Thorax And Lungs.330.Ss.09

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  • 1. Thorax and Lungs Nursing 330 Governors State University Shirley Comer
  • 2. Posterior Chest
    • Inspect- observe shape and configuration
      • Spinous process in straight line
        • Scoliosis= s shaped curve
        • Kyphosis= outward curvature
      • Thorax symmetrical
      • Ribs slope downward
      • Scapulae placed symmetrically
  • 3. Chest Diameter
      • Anteroposterior diameter less than transverse diameter
      • Barrel Chest - diameter equal to transverse diameter /c horizontal ribs and costal angles greater then 90 degrees.
        • Occurs in chronic emphysema r/t lung hyperinflation
    • Neck and Trapezius muscles- normal development
      • Hypertrophy /c COPD
  • 4. Chest diameter image
  • 5. Observe
    • Body position
      • Tripod position /c COPD so ancillary muscles can aid breathing
      • Orthopnea- inability to lie flat r/t SOB- rib cage cannot expand fully while lying-Some pt may report using several pillows in bed or sleeping sitting up
    • Skin color and condition
    • Resp rate and character
  • 6. Palpate the Posterior Chest
    • Symmetric chest expansion- place hands at T9-chest should expand evenly during inspiration.
      • Unequal may be present in:
        • Atelectasis
        • Pnuemonia
        • Trauma/fractured ribs
        • Pnuemothorax
  • 7. Chest expansion image
  • 8. Tactile Fremitus
    • Is a palpable vibration
      • Use palms
      • Pt repeats phrase “99 or blue moon”
        • Palpate over apices to bases
        • Vibrations should be equal bilaterally
        • Decreased fremitus = pleural effusion, thickened chest wall, Pnuemothorax, emphysema
        • Increased fremitus= consolidation of lung tissue, pneumonia, tumor, fibrosis
        • Crepitus = crackling sensation over skin surface = SQ emphysema
  • 9. Tactile Fremitus image
  • 10. Palpate
    • Palpate the entire chest wall
      • Note
        • Tenderness
        • Change in skin temp
        • Moisture
        • Lumps
        • Masses
        • Skin lesions
  • 11. Percuss
    • Percuss from apices to bases
    • Percuss at 5cm intervals
    • Avoid the ribs, clavicle and scapulae
      • Resonance is heard over healthy lung tissue
        • Heavily muscled or obese pt may sound duller
      • Dullness is heard over bone or abnormal lung = pneumonia, pleural effusion Atelectasis or tumor
      • Lungs are hyper inflated /c COPD=hyper resonance
  • 12. Percussion/Auscultation pattern
  • 13. Diaphragmatic Excursion
    • Percuss the position of the diaphragm during inspiration and expiration and mark.
    • Measure the difference
    • should be equal
    • Normal is 3 to 5 cm but may be as high as 8 in athletes
    • Excursion will be decreased in COPD, pleural effusion and Atelectasis
  • 14. Diaphragmatic Excursion
  • 15. Auscultate the Posterior chest
    • Normal breath sounds
      • Bronchial aka tracheal or tubular-
        • heard close to larger airways (trachea, main bronchi)
      • Bronchovesicular -
        • heard over medium sized airways
      • Vesicular -
        • heard over lung periphery
  • 16. Decreased/ Diminished Breath Sounds
    • Occur when
      • Bronchial tree is obstructed by secretions, mucous plug or foreign body
      • Emphysema r/t loss of elasticity in lung and decreased force of inspired air
      • Sound transmission is obstructed- pleurisy, pleural thickening, Pnuemothorax, pleural effusion
      • Absent breathing
  • 17. Adventitious Sounds
    • Crackles AKA fine rales
      • Short popping sounds at the end of inspiration
      • Caused by fluid collapsing the alveoli during expiration
      • Common /c pneumonia, CHF, Atelectasis
    • Coarse Rales
      • Similar to crackles but more bubbling sounds earlier in inspiration
      • Caused by more fluid than crackles
  • 18. Adventitious Sounds cont
    • Rhonchi
      • Snoring sound heard during expiration
      • Caused by secretion in bronchial tree
    • Wheezes
      • Musical whistling sounds heard mainly on expiration but can be through our cycle
      • Present in asthma, emphysema, bronchitis or bronchospasm
  • 19. Anterior Chest
    • Observe shape and configuration of chest
    • Costal angle less than 90 degrees
    • Position of ribs
    • Observe
      • Facial expression- COPD may have tense or tired faces
      • LOC- Cerebral hypoxia = drowsiness, irritability confusion
      • Skin color and condition
      • Quality of respirations-noisy, use of ancillary muscles
  • 20. Auscultate the Anterior chest
    • Listen for 1 full respiratory cycle over the entire anterior chest.
    • Will hear vesicular lung sounds over most of anterior chest.
    • Pt should take deep breath in and out through mouth.
  • 21. Vocal Fremitus
    • Egophony
      • Pt says “E”
    • Bronchophony
      • Pt says “99 or blue moon”
    • Whispered Pectoriloquy
      • Pt says “1-2-3”
  • 22. Age Specific Considerations
    • Infants and Children
      • Resp rate will be irreg during feeding or sleeping in neonate.
      • Broncho vesicular sounds heard over entire lung field r/t thin chest wall
      • Crackles heard in upper fields /c cystic fibrosis.
      • Stidor is a high pitched inspiratory sound heard audibly /c croup epiglottis or foreign body aspiration
  • 23. Age Specific Continued
    • Pregnant women
      • Thoracic cage widens
      • Apical pulse displaced laterally
      • Orthopnea may be present
      • Change in resp character
    • Elderly
      • Kyphosis-Barrel chest
      • Marked bony prominences r/t decreased subcutaneous fat.
      • May fatigue during exam or hyperventilate
      • More likely to have disease present-pneumonia,` Atelectasis ect
  • 24. Practice Exam Question
    • Your client has a 20 year history of cigarette smoking and a productive cough. What adventitious breath sound are you most likely to hear during your assessment?
      • A. Stridor
      • B. Rhonchi
      • C. Coarse Rales
      • D. Vesicular
  • 25. Rationale
    • B is the correct answer. A productive cough and history of cigarette smoking indicate the possible presence of secretions in the bronchial tree.
    • A is a condition seen in children
    • C is caused by fluid
    • D is not an adventitious breath sound