems (pollen) irritants (tobacco, ozone), microbes, stress, or exercise that produces a complex response characterized by bronchospasm and inflammation, edema in walls of bronchioles, and secretions of highly viscious mucus into airways. These factors greatly increase airway resistance, especially during expieration, and produce the symptoms of wheezing, dyspnea and chest tightness.
Inspection: During severe attack: increased respiratory rate, shortness of breath with audible wheeze, use of accessory neck muscles, cyanosis, apprehension, retraction of intercostal spaces. Expiration labored, prolonged. When chonic may have barrel chest.
Palpation: tactile fremitus, decreased tachycardia.
Percussion: resonant. May be hyperresonant if chronic.
Auscultation; diminiashed iar movment. Breath sounds decreased with prolonged espiration. Voice sounds decreased.

Ch 18:

Atelectasis

Condition: collapsed shrunken section fo alveoli or an entire lung as a result of 1 airway obstruction (eg. The broncus is completely blocked by thick exudate, aspirated foreign body, or tumor), the alvolar air beyond it is gradually absorbed by the pulmonary capillaries and the alveolar walls cave in 2. compression on the lung and 3 lack of surfactant (hyaline memrbane disease)
Inspection; cough. Lag on expansion on affected side. Increased respriatory rate and pulse. Possible cyanosis.
Palpation: cehst expansion decreased on affected side. Tactile fremitus decreased or absent over area. With large collapse, tracheal shift toward affected side.
Percussion: dull over area (remainder of thorax sometimes may have hyperresonant note).
Auscultation: breath sounds decreased vesicular or absent over area. Voice sounds variable, susually decreased or absent over affected area.
Adventitious sounds: none if broncus is obstructed> occasional fine crackles if broncus is patent.

Ch 18:

Bradypnea

slow breathing <10 breaths per minute, regular rate

Ch 18:

Bronchiole

one of the smaller respiratory passageways into which the segmental bronchi devide

Ch 18:

Bronchitis

Condition: proliferation of mucus glands in the passageways, resultign in excessive mucus secretion. Inflammation of bronchi with partial obstruction of bronchi by secretions or constrictions. Secretions of lung distal to obstruction may be deflated. Bronchitis may be acute or chonic with recurrent productive cough. Chronic bronchitis is usually caused by cigarrette smoking.
Inspection: Hacking, rasping cough productive of thick mucoid sputum, chonic dyspnea, fatigue cyanosis, possible clubbing of fingers. possible clubbing of fingers.
Palpation: tactile fremitis normal.
Percussion: Resonant
Auscultation: Normal vesicular. Voice sounds normal. Chonic--prolonged expiration.
Adventitious sounds: Crackles over deflated areas. May have wheeze.

Ch 18:

Pulmonary Embolism

Condition: undissolved materials (eg. Thrombus or air bubbles, fat globules) originating in legs or pelvis detacha nd travel through vnous system returning blood to right heart and lodge to occludie pulnonary vessels. Over 95% arise from deep vein thrombi in lower legs as a result of stasis of blood, vessel injury, or hypercoagulability. Pulmonay occusion resuts in ischmia of downstream lung tissue, increased pulmonary artery pressure, decreased cardiac output and hypoxia. Rarely, a saddle embolus in bifurcation of pulmonary arteries leads to a sudden death from hypoxia. More often, small to medium pulmonary branches occlude, leading to dyspna, These may resolve by fibrolytic activity.
Subjective; chest pain, worse on deep inspiration, dyspnea.
Inspection: Apprehensive, restlessness, axiety, mental status chagnes, cyanoosis, tachypnea, cought, heoptysis, PAO2 < 80% on pulse oximetry. Arterial blood gases show respiratory alkalosis.
Palpation; diaphoresis, hypotension.
Auscultation: tachycardia, accentuated pulmonic component of S2 heart sounds.
Adventitious sounds: crackles, wheezes.

Ch 18:

Bronchophony

the spoken voice sound heard through the stethoscope, which sounds soft, muffled, and indistinct over normal lung tissue

Ch 18:

Chronic obstructive pulmonary disease (COPD)

a functional category of abnormal respiratory conditions characterized by airflow obstruction, e.g.; ephysema, chronic bronchitis

Ch 18:

Cilia

millions of hairlike cells lining the tracheobronchial tree

Ch 18:

Consolidation

the solidification of portions of lung tissue as it fills up with infectious exudate, as in pneumonia

Ch 18:

Crackles / Rales

abnormal, discontinuous, adventitous lung sounds heard on inspiration

Ch 18:

Crepitus

coarse crackling sensation palpable over the skin when air abnormally escapes from the lung and enters the subcutaneous tissue

Ch 18:

Dead space

passageways that transport air but are not available for gaseous exchange, e.g. trachea and bronchi

Ch 18:

Egophony

the voice sound of "eeeeee" heard through the stethoscope

Ch 18:

Emphysema

the chronic obstructive pulmonary disease characterized by enlargement of alveoli distal to terminal bronchioles

Ch 18:

Fissure

the narrow crack dividing the lobes of the lungs

Ch 18:

Fremitus

a palpable vibration from the spoken voice felt over the chest wall

Ch 18:

Friction rub

a coarse, grating, adventitious lung sound heard when the pleurae are inflamed

Ch 18:

Hypercapnia

(hypercarbia) increased levels of carbon dioxide in the blood

Ch 18:

Intercostal space

space between the ribs

Ch 18:

Kussmaul's respiration

a type of hyperventilation that occurs with diabetic ketoacidosis

Ch 18:

Orthopnea

ability to breathe easily only in an upright position

Ch 18:

Paroxysmal nocturnal dyspnea

sudden awakening from sleeping with shortness of breath

Ch 18:

Percussion

striking over the chest wall with short sharp blows of the fingers in order to determine the size and density of the underlying organ

Ch 18:

Tuberculosis

Condition: inhalation of tubercle bacilli into the alveolar wall starts 1. inditial complex is acute inflammatory response--macrophages engulf bacilli but do not kill them. Tubercle forms around the bacilli. 2. Scar tissue forms, lesion, clacifies and hwos on x ray. #. Reactivation of previously healed lesion. Dormant bacilli now multiply, producing necrosis, cavitation, and caseous lung tissue (cheeselike) 4. Extensive destruction as lesion erodes into broncus forming air filled cavity. Apex usually ahs the most damage.
Subjective: Initially asymptomatic, showing as positive skin test or on x ray film. Progressive tuberculosis involves weight loss, anorexia, easily fatigability, low grade afternoon fevers, night sweats. May have pleural effusion, recurrent lower respiratory infections.
Inspection: Cough initially nonproductive, later productive of purulent, yellow green sputum, may be blood tinged. Dyspnea, orthopnea, fatigue, weakness.
Palpation: skin moist at night from night sweats.
Percussion: resonant initially. Dull over any effusion.
Auscultation; normal or decreased vesicular breath sounds.
Adventitious sounds: craclkles over upper lobes common, persist following full expiration and cough.

Ch 18:

Acute respiratory distress syndrome (ARDS)

Condition: an acute pulmonary insult (trauma, gastric acid inspiration, shock, sepsis) damages alveolar capillary memrbane, leading to increased permeability of pulmonary capillaries and alveolar epithelium and to pulmonary edema Gross examination 9autopsy) would show dark red, firm, aritless tissue with some alveoi collapsed, and hyaline memrbanes lining the distended alveoli. Subjective; acute onset of dyspnea, apprehension.
Inspection: restlessness; disorrientation, rapid shallow breathing productive cough, thin, frothy sputum; retractions of intercostal spaces and sternum. Decreased paO2, blood gases show respriatory alkalosis, x ray fils show diffuse pumonary infiltates, a late sign is yanosis.
Palpation; hypotension
Ausculattion: tachycardia
Adventitious sounds: crackles, rhonchi

Ch 18:

Pleural effusion

Condition: Collection of excess fluid in the intrapleural space, with compression of overlying lung tissue. Effusion may contain watery capillary fluid (transduative); protein (exudative), purulent matter (empyemic), blood (hemothroax), or milky lymphatic fluid (chylothroax). Gravity settles fluid in dependent areas of thorax. Presence of fluid subdues all lung sounds.
Inspection: Increased respirations, dyspnea, may have dry cough, tachycardia, cyanosis, abdominal distention.
Palpation: tactile fremitus decreased or absent. Tracheal shift always from affected side. Chest expansion decreased on affected side.
Percussion: Dull to flat. No diaphragmetic excursions on affected side.
Auscultation: rbeath sound sdecreased or absent. Voice sound decreased or absent. When remainder of lung is compressed near the effusion, may have bronchial breath sounds over the compression alsong with bronchophony, egophony, whispered pectoriloquy.
Adventitious sounds: none

Ch 18:

Pneumocystis jiroveci (P. Carinii) Pneumonia

Condition: this virulent form of pneumoia is a protozoal infection associated with Aids. The paracsite. P. Jiroveci (p. carinii) is common in the united states and harmless ot most people, except to the immunocompromised, in whome a diffuse interstitial pneumonitis ensues. Cysts containing the organsims and macrophages form in alveolar spaces, alveolar walls thicken and the disease spreadds to bilateral interstitial filtrates of fomy, protein rich fluid.
Inspection: Anxiety, shortness of beath, dyspnea on exertion, malaise are common. Also tachypnea, fevere a dry nonproductive cough; intercostal retractiosn in children; cyanosis.
Palpation; decreased chest expansion.
Percussion: Dull over areas of diffuse infiltrate.
Auscltation: breath sounds may be diminished
Adventitious sounds: crackles may be presnt but often are absent.

Ch 18:

Rhonchi

low-pitched, musical, snoring, adventitious lung sound cause by air-flow obstruction from secretions

Ch 18:

Tachypnea

rapid shallow breathing, >24 breaths per minute

Ch 18:

Bronchial lung sounds

pitch: high
amplitude: loud
duration: inspiration < expiration
quality: harsh, hollow tubular
normal location: trachea and larynx

Ch 18:

Bronchovesicular lung sounds

pitch: moderate
amplitude: moderate
duration: moderate inspiration = expiration
quality: mixed
normal location: over major bronchi where fewer alveoli are located; posterior, between scapulae especially on right, anterior around upper sternum in first and second intercostal spaces

Ch 18:

Vesicular lung sounds

pitch: low
amplitude: soft
duration: inspiration > expiration
quality: rustling, like the sound of the wind in the trees
normal location: over peripheral lung fields where air flows through smaller bronchioles and alveoli

Ch 18:

Vital capacity

the amount of air, following maximal inspiration, that can be exhaled

Ch 18:

Wheeze

high-pitched, musical, squeaking adventitious lung sound

Ch 18:

Whispered pectoriloquy

a whispered phrase heard through the stethoscope that sounds faint and inaudible over normal lung tissue

Ch 18:

Xiphoid process

sword-shaped lower tip of the sternum

Ch 18:

Apex border of the lungs

3 to 4 cm above the inner third of the clavicles

Ch 18:

Base border of the lungs

rests on the diaphragm

Ch 18:

Lateral left lung border

sixth rib, midclavicular line

Ch 18:

Lateral right lung border

fifth intercostal space

Ch 18:

Posterior apex border of the lungs

C7

Ch 18:

Barrel chest

anteroposterior = transverse diameter

Ch 18:

Pectus excavatum

sunken sternum and adjacent cartilages

Ch 18:

Normal chest

is elliptical in shape with an anteroposterior : transverse diameter in the ratio of 1 : 2 or 5 : 7

Ch 18:

Adventitious breath sounds

These are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused by moving air colliding with secretions in the trachobronchial passageway or by poppign open of previously deflated airways. Sources differ as to the classification and nomenclature of these sounds, but crackles (or rales) and wheeze (or rhonchi) are the terms most common ly used by examiners
One type of adventitious sound, atelecatatic crackles, it is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoi are not fully aerated as in people who are asleep or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these secretions are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs and disappear after the first few breath or after a cough. In the past persons were asked to "take a deep breath and blow it out hard" to screen for the presence of wheezing. However, this maneuver is futile because evidence shows wheezing may occur on maximal forced exhalation in healthy people.

Ch 18:

Lobar pneumonia

Condition: Infection in lung parenchyma leaves alveolar emmbrane edematous and porous, so red blood cells (RBCs) and white blood cells (WBCs) pass from blood to alveoli. Alveoli progressively fill up (become conslidated) with bacteria, solid cellurlar debris, fluid and blood cells, which repalce alveolar aire. This decreases surface area of the respiratory memrbane causing hypoxemia.
Inspection: Increased respriatory rate, guarding and lag con nasal flaring.
Palaption: chest expasion decreased on affected side. Tactile fremitus increased if broncus patent, decreased if broncus obstructed.
Percussio: dull over lobar pneumonia.
Ausculation: breath sounds louder with patent bronchus as if coming directly from larynx. Voice sounds have increased clarity; bronchophyony, egophony, whispered pectoriloquy present. Children---diminished breath sounds may occur early in pnumonia.
Adventitious sounds: crackles, fine to medium.

Ch 18:

Pectus carinatum

forward protrusion of the sternum with ribs sloping back at either side

Ch 18:

Scoliosis

lateral, S-shaped curvature of the thoracic and lumbar spine

Ch 18:

Kyphosis

exaggerated posterior curvature of thoracic spine

Ch 18:

The manubriosternal angle is:

A) the articulation of the manubrium and the body of the sternum
B) a hollow, U-shaped depression just above the sternum
C) also known as the breastbone
D) a term synonymous with costochondral junction

A) the articulation of the manubrium and the body of the sternum

Ch 18:

Select the correct description of the left lung.

A) narrower than the right lung with three lobes
B) narrower than the right lung with two lobes
C) wider than the right lung with two lobes
D) shorter than the right with three lobes

B) narrower than the right lung with two lobes

Ch 18:

Some conditions have a cough with characteristic timing. The cough associated with chronic bronchitis is best described as

A) continuous throughout the day
B) productive cough for at least 3 months of the year for 2 years in a row
C) occurring in the afternoon/evening because of exposure to irritants at work
D) occuring in the early morning

B) productive cough for at least 3 months of the year for 2 years in a row

Ch 18:

Symmetric chest expansion is best confirmed by:

A) placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10, then sliding the hands up to pin up a small fold of skin between the thumbs
B) inspection of the shape and configuration of the chest wall
C) placing the palmar surface of the fingers of one hand against the chest and having the person repeat the words "ninety-nine"
D) percussion of the posterior chest

A) placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10, then sliding the hands up to pin up a small fold of skin between the thumbs

Ch 18:

Absence of diaphragmatic excursion occurs with

A) asthma
B) an unusually thick chest wall
C) pleural effusion or atelectasis of the lower lobes
D) age-related changes in the chest wall

C) pleural effusion or atelectasis of the lower lobes

Ch 18:

Ascultation of breath sounds is an important components of respiratory assessment. Select the most accurate description of this part of the examination.

A) Hold the bell of the stethoscope against the chest wall, listen to the entire right field, then the entire left field.
B) Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons.
C) Listen for the apices to the bases of each lung field using the bell of the stethoscope
D) Select the bell or diaphragm depending upon the quality of sounds heard; listen for one respiration in each location, moving from side to side.

B) Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons.

Ch 18:

Select the best description of bronchovesicular breath sounds:

A) high pitched, of longer duration on inspiration than expiration
B) moderate pitch, inspiration equal to expiration
C) low pitched, inspiration greater than expiration
D) rustling sound, like the wind in the trees

B) moderate pitch, inspiration equal to expiration

Ch 18:

After examining a patient, you make the following notation: Increased respiratory rate, chest expansion decreased on the left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These finding are consistent with a diagnosis of:

A) bronchitis
B) asthma
C) pleural effusion
D) lobar pneumonia

D) lobar pneumonia

Ch 18:

Upon examining a patient's nails, you note that the angle of the nail base is > 160 degrees and that the nail base feels spongy to palpation. These findings are consistent with:

A) adult respiratory distress syndrome
B) normal findings for the nails
C) chronic, congenital heart disease and COPD
D) atelectasis

C) chronic, congenital heart disease and COPD

Ch 18:

Upon examination of a patient, you note a coarse, low-pitched sound during both inspiration and expiration. This patient complains of pain with breathing. These findings are consistent with:

A) fine crackles.
B) wheezes
C) atelectatic crackles
D) pleural friction rub

D) pleural friction rub

Ch 18:

In order to use the technique of egophony, ask the patient to:

A) take several deep breaths, then hold for 5 seconds
B) say "ee" each time the stethoscope is moved
C) repeat the phrase "ninety-nine" each time the stethoscope is moved
D) whisper a phrase as auscultation is performed.

B) say "ee" each time the stethoscope is moved

Ch 18:

When examining for tactile fremitus, it is important to:

A) have the patient breathe quickly
B) ask the patient to cough
C) palpate the chest symmetrically
D) use the bell of the stethoscope

C) palpate the chest symmetrically

Ch 18:

The pulse oximeter measures:

A) arterial oxygen saturation
B) venous oxygen saturation
C) combined saturation of arterial and venous blood
D) carboxyhemoglobin levels

A) arterial oxygen saturation

Ch 18:

Increased tactile fremitus would be evident in an individual who has which of the following conditions?

A) Emphysema
B) Pneumonia
C) Crepitus
D) Pneumothorax

B) Pneumonia

Fremitus is a palpable vibration. Increased fremitus occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia). Decreased fremitus occurs when anything obstructs transmission of vibrations (e.g., obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema). Crepitus is a coarse crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue.

Ch 18:

A clinical manifestation common in an individual with chronic obstructive pulmonary disease (COPD) is:

A) periodic breathing patterns.
B) pursed-lip breathing.
C) unequal chest expansion.
D) hyperventilation.

B) pursed-lip breathing.

An individual with COPD may purse the lips in a whistling position. By exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive, and fewer airways collapse. Periodic breathing patterns are Cheyne-Stokes or Biot respirations. Cheyne-Stokes respirations occur in heart failure, renal failure, meningitis, drug overdose, and increased intracranial pressure; this type also normally occurs in infants and aging persons during sleep. Biot respirations occur with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis. Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain or pleurisy pain. Hyperventilation is a normal response to fever, fear, or exercise; respiration rate also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons.

Ch 18:

The thoracic cage is defined by all of the following except the:

A) sternum.
B) ribs.
C) costochondral junction.
D) diaphragm.

C) costochondral junction.

The thoracic cage is defined by the sternum, ribs, vertebrae, and diaphragm.

Ch 18:

Inspiration is primarily facilitated by which of the following muscles?

A) Diaphragm and abdominus rectus
B) Trapezia and sternomastoids
C) Internal intercostals and abdominal
D) Diaphragm and intercostals

D) Diaphragm and intercostals

The major muscle responsible for inspiration is the diaphragm. Intercostal muscles lift the sternum and elevate the ribs, making them more horizontal; this increases the anteroposterior diameter.

Ch 18:

Which of the following voice sounds would be a normal finding?

A) The voice transmission is distinct and sounds close to the ear.
B) The "eeeee" sound is clear and sounds like "eeeee".
C) The whispered sound is transmitted clearly.
D) Whispered "1-2-3" is audible and distinct.

B) The "eeeee" sound is clear and sounds like "eeeee".

A normal finding from voice sounds is egophony; "eeeee" heard through the stethoscope clearly. A normal finding from voice sounds is bronchophony; normal voice transmission is soft, muffled, and indistinct. A normal finding from voice sounds is whispered pectoriloquy: whispered sound is faint, muffled, and almost inaudible.

Ch 18:

The gradual loss of intraalveolar septa and a decreased number of alveoli in the lungs of the elderly cause:

A) hyperventilation.
B) spontaneous atelectasis.
C) decreased surface area for gas exchange.
D) decreased dead space.

C) decreased surface area for gas exchange.

The histologic changes result in less surface area for gas exchange.

Ch 18:

The function of the trachea and bronchi is to:

A) transport gases between the environment and the lung parenchyma.
B) condense inspired air for better gas exchange.
C) moisturize air for optimum respiration.
D) increase air turbulence and velocity for maximum gas transport.

A) transport gases between the environment and the lung parenchyma.

The trachea and bronchi transport gases between the environment and the lung parenchyma.

Ch 18:

Stridor is a high-pitched, inspiratory crowing sound commonly associated with:

A) upper airway obstruction.
B) atelectasis.
C) congestive heart failure.
D) pneumothorax.

A) upper airway obstruction.

Stridor is associated with upper airway obstruction from swollen, inflamed tissues or a lodged foreign body.

Ch 18:

Percussion of the chest is:

A) a useful technique for identifying small lesions in lung tissue.
B) helpful only in identifying surface alterations of lung tissue.
C) is not influenced by the overlying chest muscle and fat tissue.
D) normal if a dull note is elicited.

B) helpful only in identifying surface alterations of lung tissue.

Percussion detects only the outer 5 to 7 cm of tissue; it will not penetrate to reveal any change in density deeper than that. An abnormal finding must be 2 to 3 cm wide to yield an abnormal percussion note. Percussion findings (resonant notes) may be modified by a muscular chest wall of an athlete or subcutaneous tissue of the obese person. Resonance is a low-pitched, clear, hollow sound that predominates with percussion of healthy lung tissue.

Ch 18:

Which of the following correctly expresses the relationship to the lobes of the lungs and their anatomic position?

A) Upper lobes—lateral chest
B) Upper lobes—posterior chest
C) Lower lobes—posterior chest
D) Lower lobes—anterior chest

C) Lower lobes—posterior chest

The posterior chest is almost all lower lobe. The anterior chest contains mostly upper and middle lobe with very little lower lobe.

Ch 18:

An increase in the transverse diameter of the chest cage in a pregnant female is due to a(n):

A) compensatory increase in respiratory parenchyma.
B) increase in estrogen.
C) increase in surfactant.
D) increase in tidal volume.

B) increase in estrogen.

The increase in estrogen level during pregnancy relaxes the chest cage ligaments. This allows an increase in the transverse diameter of the chest cage by 2 cm, and the costal angle widens.

Ch 18:

Which of the following alterations is most likely to be present in an older adult?

A. Increased vital capacity
B. Increased residual volume
C. Increased tidal volume
D. Increased dead space

B. Increased residual volume

Ch 18:

Mr. Jones is a 37-year-old patient who presents with complaints of a cough that generally occurs at night. This is commonly associated with:

A. acute respiratory infections.
B. exposure to noxious irritants.
C. chronic bronchitis.
D. sinusitis.

D. sinusitis.

Ch 18:

Mrs. Roman is a 47-year-old patient who returns to the emergency room because of several respiratory problems. If you were concerned that a patient was experiencing hemoptysis, which of the following questions should you ask her?

A. "Have you or are you experiencing shortness of breath?"
B. "Have you or are you experiencing a chronic productive cough?"
C. "Have you or are you experiencing difficulty breathing in a lying position?"
D. "Have you or are you coughing up blood?"

D. "Have you or are you coughing up blood?"

Ch 18:

Mrs. Hess is a 48-year-old patient who comes to the ambulatory health center. On examination you note increased tactile fremitus. Which of the following conditions reflects this finding?

A. Emphysema
B. Pneumonia
C. Crepitus
D. Pneumothorax

B. Pneumonia

Ch 18:

Mrs. Jones is a 29-year-old patient who is pregnant and comes to the clinic for routine prenatal care. On examination, you note an increase in the transverse diameter of the chest cage. This is a common finding in women who are pregnant and is due to a(n):

A. compensatory increase in respiratory parenchyma.
B. increase in estrogen.
C. increase in surfactant.
D. increase in tidal volume.

B. increase in estrogen.

Ch 18:

Mrs. Douglas is a 38-year-old patient who comes to the ambulatory clinic with symptoms of pneumonia. Which of the following breath sounds would you hear in the peripheral lung fields?

A. Bronchovesicular
B. Vesicular
C. Adventitious
D. Bronchial

D. Bronchial

Ch 18:

Adventitious sounds are:

A. heard when moving air collides with secretions in the tracheobronchial passageways.
B. high-pitched and mimic normal breath sounds.
C. heard in the presence of vocalization of sounds.
D. heard between normal breath sounds.

A. heard when moving air collides with secretions in the tracheobronchial passageways.

Ch 18:

Mr. Oliver, who is 67 years of age, returns to the clinic for a follow-up appointment related to his COPD. On examination, which of the following manifestations associated with breathing may be evident?

A. Periodic breathing patterns
B. Pursed lip breathing
C. Unequal chest expansion
D. Hyperventilation

B. Pursed lip breathing

Ch 18:

Ms. Buckman is a 39-year-old patient who presents to the emergency room with an exacerbation of her asthma. When assessing tactile fremitus on the anterior chest, which of the following areas is generally avoided due to the dampening of sound?

A. Lateral lobes
B. Female breast tissue
C. Scapulae
D. Cardiac

B. Female breast tissue

Ch 18:

When assessing a newborn, which of the following Apgar scores is considered to represent adequate transition to extrauterine life?

A. 10 to 12

C. 6 to 8
D. 3 to 6

B. 7 to 10

Ch 18:

Which of the following interventions would be appropriate to suggest to a female patient to help her prevent the development of kyphosis?

A. Correct posture
B. Reduction in her diet if she is more than 10% above her desired weight
C. Physical exercise
D. Not to get pregnant after reaching 35 years of age

C. Physical exercise

Ch 18:

Mrs. Goldsmith brings her mother to the clinic because her mother is complaining about breathing problems. On examination, you note stridor, which is a high-pitched, inspiratory crowing sound. This is commonly associated with:

A. upper airway obstruction.
B. atelectasis.
C. congestive heart failure.
D. pneumothorax.

A. upper airway obstruction.

Ch 18:

Which of the following is an anterior thoracic landmark?
A. Vertebrae prominens
B. Manubriosternal angle
C. Inferior border of scapula
D. Midaxillary line

B. Manubriosternal angle

Ch 18:

The floor of the thoracic cage is identified as the:

A. costochondral junction.
B. twelfth rib.
C. diaphragm.
D. inferior border of the lung.

C. diaphragm.

Ch 18:

The costal angle formed by the right and left costal margins is approximately a ___-degree angle.

A. 45
B. 60
C. 90
D. 10

C. 90

Ch 18:

Which of the following correctly expresses the relationship of the lobes of the lung and their anatomic position?

A. Upper lobes—lateral chest
B. Upper lobes—posterior chest
C. Lower lobes—posterior chest
D. Lower lobes—anterior chest

C. Lower lobes—posterior chest

Ch 18:

In comparing the right and left lungs, which of the following is a true statement?

A. The left lung has three lobes, and the right lung has two lobes.
B. The right lung is shorter than the left lung due to the position of the underlying liver.
C. The left lung is wider than the left lung because it has more lobes.
D. The right lung is separated from the left lung by the oblique fissure.

B. The right lung is shorter than the left lung due to the position of the underlying liver.

Ch 18:

The function of the negative pressure in the pleural lining of the lungs is to:

A. maximize ventilation.
B. facilitate distribution of oxygen throughout the alveoli.
C. hold the lungs tightly against the chest wall.
D. increase the surface area within the lung tissue.

C. hold the lungs tightly against the chest wall.

Ch 18:

The functional respiratory unit consists of the bronchioles and alveolar ducts. Alveolar sacs and the alveoli are collectively identified as the:

A. acinus.
B. respiratorius.
C. acinose.
D. ventilorius

A. acinus.

Ch 18:
Inspiration is primarily facilitated by which of the following muscles?

A. Diaphragm and abdominus rectus
B. Trapezia and sternomastoids
C. Internal intercostals and abdominal
D. Diaphragm and intercostals

D. Diaphragm and intercostals

Ch 18:

Control of respiration is primarily under the influence of the amount of _________ in the blood.

A. oxygen
B. carbon dioxide
C. hydrogen
D. nitrogen

B. carbon dioxide

Ch 18:

In pregnancy, which of the following generally increases to accommodate the developing fetus?

A. Respiratory rate
B. Lung volume
C. Tidal volume
D. Vertical diameter of the thoracic cage

C. Tidal volume

Ch 18:

Which of the following best describes age-related changes that occur in older patients?

A. The lungs increase their vital capacity to compensate for the reduction in tidal volume.
B. The lungs become more rigid and difficult to inflate.
C. The respiratory rate increases to compensate for a reduction in muscle strength.
D. The diaphragm loses much of its strength, making it difficult to ventilate the lower portions of the lungs.

B. The lungs become more rigid and difficult to inflate.

Ch 18:

Which of the following premature infants would be less at risk of developing respiratory distress syndrome?

A. A black female
B. A white male
C. An Asian/Pacific Islander female
D. An American Indian male

A. A black female

Ch 18:

Fetal pulmonary development is measured by the ratio of which two factors present in the amniotic fluid?

A. Oxygen and carbon dioxide
B. Surfactant and relaxin
C. Pleurisies and hyalinoses
D. Lecithin and sphingomyelin

D. Lecithin and sphingomyelin

Ch 18:

Mr. Lewis is a 61-year-old patient who comes to the clinic for follow-up after an emergency room visit. Mr. Lewis complains that he is only able to sleep when supported in an upright position. This is caused by:

A. paroxysmal nocturnal dyspnea.
B. orthopnea.
C. cyanopnea.
D. dysopnea.

B. orthopnea.

Ch 18:

On inspection of a middle-aged client, you observe that the ratio of the anteroposterior:transverse diameter is approximately 1:1. A descriptor of this type of chest would be which of the following?

A. Pectus excavatum
B. Pectus carinatum
C. Barrel chest
D. Bronchial chest

C. Barrel chest

Ch 18:

When palpating the chest wall of an individual who has just had a traumatic injury to the chest, which of the following assessment findings would be consistent with this type of injury?

A. Increased fremitus
B. Rhonchal fremitus
C. Crepitus
D. Hyperresonance

C. Crepitus

Ch 18:

Which of the following is a true statement regarding the findings related to percussion?

A. Percussion is a useful technique for identifying small lesions in lung tissue.
B. Percussion is helpful only in identifying surface alterations of lung tissue.
C. Percussion notes are not influenced by the overlying chest muscle and fat tissue.
D. A dull note elicited with percussion is the expected finding.

B. Percussion is helpful only in identifying surface alterations of lung tissue.

Ch 18:

Mr. Jessup is a 62-year-old gentleman who presents for a health assessment. On examination, you note the diaphragmatic excursion, which measures:

A. the distance the diaphragm moves with inspiration and expiration.
B. the level at which the diaphragm separates the thoracic cavity from the abdominal cavity.
C. how long the diaphragm is able to maintain its position while the individual holds his/her breath.
D. how easily the diaphragm moves between inspiration and expiration.

A. the distance the diaphragm moves with inspiration and expiration.

Ch 18:

Asking the individual to breathe a little deeper than usual through the mouth may have what effect during the examination?

A. Breath sounds will be artificially augmented and not reliable.
B. The individual will have to use accessory muscles to breathe, and this may tire the individual.
C. High-pitched sounds will be enhanced, masking lower-pitched sounds.
D. The individual may hyperventilate and experience dizziness.

D. The individual may hyperventilate and experience dizziness.

Ch 18:

Bronchial breath sounds may be heard over peripheral lung tissue in which of the following situations?

A. There is an obstruction of the bronchial tree.
B. The individual has emphysema.
C. The individual has pneumonia.
D. The individual is breathing too rapidly and deeply.

C. The individual has pneumonia.

Ch 18:

Adventitious sounds heard when auscultating the chest are:

A. additional sounds not normally heard in the lungs.
B. augmented sounds related to an increased rate and depth of respirations.
C. best heard in the lower lobes of the lungs.
D. only heard with the bell of the stethoscope.

A. additional sounds not normally heard in the lungs.

Ch 18:

Which of the following findings relates to the assessment of voice sounds?

A. The normal voice transmission during bronchophony is very distinct and sounds close to the ear.
B. With egophony over areas of consolidation, the "eee" sound changes to an "aaa" sound.
C. With whispered pectoriloquy, the whispered sound is muffled and almost inaudible over consolidation.
D. To test for egophony, ask the individual to repeat the phrase "ninety-nine."

B. With egophony over areas of consolidation, the "eee" sound changes to an "aaa" sound.

Ch 18:

In comparing the infant's chest configuration to that of an adult, which of the following is true?

A. The infant's transverse diameter is narrower than the anteroposterior diameter.
B. The infant's chest wall configuration closely resembles that of an adult.
C. The infant's anteroposterior diameter is equal to the transverse diameter.
D. The anteroposterior diameter is approximately three times the transverse diameter.

C. The infant's anteroposterior diameter is equal to the transverse diameter.

Ch 18:

When auscultating the chest of a toddler, which of the following breath sounds will predominate?

A. Bronchovesicular
B. Vesicular
C. Bronchial
D. Adventitious

A. Bronchovesicular

Ch 18:

Which of the following alterations is commonly present in postmenopausal females?

A. Scoliosis
B. Pectus excavatum
C. Pectus carinatum
D. Kyphosis

D. Kyphosis

Ch 18:

Respirations that are cyclical in nature, characterized by an increasing and decreasing rate and depth, and separated by periods of apnea are identified as:

A. Biot's.
B. sighing.
C. Cheyne-Stokes.
D. bradypneic.

C. Cheyne-Stokes.

Ch 18:

The thoracic cage is a structure formed by all of the following except the:

A. sternum.
B. ribs.
C. costochondral junction.
D. diaphragm.

C. costochondral junction.

Ch 18:

The "angle of Louis" is best described by which of the following?
A. It is the articulation of the manubrium and the body of the sternum, and is continuous with the second rib.
B. It is the angle formed by the right and left costal margins where they meet the xiphoid process.
C. It is the U-shaped depression just above the sternum, in between the clavicles.
D. It is the angle formed by the joining of the ribs with their cartilages on the body of the sternum.

A. It is the articulation of the manubrium and the body of the sternum, and is continuous with the second rib.

Ch 18:

The location of the inferior border of the scapula usually corresponds to the:
A. xiphoid process.
B. seventh or eighth rib.
C. costal angle.
D. manubriosternal angle.

B. seventh or eighth rib.

Ch 18:

The right and left lungs are contained within the thoracic cavity in the:

A. mediastinum.
B. pleural cavities.
C. pulmonary chambers.
D. respiratory sockets.

B. pleural cavities.

Ch 18:

Which of the following statements best describes the characteristics of the lungs?

A. They are symmetrically paired structures.
B. They are arranged in horizontal segments separated by the pleural lining.
C. They are stacked in diagonal sloping segments separated by fissures.
D. The right lung is more compact because it competes with the liver for space.

C. They are stacked in diagonal sloping segments separated by fissures.

Ch 18:

The function of the trachea and bronchi is to:
A. transport gases between the environment and the lung parenchyma.
B. condense inspired air for better gas exchange.
C. moisturize air for optimum respiration.
D. increase air turbulence and velocity for maximum gas transport.

A. transport gases between the environment and the lung parenchyma.

Ch 18:

An increase in carbon dioxide in the blood will do which of the following?

A. Decrease the amount of dead space in the tracheobronchial tree.
B. Increase respirations.
C. Shunt blood from the lower lobes to the upper lobes to increase gas exchange.
D. Increase the blood flow through the lungs.

B. Increase respirations.

Ch 18:

The complex lipid substance needed to sustain inflation of the air sacs is:

A. surfactant.
B. acinus.
C. sphingomyelin.
D. lecithin.

A. surfactant.

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