copyright 2002, delmar, a division of thomson learning chapter 15 thorax and lungs
TRANSCRIPT
Copyright 2002, Delmar, A division of Thomson Learning
Chapter 15
Thorax and Lungs
Copyright 2002, Delmar, A division of Thomson Learning
Competencies Identify the anatomic landmarks of
the thorax. Describe the characteristics of the
most common respiratory chief complaints.
Perform inspection, palpation, percussion, and auscultation on a healthy adult and on a patient with pulmonary pathology.
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Competencies Explain the pathophysiology for
abnormal findings. Document respiratory assessment
findings. Describe the changes that occur in
the lungs with the aging process.
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Anatomy—Anterior Thorax Sternum Clavicles Nipples Suprasternal notch Angle of Louis Costal angle
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Anatomy—Posterior Thorax Vertebra prominens Spine
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Anatomy—Lungs Right lung—three lobes Left lung—two lobes Apex Base Midclavicular line (MCL) Midaxillary line (MAL)
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Anatomy—Lungs Pleura
Parietal Visceral
Mediastinum or interpleural space Bronchi
Right Left
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Anatomy—Lungs Alveoli Diaphragm External intercostal muscles Accessory muscles
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Thoracic Anatomic Topography Anterior axillary line Midspinal (vertebral) line Midsternal line Posterior axillary line Scapular line
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Physiology Ventilation External respiration Internal respiration Control of breathing
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Health History Patient profile
Age Children and young adults: bronchiectasis,
cystic fibrosis Adults and older adults: chronic bronchitis,
emphysema, pneumonia, lung cancer Gender Race
African American: sarcoidosis Caucasian: cystic fibrosis
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Common Chief Complaints Dyspnea Cough Sputum Chest pain
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Characteristics of Chief Complaint Quantity Quality Associated manifestations Aggravating factors Alleviating factors Timing Setting
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Past Health History Medical
Respiratory specific Nonrespiratory specific
Surgical Medications Communicable diseases Allergies Special needs Childhood illnesses
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Family Health History Allergies? Asthma? Cystic Fibrosis? Emphysema? Cancer? Bronchiectasis? TB?
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Social History Alcohol, drug, or tobacco use Travel history Work and home environment Hobbies and leisure activities Stress Economic status
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Health Maintenance Activities Sleep Diet Exercise Use of safety devices Health check-ups
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Assessment of the Thorax and Lungs Equipment
Stethoscope Centimeter ruler and measuring tape Washable marker Watch with second hand
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Inspection Shape of thorax
Transverse diameter Anteroposterior (AP) diameter
Symmetry of chest wall Presence of superficial veins Costal angle Angle of the ribs Intercostal spaces Muscles of respiration
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Respirations Rate
Eupnea 12 – 20 bpm Tachypnea > 20 bpm Bradypnea < 12 bpm Apnea: no respiration for 10 or more
seconds
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Respirations Pattern
Cheyne-Stokes Biot’s or Ataxisic Apneustic Agonal
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Respirations Depth
Shallow Hyperpnea Air trapping Kussmaul’s Sighing
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Respirations Symmetry Audibility Patient position
Upright Supine Orthopnea
Mode of breathing
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Sputum Color Odor Amount Consistency
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Assessing Patients with Respiratory Assistive Devices Oxygen therapy
Mode of delivery Percentage of oxygen Flow rate Humidification
Pulse oximeter(continues)
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Assessing Patients with Respiratory Assistive Devices Incentive spirometer
Frequency of use; volume achieved; number of repetitions
Endotracheal tube Size Nasal or oral insertion
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Assessing Patients sith Respiratory Assistive Devices
Length of tube as it exits mouth or nose
Cuff inflated or deflated Tracheostomy tube
Size Cuffed or cuffless How tube is secured to neck
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Assessing Patients with Respiratory Assistive Devices Mechanical ventilation
Type of ventilator Fio2 Mode Peep Rate Tidal volume Alarms
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Palpation Anterior Posterior Lateral Pulsations Masses
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Palpation Thoracic tenderness Crepitus Thoracic expansion Tactile or vocal fremitus
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Percussion Anterior Posterior Lateral Diaphragmatic excursion
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Auscultation—Fields Anterior Posterior Lateral
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Auscultation—Breath Sounds Pitch Intensity Quality Duration Location
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Normal Breath Sounds Bronchial Bronchovesicular Vesicular
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Adventitious Breath Sounds Crackle or Rale
Fine Coarse
Wheeze Sonorous (Rhonchi) Sibilant
Pleural friction rub Stridor
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Voice Sounds Bronchophony Egophony Whispered pectoriloquy
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Normal Findings AP to transverse diameter is 1:2 Elliptical-shaped thorax Shoulders and scapula at same
height bilaterally
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Normal Findings No masses or superficial veins Costal angle < 90 degrees during
exhalation and at rest Ribs articulate at a 45-degree angle
with the sternum Absence of intercostal retractions
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Normal Findings No accessory muscle use Respiratory rate 12–20 breaths per
minute Eupnea Respiratory pattern is regular and
even Respiratory depth is nonexaggerated
and effortless(continues)
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Normal Findings Symmetrical rise and fall of thorax Respirations are quiet, unless a few
centimeters from patient’s nose or mouth
Able to breath comfortably in supine, prone, or upright position
Usually breathe through nose
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Normal Findings Small amount of sputum may be present Sputum should be odorless and light yellow
to clear in color No pulsations, masses, thoracic tenderness,
crepitus present Thoracic expansion is 3 to 5 cm Normal fremitus present on ulnar aspect of
hand Trachea is midline
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Normal Findings Resonant sound on percussion over
lung tissue Dull sounds over diaphragm and
cardiac silhouette Rib sounds are flat Hyperresonance present if adult is
thin
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Normal Findings Diaphragmatic excursion is 3 to 5
cm Bronchial breath sounds over
trachea Bronchovesicular breath sounds
over scapular area Vesicular breath sounds over
peripheral lung(continues)
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Normal Findings Whispered pectoriloquy,
bronchophony, egophony are muffled
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Age-Related Changes Anatomic changes
Increased work of breathing Limited chest wall expansion Muscle atrophy
Alveolar gas exchange Decreased surface area for diffusion
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Age-Related Changes Regulation of ventilation
Decreased sensitivity to changes in carbon dioxide and oxygen
Lung defense mechanisms Decreased ciliary action Diminished cough reflex Increased susceptibility for infection