thorax and lungs n1037 chapter 15. a & p of thorax thorax pleura –parietal = external surface...
TRANSCRIPT
Thorax and Lungs
N1037
Chapter
15
A & P of Thorax• Thorax• Pleura
– Parietal = external surface– Visceral = internal surface
• Mediastinum or interpleural space• Bronchi bifurcate T4/5 post, sternal angle ant
– Right - more vertical, risk aspiration
– Left
• Alveoli• Diaphragm (R5 ICS MCL, L6ICS MCL)
– phrenic nerve
• External intercostal muscles– inspir = ext ICM contract– expir = int ICM contract
• Accessory muscles– scalene, sternocleidomastoid, trapezius, abdominal
rectus
A & P of Thorax Sternum Ribs Intercostal spaces
Anatomy: Lungs
• Right lung: three lobes• Left lung: two lobes• Apex• Base• Midclavicular line
(MCL)• Midaxillary line
(MAL)
Anatomy: Lungs
Thoracic Anatomic Topography
• Anterior axillary line
• Midspinal (vertebral) line
• Midsternal line
• Posterior axillary line
• Scapular line
Thoracic Anatomic Topography
Physiology of Respiration• Ventilation
– active = inspiration and passive = expiration
– during inspiration pressure inside lungs = subatmospheric as diaphragm & ext ICM contract diaphragm lowers & ribs elevate which intrapulmonic volume creating a neg intra-alveolar pressure gradient with the atmosphere so air is pulled into the lungs until the intra-alveolar pressure= air pressure, thus lungs become full with air.
– Expiration occurs more rapidly. The diaphragm and ext ICM relax, which means the diaphragm rises & the ribs move closer = volume in the thoracic cavity causing a intrapulmonic volume & intrapulmonic pressure above atmospheric pressure, the lungs recoil and expel air until the intrapulmonic pressure = atmospheric pressure.
• External respiration- O2 diffuses from alveoli to blood
• Internal respiration - O2 in the blood diffuses into tissues
• Control of breathing- neural and chemical factors
– pons & medulla = CNS structures responsible for involuntary respiration
– stimulus for breathing = Co2, PH, O2 levels
Health History
• Patient profile– Age
• Children and young adults: bronchiectasis, cystic fibrosis• Adults and older adults: lung cancer, chronic bronchitis, pneumonia,
emphysema
– Gender
• Patient profile (cont’d)– Race
• African American: sarcoidosis• Caucasian: cystic fibrosis
(continues)
Common Chief Complaints
• Dyspnea
• Cough
• Sputum
• Chest pain
Characteristics of Chief Complaint
• Quality
• Quantity
• Associated manifestations
• Aggravating factors
• Alleviating factors
• Setting
• Timing
Past Health History• Medical
– Respiratory specific– Nonrespiratory specific
• Surgical• Medications• Communicable diseases• Allergies• Injuries and accidents• Special needs• Childhood illnesses
Family Health History
• Allergies
• Asthma
• Bronchiectasis
• Cancer
• Cystic fibrosis
• Emphysema
• TB
Social History
• Alcohol, drug, or tobacco use
• Travel history
• Work and home environment
• Hobbies and leisure activities
• Stress
• Economic status
Health Maintenance Activities
• Sleep
• Diet
• Exercise
• Use of safety devices
• Health check-ups
Assessment of the Thorax and Lungs
• Equipment– Stethoscope– Centimeter ruler or tape measure– Washable marker– Watch with second hand
Inspection
• Shape of thorax– Transverse diameter– Anteroposterior (AP) diameter
• Symmetry of chest wall
• Presence of superficial veins
• Costal angle
(continues)
Assessment of Thorax & Lungs• Inspect shape of thorax
– Transverse diameter– Anteroposterior (AP) diameter
– N=AP to transverse = 1:2
• Symmetry of chest wall
• Presence of superficial veins
• Abnormal– barrel chest dt COPD
– pectus carinatum dt congenital abn
– kyphosis :humpback
– scoliosis: curvature of spine
Assessment of Thorax & Lungs
• Costal angle – N=<90 with inspir & expir
• Angle of the ribs– N= ribs articulate at 45 angle
• Intercostal spaces– N= No retractions or bulging in ICS
• Muscles of respiration– N= no use of accessory muscles
Respirations
• Rate N= 12-20 bpm for adult
• Abnormalities– Eupnea: 12–20 breaths per minute– Tachypnea: > 20 breaths per minute– Bradypnea: < 12 breaths per minute– Apnea: no respiration for 10 or more seconds
(continues)
Inspect Respiration• Patterns
N= regular and even in rhythm– Cheyne-Stokes-brain injury
– Biot’s or ataxic -damaged medulla
– Apneustic -injured pons
– Agonal - impending death
• DepthN= nonexaggerated & effortless– Shallow -obese, pain, PE, puemonia,
pneumothorax
– Hyperpnea - exercise, emotional, high altitudes
– Air trapping-COPD
– Kussmaul’s-diabetic ketoacidosis
– Sighing- N or CNS lesions
Inspect Respirations• Symmetry -
N= thorax rises & falls in unison, no paradoxical movement
Abnormal = unilateral expansion dt collapsed lung
= paradoxical movement dt broken ribs
• AudibilityN= respirations are audible by ear
• Patient positionN= breaths comfortably upright, supine
Abnormal = Orthopnea dt COPD, CHF, PE
• Mode of breathingN= inhale & exhale through nose
Inspect Sputum
• Color N= light yellow or clear
• Odor N= none
• Amount N = small • Consistency N = thick or thin depends on hydration
• Abnormal – Table 15-1
Assessing Patients with Respiratory Assistive Devices
• Oxygen therapy– Mode of delivery– Percentage of oxygen– Flow rate– Humidification
• Incentive spirometer– Frequency of use, volume achieved, number of
repetitions
• Endotracheal tube– Size– Nasal or oral insertion– 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
•Mechanical ventilation–Type of ventilator–FiO2 setting–Mode–Amount of PEEP–Rate and tidal volume–Alarms
•Pulse oximeter
•Peak flow Meter
Thoracic Palpation• Palpate the Anterior, Posterior & Lateral thorax
– Assess for• Pulsations• Masses• Thoracic tenderness• Crepitus
N= no pulsations, masses, tenderness,crepitus
– Abnormal• aortic aneurysm• tumor or cyst• chest trama • subcutaneous emphysema (air in subcutaneous tissue)
Thoracic Palpation
• Thoracic expansion– Expansion– Symmetry
• Tactile fremitus– Anterior– Posterior– Lateral
(continues)
Thoracic Palpation• Thoracic expansion
– Expansion
– Symmetry
Thoracic Palpation• Tactile fremitus
– Anterior, Posterior, Lateral
N= buzzing over bronchi & trachea
Abnormal = dt consolidation
= dt pneumothorax, emphysema, asthma
Palpation Pattern for Tactile Fremitus
Thoracic Percussion
• Anterior
• Posterior
• Right and left lateral
• Diaphragmatic excursion
Pt position for Posterior Percussion
Percussion Patterns
Diaphragmatic Excursion
• Percuss lung while pt resting & mark thorax
• Percuss lung while pt takes a deep breath & mark thorax
• Measure distance btwn two marks
• Repeat other lung
N= T12 on inspir, T 10 on expir
Auscultation: Fields• Anterior • Posterior
• Lateral • Lateral
• Bronchial• Bronchovesicular• Vesicular
Auscultation: Breath Sounds
Auscultation: Breath Sounds• Assess for Pitch, Intensity, Quality, Duration, Location N= Table 15-2• Abnormal
– Adventitious Breath Sounds• Crackles - moisture in airways
• Wheeze - narrowing of airway
• Pleural friction rub - inflamed parietal & viseral pleura
• Stridor - partial obstruction
Assessment of Voice Sounds
• Reveals if lungs are full of air, fluid or solid– Instruct pt to say “99” each time you place stethescope
N= Muffled or unclear transmission
Abnormal dt any type of consolidation• Bronchophony - clear transmission of “99”
• Egophony - transmission of “ee” to “ay” with intensity
• Whispered pectoriloquy - clear transmission of “99”
• Voice sounds absent - dt air in lungs from disease - emphysema,asthma pneumothorax
Age-Related Changes
• Anatomic changes– Limited chest wall expansion– Muscle atrophy– Increased work of breathing
• Alveolar gas exchange– Decreased surface area for diffusion
(continues)
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 to infection