Thorax And Lungs.330.Ss.09


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Thorax And Lungs.330.Ss.09

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