Thorax and Lungs Chapter 18

Structure and Function Subjective Data—Health History Questions Objective Data—The Physical Exam Abnormal Findings

Structure and Function Position and Surface Landmarks Thoracic cage—borders Anterior thoracic landmarks Suprasternal notch Sternum Manubriosternal angle Costal angle Posterior thoracic landmarks Vertebra prominens Spinous processes Inferior border of scapula Twelfth rib

Anterior Thoracic Cage

Posterior Thoracic Cage

Reference lines Midsternal line Midclavicular line Scapular line Vertebral line Anterior, posterior, midaxillary lines

Reference Lines (Anterior)

Reference Lines (Posterior)

Reference Lines (Lateral)

Structure and Function (cont.) Thoracic cavity Mediastinum defined Lobes of the lungs Anterior Posterior Lateral Pleurae Trachea and bronchial tree Location of trachea and bronchi Dead space Function of acinus

Structures of the Respiratory System

Mechanics of respiration Four functions of respiratory system Changing chest size during respiration Inspiration Expiration Control of respiration

Mechanics of Respiration (cont.) © Pat Thomas, 2006.

Subjective Data— Health History Questions Cough Shortness of breath Chest pain with breathing History of respiratory infections Smoking history Environmental exposure Self-care behaviors Cough. Do you have a cough? When did it start? Gradual or sudden? Shortness of breath. Have you ever had any shortness of breath or hard-breathing spells? What brings it on? How severe is it? How long does it last? Chest pain with breathing. Do you have any chest pain with breathing? Please point to the exact location. Past history of respiratory infections. Do you have any past history of breathing trouble or lung diseases like bronchitis, emphysema, asthma, pneumonia? Smoking history. Do you smoke cigarettes or cigars? At what age did you start? How many packs per day do you smoke now? For how long? Environmental exposure. Are there any environmental conditions that may affect your breathing? Where do you work? At a factory, chemical plant, coal mine, farming, outdoors in a heavy traffic area? Self-care behaviors. Last tuberculosis skin test, chest x-ray study, pneumonia or influenza immunization?

Objective Data—The Physical Exam Preparation Position Draping Timing during a complete examination Cleaning stethoscope endpiece Equipment needed Stethoscope Small ruler marked in centimeters Marking pen Alcohol swab

Objective Data—The Physical Exam (cont.) Posterior Chest—Inspect Thoracic cage Shape and configuration of chest wall Anteroposterior/transverse diameter Position of person Skin color and condition

Objective Data—The Physical Exam (cont.) Posterior Chest—Palpate Symmetric expansion Tactile (or vocal) fremitus Technique Factors that affect normal intensity of tactile fremitus Palpate the entire chest wall Posterior Chest—Percuss Predominant note over lung fields Diaphragmatic excursion

Objective Data—The Physical Exam (cont.) Posterior Chest—Auscultate Breath sounds Technique Bronchial breath sounds—characteristics Bronchovesicular breath sounds—characteristics Vesicular breath sounds—characteristics Adventitious sounds Crackles Wheeze Atelectatic crackles Voice sounds Bronchophony Egophony Whispered pectoriloquy

Objective Data—The Physical Exam (cont.) Anterior Chest—Inspect Shape and configuration of chest wall Facial expression Level of consciousness Skin color and condition Quality of respirations Rib interspaces Accessory muscles

Objective Data—The Physical Exam (cont.) Anterior Chest—Palpate Symmetric chest expansion Tactile fremitus Palpate the anterior chest wall Anterior Chest—Percuss Predominant note over lung fields Borders of cardiac dullness

Objective Data—The Physical Exam (cont.) Anterior Chest—Auscultate Breath sounds Abnormal breath sounds Adventitious sounds

Objective Data—The Physical Exam (cont.) Measurement of pulmonary function status Forced expiratory time Pulse oximeter 6-Minute distance walk Edition Change: 12-minute walk is changed to 6-minute walk. Examiner should stop the patient if extreme breathlessness is observed, if the patient’s O2 saturation falls below 85%. Patient who covers 300 m or more is more likely to participate in ADLs.

Sample Charting

Sample Charting (cont.)

Abnormal Findings Configurations of the Thorax Barrel chest Pectus excavatum Pectus carinatum Scoliosis Kyphosis

Barrel Chest

Scoliosis

Kyphosis

Abnormal Findings Respiration Patterns Sigh Tachypnea Bradypnea Hyperventilation Hypoventilation Cheyne-Stokes respiration Biot’s respiration Chronic obstructive breathing

Abnormal Findings Abnormal Tactile Fremitus Increased tactile fremitus Decreased tactile fremitus Rhonchial fremitus Pleural friction fremitus

Abnormal Findings Adventitious Lung Sounds Discontinuous sounds Crackles—fine Crackles—course Atelectatic crackles Pleural friction rub Continuous sounds Wheeze—sibilant Wheeze—sonorous rhonchi Stridor

Abnormal Findings Common Respiratory Conditions Atelectasis Lobar pneumonia Bronchitis Emphysema Asthma (reactive airway disease) Pleural effusion thickening Congestive heart failure Pneumothorax Pneumocystis carinii pneumonia Tuberculosis Pulmonary embolism Acute respiratory distress syndrome (ARDS)