53 terms

1145 Thorax & lungs

Anterior thoracic landmarks
- Suprasternal notch
- Sternum
- Manubriosternal angle
- Costal angle
Posterior thoracic landmarks
- Vertebra prominens
- Spinous processes
- Inferior border of scapula
- Twelfth rib
Reference lines
• Midsternal line *
• Midclavicular line *
• Scapular line - posterior
• Vertebral line - posterior
• Anterior, posterior, midaxillary lines
4 functions of respiratory system
- Changing chest size during respiration
- Inspiration
- Expiration
- Control of respiration
deep breaths - in thru nose out thru mouth
health history
• Cough
• Shortness of breath = when are you experiencing this? speech? walking?
• Chest pain with breathing = when
• History of respiratory infections = pneumonia, some pre disposal once you get it once
• Smoking history
• Environmental exposure = chemicals, allergies
• Self‐care behaviors = wash hands, flu shot
cough assessment (2 & details)
- when do have? anything lead to cough? productive?
• Timing
- Continuous
- Afternoon & evening
- Night (maybe drainage)
- Morning
- 3 months per year for 2 years
• Dry vs.Moist - Hacking
- Barking
- Dry
- Moist
- Congested
sputum: white or clear
• White or clear = colds, allergies, infections, bronchitis (some bacterial)
sputum: yellow or green
bacterial infections (they sit longer in lungs)
sputum: rust colored
TB, pneumonia, blood, cancer
sputum: pink & frothy
with dyspnea = pulmonary edema (fluid overdrive)
Pink = blood
- hard to cough up b/c they are very weak. usually see when they have to be ventilated
routine techniques: general
• Inspect -general
• Inspect‐ chest
• Inspect‐color
• Respirations
• Auscultate‐BS
- Palpate & Percuss
Inspect: posterior chest
• Thoracic cage
- Shape and configuration of chest wall
- Anteroposterior/transverse diameter
- Position of person
- Skin color and condition
Inspect chest: abnormalites
1. barrel chest = emphysema, kids w/cystic fibrosis
2. look at position → tripod
3. when they are sweating, they are working harder using accessory muscles
4. skin color = blue/cyanosis (hands, around the mouth)
symmetric chest expansion
- thumbs move 5-10cm
- unilateral movement = caused by pain, fractured ribs or chest wall injury, pneumonia & atelectasis (shrunken, airless alveoli or collapse of lung tissue)
Palpate: posterior chest
• Symmetric expansion = unequal if rib fracture, bruising
• Tactile (or vocal) fremitus (non-routine) "99"
- Technique (ulnar surface of hands)
- Factors that affect normal intensity of tactile fremitus
• Palpate the entire chest wall - for discomfort
posterior chest: symmetric abnormalities
unequal if rib fracture, bruising
posterior chest: Tactile fremitus
use 2 hands & you can compare each
- if you feel stronger than pneumonia
posterior chest: percuss
• Predominant notes over lung fields
Posterior chest: Auscultate
• Breath sounds
- Technique
- Bronchial breath sounds—characteristics (anterior chest)
- Bronchovesicular breath sounds—characteristics
- Vesicular breath sounds—characteristics
* careful of patients making noise while breathing
auscultate technique
• Diaphragm of stethoscope
• Mouth open
• Breathing deeply and fairly rapidly (not too rapid)
• Systematic approach over several areas, comparing both sides
clear to auscultation
bronchial breath sounds
- heard over trachea & immediately above the manubrium
- high pitch, loud intensity
- inspiration < expiration
- 1:2
- Abnormal location = over peripheral lung fields, anywhere over the posterior or lateral thorax
Abnormal = consolidation of the lung, pneumonia
bronchovesicular breath sounds
- hear over main bronchi
location = posterior, btw scapulas
- moderate pitch, medium intensity
- inspiration = expiration
Abnormal location = over peripheral lung fields
vesicular breath sounds
- low pitch, soft intensity
- inspiration > expiration
- 2.5:1
- peripheral lung fields
Adventitious sounds
- Crackles
- Wheeze
- Atelectatic crackles
Tactile (vocal) fremitus
- say 99
- vibrations should feel equal on both sides, quality may vary from person to person
Abnormal = unequal/decrease → emphysema, pleural effusion, pulmonary edema, bronchial obstruction.
increase (rougher/coarser) → lung tissues are congested, consolidation, pneumonia, tumor
Voice sounds: bronchophony
Vocal resonance #1
= the abnormal transmission of sounds from the lungs or bronchi.
- detected by auscultation
- patient says 66 or 99 while you osculate. sound of voice becomes less distinct as you move peripherally99 or 66 should be muffled
Voice sounds: whispered pectoriloquy
Vocal resonance #2
- performed when bronchophony is positive (magnified from of bronchoscopy
- auscultate & have patient whisper
- thru stethoscope won't hear words clearly (should be muffled) unless build up of fluid in alveolar regions of the lungs (consolidation, compression, pneumonia)
voice sounds: Egophony
Vocal resonance #3
- auscultate while patient says EEE
- negative is hearing muffled EEE
- positive is hearing AAA = pneumonia, pulmonary edema, inflammatory exudate, pus, inhaled water or blood
Inspect: Anterior chest
• Shape and configuration of chest wall
• Facial expression
• Level of consciousness = changes → respiratory distress
• Skin color and condition = pale, flushed, sweaty, cyanosis
• Quality of respirations = labored or not
• Rib interspaces
• Accessory muscles = big ones in the neck
palpate: anterior chest
• Symmetric chest expansion
• Tactile fremitus = vibrations of spoken voice felt thru chest wall on palpations
• Palpate the anterior chest wall
percuss: anterior chest
• Predominant note over lung fields
• Borders of cardiac dullness
lung sound
auscultate: anterior chest
• Breath sounds
• Abnormal breath sounds
• Adventitious sounds
measurement of pulmonary function status (3)
- Forced expiratory time
- Pulse oximeter = saturation ≥ 95%
- 6‐Minute distance walk
abnormality: barrel chest
chronic overinflation, hyperinflation, emphysema, pulmonary disease
abnormality: pectus excavatum
- funnel sternum
- could be just physical abnormality or cardiac/respiratory problems
abnormality: pectus carinatum
- prominent sternum
- could be just physical abnormality or cardiac/respiratory problems
abnormality: scoliosis
- curved spine
- can effect lungs b/c not as much room.
- ↑ risk of pneumonia
abnormality: kyphosis
-spinal convexity to the right, ribs widely spaced
- ↑ risk of pneumonia
Discontinuous sounds
can't predict, intermittent
Discontinuous sounds: fine crackles
Fine (rales) = high pitched
-short crackling, sounds like popping or rub hair together or fingers rubbing together if dry
- during inspiration & expiration
- not cleared by cough
- Causes = heart failure, COPD, asthma, terminally ill
Discontinuous sounds: Course crackles
Course = low pitched
- popping, loud bubbling, gurgling sounds
- decrease w/coughing & suctioning then return
- not cleared by cough
- Causes = heart failure, COPD, asthma, terminally ill
Discontinuous sounds: Atelectatic crackles
Atelectatic crackles = either fine or course, after a few breaths or coughs the sound goes away.
Cause = collapse of small alveoli, prolonged bed rest, immobility
-sounds like popping
Continuous sounds: wheeze (sibilant)
- high pitched, similar to a squeak & musical
- inspiration & expiration (expiration=most common)
Cause= narrowing of airways, usually asthma
Continuous sounds: wheeze/Rhonchi
- sonorous
- due to passage of air thru narrowed bronchus
- lower pitched musical snoring (can be high)
- primarily on expiration but may be heard inspiration, expiration is prolonged
- coughing may clear
Causes= usually due to mucous or pneumonia. disorders causing obstruction of trachea or bronchitis
Continuous sounds: Stridor
- harsh, high pitched crowing, inspiratory sound over larynx
- usually louder in neck than the chest
- narrowing of upper airway, trachea
- can be life threatening
- often can be heard w/o stethoscope (croup, epiglottitis or post extubation laryngeal edema
Causes = aspirated foreign body, tracheal stenosis or laryngeal tumor. severe stridor is an emergency b/c airway may close
Pleural Rub
- coarse low pitched grating, "creaking of old leather
- best heard posteriorly in the lower lobes
- 2 separate phases at end inspiration & early expiration
- coughing does not affect the sound
- surfaces roughened by exudate
Cause = rubbing together of parietal & visceral pleura as seen in pleurisy
Be specific in descriptions of lung sounds
• loudness = coarse or fine?
• timing in the respiratory cycle
• location on the chest wall
• persistence of the pattern from breath to breath
• Do sounds clear after a cough or a few deep breaths?
Auscultation abnormal: Decreased or absent
= not as clear, you can hear but not as loud
• Obstruction
• Emphysema = COPD
• Pneumothorax = collapsed lung
• Pleurisy = can't take a deep breath
Auscultation abnormal: increased
= louder
• consolidation
shrunken, airless alveoli or collapse of lung tissue
trachea palpation
- should be palpable, midline & slightly movable
abnormal = if not midline → thorax mass, mediastinal shift or some degree of lung collapse.
- other findings may be dyspnea, cough & abnormal breath sounds