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. (continues)

Copyright 2002, Delmar, A division of Thomson Learning Competencies Explain the pathophysiology for abnormal findings. Document respiratory assessment findings. Describe the changes that occur in the lungs with the aging process.

Copyright 2002, Delmar, A division of Thomson Learning Anatomy—Anterior Thorax Sternum Clavicles Nipples Suprasternal notch Angle of Louis Costal angle

Copyright 2002, Delmar, A division of Thomson Learning Anatomy—Posterior Thorax Vertebra prominens Spine

Copyright 2002, Delmar, A division of Thomson Learning Anatomy—Lungs Right lung—three lobes Left lung—two lobes Apex Base Midclavicular line (MCL) Midaxillary line (MAL)

Copyright 2002, Delmar, A division of Thomson Learning Anatomy—Lungs Pleura  Parietal  Visceral Mediastinum or interpleural space Bronchi  Right  Left

Copyright 2002, Delmar, A division of Thomson Learning Anatomy—Lungs Alveoli Diaphragm External intercostal muscles Accessory muscles

Copyright 2002, Delmar, A division of Thomson Learning Thoracic Anatomic Topography Anterior axillary line Midspinal (vertebral) line Midsternal line Posterior axillary line Scapular line

Copyright 2002, Delmar, A division of Thomson Learning Physiology Ventilation External respiration Internal respiration Control of breathing

Copyright 2002, Delmar, A division of Thomson Learning 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

Copyright 2002, Delmar, A division of Thomson Learning Common Chief Complaints Dyspnea Cough Sputum Chest pain

Copyright 2002, Delmar, A division of Thomson Learning Characteristics of Chief Complaint Quantity Quality Associated manifestations Aggravating factors Alleviating factors Timing Setting

Copyright 2002, Delmar, A division of Thomson Learning Past Health History Medical  Respiratory specific  Nonrespiratory specific Surgical Medications Communicable diseases Allergies Special needs Childhood illnesses

Copyright 2002, Delmar, A division of Thomson Learning Family Health History Allergies? Asthma? Cystic Fibrosis? Emphysema? Cancer? Bronchiectasis? TB?

Copyright 2002, Delmar, A division of Thomson Learning Social History Alcohol, drug, or tobacco use Travel history Work and home environment Hobbies and leisure activities Stress Economic status

Copyright 2002, Delmar, A division of Thomson Learning Health Maintenance Activities Sleep Diet Exercise Use of safety devices Health check-ups

Copyright 2002, Delmar, A division of Thomson Learning Assessment of the Thorax and Lungs Equipment  Stethoscope  Centimeter ruler and measuring tape  Washable marker  Watch with second hand

Copyright 2002, Delmar, A division of Thomson Learning 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

Copyright 2002, Delmar, A division of Thomson Learning Respirations Rate  Eupnea 12 – 20 bpm  Tachypnea > 20 bpm  Bradypnea < 12 bpm  Apnea: no respiration for 10 or more seconds (continues)

Copyright 2002, Delmar, A division of Thomson Learning Respirations Pattern  Cheyne-Stokes  Biot’s or Ataxisic  Apneustic  Agonal (continues)

Copyright 2002, Delmar, A division of Thomson Learning Respirations Depth  Shallow  Hyperpnea  Air trapping  Kussmaul’s  Sighing (continues)

Copyright 2002, Delmar, A division of Thomson Learning Respirations Symmetry Audibility Patient position  Upright  Supine  Orthopnea Mode of breathing

Copyright 2002, Delmar, A division of Thomson Learning Sputum Color Odor Amount Consistency

Copyright 2002, Delmar, A division of Thomson Learning Assessing Patients with Respiratory Assistive Devices Oxygen therapy  Mode of delivery  Percentage of oxygen  Flow rate  Humidification Pulse oximeter (continues)

Copyright 2002, Delmar, A division of Thomson Learning Assessing Patients with Respiratory Assistive Devices Incentive spirometer  Frequency of use; volume achieved; number of repetitions Endotracheal tube  Size  Nasal or oral insertion (continues)

Copyright 2002, Delmar, A division of Thomson Learning 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 (continues)

Copyright 2002, Delmar, A division of Thomson Learning Assessing Patients with Respiratory Assistive Devices Mechanical ventilation  Type of ventilator  Fio2  Mode  Peep  Rate  Tidal volume  Alarms

Copyright 2002, Delmar, A division of Thomson Learning Palpation Anterior Posterior Lateral Pulsations Masses (continues)

Copyright 2002, Delmar, A division of Thomson Learning Palpation Thoracic tenderness Crepitus Thoracic expansion Tactile or vocal fremitus

Copyright 2002, Delmar, A division of Thomson Learning Percussion Anterior Posterior Lateral Diaphragmatic excursion

Copyright 2002, Delmar, A division of Thomson Learning Auscultation—Fields Anterior Posterior Lateral

Copyright 2002, Delmar, A division of Thomson Learning Auscultation—Breath Sounds Pitch Intensity Quality Duration Location

Copyright 2002, Delmar, A division of Thomson Learning Normal Breath Sounds Bronchial Bronchovesicular Vesicular

Copyright 2002, Delmar, A division of Thomson Learning Adventitious Breath Sounds Crackle or Rale  Fine  Coarse Wheeze  Sonorous (Rhonchi)  Sibilant Pleural friction rub Stridor

Copyright 2002, Delmar, A division of Thomson Learning Voice Sounds Bronchophony Egophony Whispered pectoriloquy

Copyright 2002, Delmar, A division of Thomson Learning Normal Findings AP to transverse diameter is 1:2 Elliptical-shaped thorax Shoulders and scapula at same height bilaterally (continues)

Copyright 2002, Delmar, A division of Thomson Learning 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 (continues)

Copyright 2002, Delmar, A division of Thomson Learning 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)

Copyright 2002, Delmar, A division of Thomson Learning 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 (continues)

Copyright 2002, Delmar, A division of Thomson Learning 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 (continues)

Copyright 2002, Delmar, A division of Thomson Learning 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 (continues)

Copyright 2002, Delmar, A division of Thomson Learning 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)

Copyright 2002, Delmar, A division of Thomson Learning Normal Findings Whispered pectoriloquy, bronchophony, egophony are muffled

Copyright 2002, Delmar, A division of Thomson Learning Age-Related Changes Anatomic changes  Increased work of breathing  Limited chest wall expansion  Muscle atrophy Alveolar gas exchange  Decreased surface area for diffusion (continues)

Copyright 2002, Delmar, A division of Thomson Learning 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