1. NRS 103 Thorax and Lungs Chapter 11
Nancy Sanderson MSN, RN
Lecture 5

2. Concept Overview Oxygenation:
Processes that facilitate and impair oxygenation.
Adequate perfusion is necessary to deliver oxygenated blood to tissues and remove metabolic waste.
Intracranial regulation supports oxygenation.
Adequate oxygenation needed to support intracranial function.
Interrelationship necessary.

3. Anatomy and Physiology
The primary purpose of the respiratory system is to supply oxygen to cells and remove carbon dioxide .
This purpose is accomplished using the process of ventilation and diffusion.
Ventilation is the process of moving gases in and out of the lungs by inspiration and expiration.
Diffusion is the process by which oxygen and carbon dioxide move from areas of high concentration to areas of lower concentration.
After inspiration oxygen concentration is higher in the alveoli than in the pulmonary capillaries. This difference in concentration causes oxygen to move or diffuse from the alveoli across the alveoli-capillary membrane to the adjacent pulmonary capillaries. It is then carried by the erythrocytes (RBC’S) to the cells.

4. Structures in the Thorax: Mediastinum
Three main structures within thorax or chest:
Mediastinum and right and left pleural cavities.
Mediastinum positioned in middle of chest. Within it are:
Heart
Arch of aorta
Superior vena cava
Lower esophagus
Lower part of trachea

5. Structures within the thorax:

7. Structures of the Thorax: The lungs
Right lung has three lobes and left has two.
Each lobe has a major, oblique fissure dividing upper and lower portions.
However, right lung has a lesser horizontal fissure dividing upper lung into upper and middle lobes.
Each lung extends anteriorly about 1.5 inches above first rib into base of neck in adults.
Posteriorly, lungs’ apices rise to level of T1 (first thoracic vertebrae); lower borders expand down to T12 and, on expiration, rise to T9.
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

8. Structures in the Thorax: Pleural Cavities
Pleural cavities contain lungs.
These cavities lined with two types of serous membranes:
Parietal pleura
Visceral pleura
Chest wall and diaphragm are protected by parietal pleura, and lungs are protected by visceral pleura.
Small amount of fluid lubricates space between pleurae to reduce friction as lungs move during inspiration and expiration.

9. Health History:
Tobacco use (amount, duration, Pack year index) ½ pack/day x 30 years = 15 year smoking history
3rd hand smoke exposure
2nd hand smoke exposure
Occupation/Exposure to pulmonary irritants
Chemicals, vapors, dust, allergens, animals, smoke, asbestos, arsenic, coal dust, radiation)
PMH/FH of respiratory illness/disease/cancer or allergies
Pneumonia, TB, COPD, asthma, lung cancer
Pneumonia or influenza vaccine received?

10. Health History: TB Risk factors for TB:
HIV, substance abuse, low income or homeless, resident of nursing home, shelter or prison, immigrant from country with high TB rate

11. Health History cont. : Do you have any shortness of breath? (Dyspnea)
rest, with exercise, lying flat?
Have you heard any wheezing?
Do you have a cough?
Dry, productive, barking, etc..
Amount, color,& consistency of sputum. Presence of odor.
Hemoptysis- coughing up blood (varies from blood streaked phlegm to frank blood)
Do you have chest pain with breathing?
Have you recently had any pain in calves or been on any long car or plane rides?

12. Inspection:
Observe symmetry, rate, rhythm, depth and effort of breathing
Symmetry: Chest wall movement equal bilaterally
Rate: Adult resp/min is normal
Bradypnea: Slow (<12 per minute)
Tachypnea: Rapid (>20 per minute)
Rhythm: Regular vs. irregular
Cheyne-Stokes, Kussmaul’s respirations, Biot’s
Depth
Hypoventilation–rate slow, depth
Hyperventilation–rate rapid, depth deep
Respirations 16/min, symmetrical,relaxed and even

13. Inspection cont.:
Observe symmetry, rate, rhythm, depth and effort of breathing
Symmetry: Chest wall movement equal bilaterally
Rate: Adult resp/min is normal
Bradypnea: Slow (<12 per minute)
Tachypnea: Rapid (>20 per minute)
Rhythm: Regular vs. irregular
Cheyne-Stokes, Kussmaul’s respirations, Biot’s
Depth
Hypoventilation–rate slow, depth
Hyperventilation–rate rapid, depth deep
Respirations 16/min, symmetrical,relaxed and even

14. Inspection cont.: Body position Color of skin, lips, nail beds
Relaxed vs. Upright/Tripod position
Color of skin, lips, nail beds
Even skin tone vs. cyanotic
Presence of clubbing
Patient relaxed. Skin and mucous membrane pink. Nail beds pink without clubbing in upper and lower extremities.
Pictures of finger clubbing pg. 108

15. Inspect/Palpate Trachea Position
Should be midline
Palpate
For tracheal shift
Place finger in sternal notch and slip to each side.
Trachea midline.

16. Inspection Documentation:
Wounds, scars, drains, tubes, dressings
Documentation must include location, size, amount of drainage and discharge if present, and signs of inflammation.
Additional terms to describe location:
Supraclavicular- Above the clavicles
Infraclavicular- Below clavicles
Interscapular- Between scapula
Infrascapular- Below scapula
Midaxillary line- Along line of armpit
Midclavicular- Along line in middle of clavicle
No wounds, scars, drains, tubes, or dressings.
Or- No lesions.

17. Inspection: Shape of Thorax
Shape of Chest :
Deformities
Symmetrical vs. asymmetrical
Pectus carniatum, Pectus excavatum, Spinal deformitiies
Normal AP diameter vs.. increased AP diameter
Oval vs. barrel chest
Ribs slope downward vs. more horizontal
Barrel chest appears as if patient in continuous inspiratory position
Chest symmetrical without deformities. AP < transverse. Refer to pictures on pg. 207 for examples of the above deformities and abnormals.

18. Palpation Assess for masses, tenderness, or crepitus
Subcutaneous emphysema- air escapes form lungs into subcutaneous tissue
Assess chest expansion
Posteriorly place thumbs at level of 10th rib & place palms on posterolateral chest.
Approx 2 inches apart before inspiration. Feel thoracic expansion during quiet & deep inspiration. Look for symmetry.
Chest expansion symmetrical. No masses or tenderness.

19. Palpation Tactile Fremitus
Palpable vibrations transmitted through bronchopulmonary tree to chest when patient speaks
Have patient repeat 99 or 1, 1, 1 while palpate with ulnar surface or ball of hand
Decreased or absent when vibration impeded by obstructed bronchus, tumor, or separation of pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), or air (pneumothorax)
Increased with gross compression or consolidation (lobular pneumonia) without bronchus obstruction
Tactile fremitus equal bilaterally.

20. Percussion
Tapping of an chest to set chest wall and underlying tissues into motion
Helps to establish if underlying tissue air-filled, fluid-filled, or solid
Normal sound is resonance
Resonant to percussion over all lung fields.
Review pictures on pg. 204 for locations for percussion and auscultation: Anterior, Posterior and Lateral views.

21. Percussion

22. Auscultation Use diaphragm of stethoscope and
have patient breath out of their mouth.
Peds- use smaller pediatric diaphragm
Place stethoscope firmly on skin. Avoid movement because it may produce confusing sounds (i.e. clothing)
Auscultate at least one complete respiration
Move from one side to the other
Observe for hyperventilation, allow to rest if needed
Peds- transmission of sounds enhanced, harder to localize sounds

23. Auscultation (con’t) Hairy chest men: Put stethoscope on skin
Hold stethoscope firmly over chest hair
Prevents moving over and giving false sounds
Put stethoscope on skin
(seasoned nurses and MD’s may put over light shirt because of expert status)

24. Auscultation: Anterior

25. Auscultation Adventitious Breath Sounds Wheezes (Sibilant wheeze)
High pitched, musical sound heard during inhalation or exhalation
Mild, moderate, severe
Rhonchi (Sonorous wheeze)
Low pitch snoring sound during inspiration or exhalation, but louder on exhalation
May clear with coughing
Asthma

26. Auscultation Crackles/Rales Popping sounds heard on inhalation Fine
High pitched fine, short, interrupted crackling sounds heard during end of inspiration
Medium
Lower, more moist sounds heard during middle of inspiration
Course
Loud, bubbly sounds heard during inspiration

27. Auscultation
Stridor
High pitched, harsh sound heard on inspiration when trachea or larynx is obstructed
Croup, foreign body, large airway tumor

28. Auscultation Cont.: Voice Sounds Bronchophony Whispered Pectoriloquy
Normal- Muffled
Abnormal- Clear
Whispered Pectoriloquy
Whisper “1,2,3”
Normal- faint and indistinct
Abnormal- clear and distinct
Egophony
“eeeeeeee”
Normal
Abnormal “aaaaaa”

29. Auscultation Documentation:
Breath sounds vesicular without adventitious sounds.
Or- Lungs sounds CTA in all lung fields without wheezes, rales, rhonchi, or rubs

30. Auscultation: Abnormal
Pneumonia
Atelectasis

31. pneumothorax Also known as collapsed lung Treatment is Chest tube:
Spontaneous
Traumatic
Tension
Treatment is Chest tube:

32. Summary: Bringing it all together
Important to get good history
If smokes offer smoking cessation classes
History asthma
What is current treatment?
If has c/o chronic cough ask about history and exposure so MD can rule out (r/o):
Birds including chickens r/o TB
Smoker r/o cancer
Chemicals/asbestos r/o cancer

33. Summary (continued) Shortness of breath and recent travel:
Pulmonary embolism
Swelling of legs: DVT
Proper auscultation
Percussion
Multiple problems & concerns

34. Summary Continued Asthma Atelectasis Bronchitis Cancer Croup Emphysema
Hemothorax
Pleural Effusion
Pneumonia
Pneumothorax
Tuberculosis