Nursing 205


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Nursing 205

  3. 3. Thoracic Cage – is the entire/outer structure of the thorax.= is a bony structure with a conical shape which is narrower at the top.= it provides support and protection for many important organs= is constructed of the Sternum 12 pairs of ribs 12 thoracic vertebrae Muscles Cartilage= it is narrower at its superior end and broader at its inferior end and is flattened from front to back (Tortora: 222)
  5. 5. 1. Suprasternal notch – is an important landmark= a U-shaped indentation located on the superior border of the manubrium or joint just above the sternum in between the clavicles.2. Sternum – “breastbone”= flat bone which lies in the center of the chest anteriorly= measures about 15 cm (6 inches) in length= it is attached to the first 7 ribs
  6. 6.  3 parts:a. Manubrium – the superior part=articulates with the costal cartilage of the 1st and the 2 nd ribsb. The body – the middle and the largest part=articulates directly or indirectly with the costal cartilage of the 2nd through the 10th ribsc. Xiphoid process – the inferior and the smallest part= no ribs are attached to it the xiphoid process provides attachment for some abdominal muscles3. Costal Angle - the right and left costal margins form an angle where they meet at the xiphoid process= usually 90 degrees or less, this angle increases when the rib cage is chronically over inflated as its emphysema
  7. 7. 4. Manusbriosternal angle or sternal angle= also called the “angle of Louis”= this is the articulation of the manubrium and the body of the sternum and it is continuous with the 2nd rib and becomes a reference point for counting ribs and intercostal spaces (Jarvis, 448)5. Intercostal spaces – are the spaces in between the ribs6. Ribs – the 12 pairs of ribs give the structural support to the sides of the thoracic cavity= constitute the main structures of the thoracic cage= they are numbered superiorly to inferiorly, the uppermost pair is number one= each pair of ribs has a corresponding pair of ICS located immediately inferior to it
  8. 8. = anteriorly, the first 7 pairs articulate with the sternum by way of costal cartilages= the first pair of ribs curves up immediately under the clavicle, so only a small portion of these ribs and 1st interspaces are palpable= ribs 2 to 6 are easy to count anteriorly= ribs 7 to 10 connect to the cartilages of the pair lying superior to them rather than to the sternum= 11th and 12th ribs are floating ribs” because they do not connect to either the sternum or another pair anteriorly, they are attached posteriorly to the vertebra and their anterior tips are free and palpable
  9. 9. = posteriorly, each pair of ribs articulates with the respective thoracic vertebra= the ribs are more difficult to palpate posteriorly ( :297)7. Clavicle – or the collar bone= a slender, doubly curved bone= it attaches to the manubrium of the sternum to the acromion of the scapula= it acts as a brace to hold the arm away from the top of the thorax and helps prevent shoulder disclocation
  11. 11. 1. C 7 or vertebra prominens= the most prominent bony spur protruding at the base of the neck when the head is flexed2. Spinous process= single projection arising from the posterior aspect of the vertebral arch= it alligns with their same numbered ribs only down to T4= after T4, the spinous processes angle downward from their vertebral body and overlies the vertebral body and rib below
  12. 12. 3. Scapula – or the shoulder blades= they are triangular and are commonly called “wings”= it is not directly attached to the axial skeleton 2 important processes:a. Acromion - connects with the clavicle laterally at the acromioclavicular jointb. Coracoid – the beaklike= points over the top of the shoulder and anchors some of the muscles of the joints (Jarvis:449)
  13. 13. REFERENCE LINEANTERIOR CHEST1.Midsternal line= passes throughthe center of thesternum2. Midclavicular line=an imaginary linethat descends fromthe middle of theclavicle(Smeltzer:447)
  14. 14. POSTERIOR CHEST1. Vertebral line= also called spinalline= overlies thespinous processesof the vertebrae2. Scapular line= drops from theinferior angle of thescapula (Bickley:212)
  15. 15. LATERAL CHEST1. Anterior axillary line= line extends fromthe anterior axillaryfold where the pectoralismajor muscle inserts2. Posterior axillary line= continues down fromthe posterior axillary foldwhere latissimus dorsimuscle inserts(Smeltzer:477)3. Midaxillary line= runs down from the apexof the axilla and lies betweenand parallel to the othertwo(Jarvis:450)
  16. 16. THE THORACIC CAVITYMediastinum – is the middle section of the thoracic cavity containing the esophagus, trachea, heart and the great vessels= the right and the left pleural cavities, on either side of the mediastinum contains the lungsLungs – are two coned-shaped, elastic structure suspended within the thoracic cavity (Jarvis:457)= are paired but not precisely symmetric structures
  17. 17. = the right lung 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= at the point of the midclavicular line on the anterior surface of the thorax, the lung extends approximately to the 6 th rib= laterally, lung tissue reaches the level of the 8 th rib
  18. 18. = posteriorly, the lung base lies at about the 10 th rib= the right lung has 3 lobes= the left lung has 2 lobes (Jarvis:452) IN A HEALTHY ADULTS, DURING DEEP INSPIRATION, THE LUNGS EXTEND DOWN TO THE 8TH ICS ANTERIORLY AND 12TH POSTERIORLY DURING EXPIRATION, LUNGS RISE TO THE 5TH OR 6TH ICS ANTERIORLY AND 10TH ICS POSTERIORLY ( :300)
  19. 19. TRACHEA= is a flexible structure that lies anterior to the esophagus= begins at the level of the cricoid cartilage in the neck= is approximately 10 to 12 cm long (adult)= help to maintain the shape and prevent its collapse during respiration ( :301)
  20. 20. BRONCHI= both bronchi are at an oblique position in the mediastinum and enter the lungs at the hilum= the right main bronchus is shorter and more vertical than the left= the left bronchus is narrower and extends at more of right angle of the trachea The trachea and the bronchi represent “dead space” in the respiratory system= they function primarily as a passageway for both inspired and expired air ( Phipps: 979)
  21. 21. LUNGS BORDERSANTERIOR1. Apex – extends slightly above the clvicle= highest point of lung tissue is 3- 4 cm above the inner third of the clavicle2. Base – the broad lung area resting on the diaphragm at the 6th rib in the midclavicular line (Jarvis: 452)POSTERIOR1. C 7 – marks the apex of lung tissue2. T 10 – usually corresponds to the base= deep inspiration expands the lungs and their lower border drops to the level of T12 (Jarvis:450)
  22. 22. PREPARATIONINSTRUCTIONS FOR THE PATIENT MUST BE CLEAR AND WITH COURTESY1. Draping2. Position3. Other provisions to ensure further comfort• Provide warm room and conducive for examination = well lighted = well ventilated• Provide privacy• Wash your hands but be sure hands are not cold• The diaphragm of your stethoscope must warm• Request your client to empty his/her bladder• Examination must not be interrupted
  23. 23. II. Observe for Chest Configuration Does the chest move equally on the two sides? Does breathing appear distressing? Is it noisy? Is breathing regular? Is there any prolongation of expiration?
  24. 24. INSPECTION=Thorax provides information about the musculoskeletal structure, patients nutritional status, and respiratory system= the nurse must observe the skin over the thorax for color and turgor and for the evidence of loss of subcutaneous tissue= it is important to note symmetry, if present= when findings are recorded, anatomic landmarks are used as point of reference (Smeltzer:476)I. observe respiration1. Rate: normal, above normal. Below normal2. Rhythm: regular, irregular3. Depth: normal, deep, shallow4. Effort: use of accessory muscles
  25. 25. II. Observe for Chest Configuration Does the chest move equally on the two sides? Does breathing appear distressing? Is it noisy? Is breathing regular? Is there any prolongation of expiration?
  26. 26. 1. Barrel chest – results as a result of ossification of the lungs= increase in the anteroposterior diameter of the thorax= patient with emphysema, the ribs are more widely space and the ICS tend to buldge on expiration2. Funnel chest (Pectus Excavatum) – occurs when there is a depression in the lower portion of the sternum= this may compress the heart and the great vessels resulting in murmurs= may occur with rickets or Marfan’s syndrome
  27. 27. 3. Pigeon chest (Pectus Carinatum) – may occur as a result of displacement of the sternum= there is an increase in the anteroposterior diameter= may occur with rickets, Marfan’s syndrome or severe kyphoscoliosis4. Kyphoscoliosis – characterized by elevation of the scapula and the corresponding S-shaped spine= this deformity limits lung expansion within the thorax= may occur with osteoporosis and other skeletal disorders that affect the thorax (Smeltzer:476)
  28. 28. BREATHING PATTERNS AND RESPIRATORY RATENormal adult – 12-19 breaths per minute (rate) 500-500 ml (depth) air moving in and out/respiration even (pattern)Ratio of pulse to respiration = 4:11. Eupnea – normal breathing at 12-19 breaths/min2. Bradypnea – slower than normal, less than breaths/min with normal depth and regular rhythm= associated with increase ICP, brain injury, and drug overdose3. Tachypnea – rapid, shallow breathing, more than 24 breaths/min= commonly seen in patient with pneumonia, pulmonary edema. Metabolic acidosis, septicemia, severe pain and rib fracture
  29. 29. 4. Hyporventilation – shallow, irregular breathing5. Hyperventilation – increased rate and depth of breathing= associated with severe acidosis of diabetic, renal origin (Kausmaul breathing)6. Apnea – period of cessation of breathing= time of duration varies= may occur briefly during other breathing disorders such as sleep apnea= if sustained, apnea is life-threatening
  30. 30. 7. Cheyne stokes – characterized by alternating episodes of apnea and periods of deep breathing= deep respirations become increasingly shallow, followed by apnea that may last approx. 20 seconds= the cycle repeats after each apneic period= associated with heart failure and damage of the respiratory center (drug-induced, tumor, trauma)8. Biot’s respiration – or cluster breathing= periods of normal breathing (3-4 breaths) followed by varying period of apnea (usually 10 seconds to 1 min)= CNS disorder (Kozier:1297)
  31. 31. TABLE 35-3 POSSIBLE FINDINGS BY INSPECTION IN A PULMONARY EXAMINATION OBSERVE NORMAL ABNORMAL General Appearance Quiet respiration Lips puckered when exhaling Sitting or reclining without difficulty Restless and apprehensive Skin translucent, appears dry Leans forward with hands or elbows on knees Nailbeds pink Skin: diaphoretic, dull pale or ruddy Mucous membranes pink and moist* Cyanosis: skin or mucous membranes have bluish cast Cyanosis or pallor assessed by establishing an Central cyanosis: results from decreased oxygenation of blood early individual baseline + Peripheral cyanosis: result of local vasoconstriction or decreased cardiac output Nail clubbing: painless enlargement of terminal phalanges related to chronic tissue hypoxia Trachea Midline in neck Tracheal deviation; displacement either lateral, anterior, posterior Jugular venous distension Cough: strong or weak, dry or wet, productive or non- productive Sputum production: amount, color, odor, consistency* Dark-skinned people might have normal bluish-pigmentation mucous membranes.+ Central cyanosis is relevant to respiratory status. Observe nailbeds, mucous membrane and lips.
  32. 32. TABLE 35-3 POSSIBLE FINDINGS BY INSPECTION IN A PULMONARY EXAMINATIONOBSERVE NORMAL ABNORMALRate Eupnea: 12 to 20 Tachypnea: rate> 20 breaths/minute Bradypnea: rate < 12 breaths/minuteBreathing pattern Minimal effort with inspiration: passive, quiet Hyperpnea: increased breathing depth expiration Inspiration/expiration ratio: 1:2 Accessory muscle breathing Male: diaphragmatic breathing Apnea: total absence of breathing Female: thoracic breathing Biots: irregular rhythm with periods of apnea Cheyne-Stokes: cyclical deeper and shallower breaths, followed by periods of apnea Kussmaul’s: deep, rapid, and regular breathing Paradoxical: portion of chest wall moves in during inhalation and out during exhalation Stridorous: audible, loud, low-pitched sound with inhalation and exhalationThoracic configuration Symmetric appearance Chest expands unevenly Muscular development asymmetric Anteroposterior diameter (AP) less than Barrel chest: AP diameter increased in relation to transverse transverse diameter diameter Spine straight Kyphosis: increased thoracic curvature Scoliosis: increased lateral curvature Scapulae on same horizontal plane Scapular placement asymmetric
  33. 33. PALPATION= Start palpation by feeling for the position of the trachea.= facing to the patient, place two fingers either side of the trachea (note whether the distance between the trachea and the sternomastoid tendons are equal= at the back of the patient, hook your finger round the tendon to meet the trachea (maybe displaced- mass in the neck= palpates the thorax for tenderness, masses, lesions, respiratory excursion and vocal fremitus (Smeltzer:478)
  34. 34. Purposes (Bickley:230)1. Identification of tender areas2. Assessment of observed abnormalities3. Further assessment of chest expansion4. Assessment of tactile fremitusIdentify tender mass= palpate an area of pain or lesions are apparent – perform direct palpation with the fingertips (for the lesion and subcutaneous masses)
  35. 35. = use the ball of the hand for deeper masses or generalized flank or rib discomfortAssess any abnormalities= observe for any masses or sinus tract (inflammatory, tube-like opening onto the skinRespiratory Excursion= an examination of the thoracic expansion and may disclose significant information about thoracic movement during breathing= assess the patient for range and symmetry of excursion
  36. 36. = instruct patient to inhale deeply while moving the thumbs from the 10th rib with the fingersloosely grasping and parallel tothe lateral rib cage.= slide them medially about 2-2.5 cm(1 inch) just enough to raise foldof skin on each side bet. the thumb and the spine= watch the distance bet. the thumbas they move apart during inspiration.= feel for the range and symmetryof the rib cage as it expands andcontracts
  37. 37. TACTILE FREMITUSFremitus – refers topalpable vibrationstransmitted throughthe bronchopulmonarytree to the chest wallwhen the patient speaks= is the detection of theresulting vibration onthe chest wall by touch= normal fremitus varies= lower pitched sounds travelbetter through the normaland produce greater vibrationof the chest wall
  38. 38. = the patient is askedto repeat “99”, “1 2 3”,or “eee,eee,eee” as youmove your hands downthe thorax= the vibrations aredetected with the palmarsurfaces of the fingers andhands or the ulnar aspectof the extended hands= hands are moved in sequence down to the thorax= corresponding areas of the thorax are compared= BONY AREAS ARE NOT TESTED= if fremitus is faint, ask patient to say it again more loudly or in deeper voice (Smeltzer:479)
  39. 39. PERCUSSION= is one of the most important technique of physical examination=percussion of the chest sets and the chest wall and underlying tissues into motion, producing audible sound and palpable vibrationsPurposes: 1. to detect the resonance or hollowness of the chest (underlying tissues are air-filled, fluid-filled or solid)2. Used to estimate the size and location of certain structure within the thorax (diaphragm, heart, liver)= it penetrates only about 5-7cm into the chest therefore it will not help to detect deep-seated lesions (Epstein:627)
  40. 40.  Posterior= percussion usually begins with the posterior thorax= ideally, the patient is in a sitting position with the head flexed forward and the arm crossed on the lap – the position separates the scapulae widely and exposes more lung area= proceeds down the posterior thorax, percussing symmetry areas at 5-6cm (2-2.5 inch) interval (Smeltzer:480)
  41. 41. = hyperextend the middlefinger of your left hand(pleximeter)= press its distal interphalangealjoint firmly on the surfaceto be percussed= avoid surface contact by any part of the hand because this dampens our vibrationsNote: thumb, 2nd, 4th, 5th fingersare not touching the chest= position your right forearm quite close to the surface, with the hand cocked upward= the middle finger should be partially flexed, related, and poised to strike
  42. 42. = with a quick sharpbut relaxed wristmovement, strike thepleximeter fingerwith the right middle finger or plexor finger= aim at your distalinterphalangeal joint
  43. 43. = strike using the tipof your plexor finger, not the finger pad= your finger shouldbe almost at right angles to the pleximeterA SHORT FINGERNAIL IS RECOMMENDED TO AVOID SELF-INJURYWITHDRAW YOUR STRIKING FINGER QUICKLY TO AVOID DAMPING THE VIBRATIONS YOU HAVE CREATED (Bickley:224)
  44. 44. PERCUSSION SOUNDS1. Resonance – low-pitched sound heard over normal lungs2. Hyperresonance – loud, lower-pitched sound than normal resonance heard over hyperinflated lung such as in chronic obstructive lung disease, acute asthma3. Tympany – drumlike, loud, empty quality heard over gas-filled stomach or intestine or pneumothorax4. Dull – medium intensity pitch and duration, heard over areas “mixed” solid and lung tissue (pneumonia)5. Flat – soft, high pitched sound of short duration heard over very dense tissue where air is not present (Lewis:555)
  45. 45. = percuss one side ofthe chest and then theother at each level= omit the areas over the scapulae – thethickness of muscle andbone alters the percussionnotes over the lungs(Bickley:225)
  46. 46. Anterior= patient is an uprightposition with shouldersarched backward and arms at the table= begin in the supra-clavicular area andproceeds downward,from one intercostal space to the next= for female patient, it maybe necessary to displace the breasts with the left hand while percussing with the right= using both hands, place finger of one on the chest with fingers separated (Bickley:232)YOU MAY ASK THE PATIENT TO MOVE HER BREAST FOR YOU
  47. 47. = strike one of them with the terminal phalynx of the middle finger of the of the other hand= it must be removed again immediately, otherwise the resultant sound will be damped= the striking movement should be a flick of the wrist and the striking finger should be at right angle to the other finger= each side is compared with the equivalent area from top to bottom= DO NOT FORGET THE SIDES= the anterior and lateral thorax is examined with the patient in supine position= if patient cannot sit, percussion of the posterior thorax is performed with the patient positioned on the side
  48. 48. AUSCULTATION= prefers to use the diaphragm of the stethoscope= in thin bony chest, the bell may give a more airtight fit and is less likely to trap hairs underneath which produces a crackling sound (Epstein:628)= the most important examining technique for assessing air flow through the tracheobronchial tree
  49. 49. = it involves:1. Listening to the sounds generated by breathing2. Listening for any adventitious (added) sound3. If abnormalities are suspected, listening to the sounds of the patient’s whispered voice as they are transmitted through the chest wall
  50. 50. = ask patient to take deep breath through the mouth= listen to the breath sounds using the same pattern for percussion, moving from one side to the other and comparing symmetric areas of the lungs (Bickley:226)= listen at least 1 full breath on each locationBE ALERT FOR PATIENT DISCOMFORT DUE TO HYPERVENTILATION (light-headedness, faintness)ALLOW PATIENT TO REST AS NEEDED (Smeltzer:480)
  51. 51. BREATH SOUNDS= evaluate the presence and quality of normal breath sounds= are usually louder in the upper anterior lung fields1. Vesicular – soft and low-pitched= they are heard through inspiration, continue without pause through expiration= have 3:1 ratio with inspiration longer than expiration= can be heard over most of both lungs2. Bronchovesicular – with inspiratory and expiratory sounds about equal in length, at times separated by a silent interval differences in pitch and intensity are often easily detected during expiration
  52. 52. = often can be heard in the 1st and 2nd interspaces anteriorly and between the scapulae= can be heard over the large airways esp. on the right3. Bronchial – louder and higher in pitch= with a short silence between inspiratory and expiratory sounds= expiratory sound last longer than inspiratory sounds= can be heard over the manubrium, if heard at all (Bickley:227)
  53. 53. ADVENTITIOUS SOUND1. Wheezes – rhonchi= a high-pitched, musical sound similar to a squeak= it is heard most commonly during expiration, but also can be heard during inspiration= low-pitched, coarse, loud, low snoring or moaning sound=it is heard in narrowed airway diseases such as asthma, chronic emphysema
  54. 54. 2.
  55. 55.