THORAX AND LUNGS

Thoracic Assessment Overview

Anatomy & Physiology History IPPA Developmental Considerations Nursing Diagnoses Oro/naso pharynx and respiratory tree respiratory system extends from nares to diaphragm

Anatomy & Physiology

Thoracic cavity

two distinct pleural cavities separated by mediastinum Pleural cavities lined by serous membranes o parietal pleura o visceral pleura
o o o

parietal pleura lines chest wall and diaphragm visceral pleura lines the lungs potential space between, small amount of lubricating fluid

Lungs

R has 3 lobes L has 2 lobes

Topography 2nd rib articulates with sternum at the Angle of Louis Suprasternal notch Costal Angle Midsternal line Midclavicular line Anterior Axillary line

Note:
Intercostal space - named for rib above

Lung Borders anterior thorax o apices extend 2-4 cm ABOVE clavicle posterior thorax o apices extend to T1 lower borders o T 10 on exhalation o T12 on deep inspiration

Physiology of respiration

Specifically ventilation ("breathing") inspiration/expiration o inspiration- air from atmosphere lungs o expiration - outflow, passive o accomplished by movement of o diaphragm o muscles - intercostal and neck o change in intrathoracic pressure Inspiration accomplished by movement of o diaphragm o muscles o change in intrathoracic pressure o diaphragm moves down, flattens o intercostal and neck muscles expand o diameter and length of thoracic cavity o pressure in lungs below atmospheric o air rushes in

Exhalation
o o o o o

nearly opposite passive event diaphragm relaxes chest wall and lungs recoil (elastic) air is expelled

Pulmonary pressures Intrapulmonic (within lungs) Intrapleural (around lungs)

o o o

Boyles law - volume of gas varies inversely with P

intrapleural pressure ALWAYS NEGATIVE (unless chest cavity open) essential - creates suction holds visceral and parietal pleural tog.

Health History

Any risk factors for respiratory disease smoking o pack years ppd X # years o exposure to smoke o history of attempts to quit, methods, results sedentary lifestyle, immobilization age environmental exposure o Dust, chemicals, asbestos, air pollution obesity family history

Present health status

URI Allergies Recent screening or diagnostic assessments, last CXR Medications o Rx or OTC Use of aerosols or inhalants for any purpose Exercise tolerance

Past Health History

Respiratory infections or diseases (URI) Trauma Surgery Chronic conditions of other systems

Family Health History

Tuberculosis Emphysema Lung Cancer Allergies Asthma

Other considerations

Employment place exposure Current or past residence/travel Hobbie

Thoracic Assessment

Privacy Warm Well lit

Inspection

Skin color and nutritional state lips - color nail beds - color and shape posture Thoracic contour
o o

shape, symmetry developmental:

o Pigeon chest - a patient with pigeon chest or pectus carinatum , has a chest with sternum that protrudes beyond front of the abdomen.The displaced sternum increases to front-to-back diameter of the chest. o Funnel chest - A patient with a funnel chest or pectus excavatum,has a funnel-shaped depression on all or part of the sternum. The shape of the chest may interfere with respiratory and cardiac function . Compression of the heart and great vessel may cause murmurs . o Kyphoscholiosis - The patients spine curves to one side and the vertebrae are rotated. It because the rotation distorts lung tissues , it may be more difficult to assess respiratory status. o Barrel chest - A barrel chest looks like its name implies: the chest is abnormally round and bulging, with a greater-than-normal front-to-back diameter . Barrel chest may be normal in infants and elderly patients. In other patients barrel chest occurs as a result of COPD .

Ribs and interspaces o retraction of interspaces indicative of obstruction o bulging during exhalation result of air outflow obstruction: tumor, aneurysm, cardiac enlargement o slope of ribs, costal angle Respiratory Pattern o Rate -tachypnea = > 20 -bradypnea= <10 -adult NL: 12 - 20 resting
o o

Rhythm Depth - shallow, deep

Palpation
Assess for any lesions Tracheal positions Thoracic expansion Tactile fremitus

Thoracic Expansion

Posteriorly- level of 10th rib Thumbs should separate 3 - 5 cm Feel during quiet I & E Palpate during deep inspiration Should be symmetrical atelectasis (lung collapse)

Tactile Fremitus

palpable vibrations of chest wall over lung fields from speech or sounds Use palmar or ulnar surface Palpate vocal sounds Systematically palpate side to side in same area Normal, increased or decrease

What does increased or decreased tactile fremitus mean ? Tactile Fremitus Increased- conditions that increase density of thoracic tissue Tactile Fremitus Decreased - obstruction of transmission of vibrations

Vocal fremitus Bronchophony -ask the client to say ninety-nine Egophony -ask the client to say E Whispered pectoriloquy -ask the client to whisper 1, 2, 3

Percussion
check underlying area for

air fluid solid

Percussion sounds flatness -is an extremely dull sound produced by a very dense tissue, such as muscle or bone .
Dullness -Is a thudlike sound produced by dense tissue such as liver,spleen,or heart.

 Resonance -is a hallow sound such as that produced by lungs filled with air. Hyperresonance -is not produced in the normal body. It describes as booming and can be heard over an emphysematous lung.

Tympany -is a musical or drumlike sound.

Diaphragmatic excursion
o o o o

done when breathing is shallow when suspect something is limiting diaphragmatic movement percuss to mark level of diaphragm at full exhalation, then full inhalation should be 3 -6 cm difference

Auscultate

Normal breath sounds Note:

Pitch Intensity Quality Duration

Vesicular -heard over most of lung -low pitch

-soft intensity sigh Bronchovesicular-over bronchi -moderate pitch and intensity, breezy Bronchial/Tracheal -high pitched, loud, blowing Adventitious Breath Sounds (Abnormal sounds imposed on top of normal) Crackles
o o o

due to air passing thru moisture in airway usually heard R and L lung bases best heard during inspiration fine (in small airways, alveoli) medium (in bronchioles) coarse (larger airway, "gurgle", thick secretions, coughing may affect)

Rhonchi and wheezes

continuous sounds produced by movement of air thru narrowed areas in larger airways (tracheobronchial tree) 0 narrowed 2 fluid, secretions COPD mass wheeze high pitched suggests COPD or bronchitis rhonchi lower pitched whistle, rumble, snore suggests secretions in large airways

Pleural Friction Rubs Caused by inflamed visceral and parietal pleura rubbing together Very painful not cleared by coughing

Abnormal respiratory patterns Tachypnea -shallow breathing with increased respiratory rate Bradypnea -decreased rate but regular in breathing Apnea -absence of breathing: may be periodic Hyperpnea -deep, fast breathing Kussmauls respiration -rapid, deep breathing without pauses: in adult, more than 20 breaths per minute; breathing usually sounds labored with deep breaths that resemble sights. Cheyne-strokes respiration -breaths that gradually become faster and deeper than normal, then slower during a 30 to 70 second period; alternates between 20 to 60 second periods of apnea. Biots respiration -rapid, deep breathing with abrupt pauses between each breath; equal depth with each breath.