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diaphragm

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*primary muscles *contracts during inspiration

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Primary Muscles of Respiration?

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*Interior Intercostal Muscles: decrease the transverse chest diameter during expiration *Sternocleidomastoid and trapezius accessory muscles: brought into play when there are pulmonary problems and compromise.

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Interior divided into three spaces

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1. mediastinum: situated between the lungs; contains all thoracic viscera except the lungs 2. Right and Left pleural cavities: lined with parietal and visceral pleurae; lungs enclosed by serous membrane.

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Lungs

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*highly elastic lungs paired but not symmetric; -->right lung: 3 lobes -->left lung: 2 lobes and lingula

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Anatomical Landmarks

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*Topographic markers -nipples -manubriosternal junction -suprasternal notch -costal angles -vertebra prominences -->spinous process of C7 -clavicles

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Older Adult changes

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*barrel chest from loss of muscle strength in thorax and diaphragm and loss of lung resiliency *skeletal changes emphasizing dorsal curve of thoracic spine *alveoli less elastic, causing fatigue and dyspnea on exertion * decrease in vital capacity/increase in residual volume *mucous membranes drier

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HPI: Coughing

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-onset -nature of cough -sputum production -sputum characteristics -pattern -severity -associated symptoms -efforts to treat ***coughing can indicate cardiac problem

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HPI: shortness of breath

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-onset -pattern -position most comfortable, number of pillows used -relaxed to extent of exercise, certain activities, time of day, eating -harder to inhale or exhale -severity -associated symptoms -efforts to treat

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HPI: chest pain

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-onset and duration -associated symptoms -efforts to treat -other medications -->recreations drugs

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PMH

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-Thoracic trauma or surgery, dates of hospitalization for pulmonary disorders -use of oxygen and ventilation-assisting devices -->CPAP or BiPAP -chronic pulmonary diseases -other chronic disorders -Testing -immunization against streptococcus pneumoniae influenza

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Family History

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-TB -cystic fibrosis -emphysema -allergy, asthma, atopic dermatitis -malignancy -bronchiectasis -bronchitis -clotting disorders (risk of pulmonary embolism)**important to ask about

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Personal and Social History

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-Employment -home environment -tobacco use -exposure to respiratory infections, influenza, tb -nutritional status -use of herbal or other remedies -regional/traveling exposures -hobbies -use of alcohol/drugs -exercise tolerance

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Older Adults 1

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-exposure to and frequency of respiratory infections --> history of pneumonococcal and flu vaccine -effects of weather on respiratory efforts and infection occurrence -immobilization and sedentary habits -difficulty swallowing -altered activities from respiratory symptoms *****high risk of pulmonary infections

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Older adults (Emphasize)

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-smoking history -cough -dyspnea -fatigue; heart, bones, infection, endocrine -weight changes -fever and night sweats

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Equipment

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-marking pencil -centimeter ruler -stethoscope -drapes

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Inspection: CHEST

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-shape and symmetry -chest wall movement -superficial venous patterns -prominence of ribs -anteroposterior versus transverse diameter ---> barrel chest -sternal protrusion -spinal deviation

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Thoracic landmarks

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-anterior thorax -right lateral thorax -posterior thorax

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Inspection: peripheral

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-Fingers: clubbing -breath: odor -skin, nails, and lips; cyanosis and pallor -lips: pursing -nostrils: flaring

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Inspection: Respiration

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-rate -quality -pattern *count rate while palpating

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Patterns of Respiration

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-Normal: regular and comfortable at a rate of 12-20 BPM -Bradypnea:slower than 12 breath per minute -Tachypnea: faster than 20 breaths per minute -Hyperventilation (hyperpnea): faster than 20 breaths per minute; deep breathing. - sighing: frequently intersperses deeper breathing -cheyenne-stokes: varying periods of increasing depth interspersed with angina -Kussmaul: rapid, deep labored

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Observing Respiration

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-inspect the chest wall movement during respiration --> symmetry -->retraction are when the chest seems to cave in at the sternum, between the ribs, at the suprasternal notch, above the clavicles, and at the lowest costal margins. -suggests an obstruction to inspiration at any point in the respiratory tract -Paradoxic breathing: on inspiration, the lower thorax is drawn in, and on expiration , the opposite occurs

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Palpation: TACTILE FREMITUS

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-Palpable vibration of the chest wall that results from speech or other vibrations

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Palpation: CREPITUS

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-Crackly or crinkly sensation, can be both palpated and heard -indicates air in the subcutaneous tissue -->rupture somewhere in the respiratory system -->infection with a gas-producing organism

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Palpation:FRICTION RUB

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-palpable, coarse, grating vibration, usually on inspiration

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Palpation: Thoracic Muscles/Skeleton

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-pulsations -tenderness -bulges/depressions -masses -unusual movement/positions -elasticity of rib cage -immovability of sternum -rigidity of thoracic spine

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Percussion: chest

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Chest -anterior -posterior -lateral Compare tones bilaterally Measure diaphragmatic expansion (3-5 cm)

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Percussion: Percussion tone indicators for lungs

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-Resonance is normal -hyperreasonance indicates hyperinflation **emphysema -Dullness indicates diminished air exchange**COPD

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Ausculatation

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-Auscultation with a stethoscope provides important clues to the condition of the lungs and pleura -All sounds can be characterized in the same manner as the percussion notes; -->intensity -->pitch -->quality -->duration

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Breath Sounds

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-Vesicular -Bronchovesicular -Bronchial -Both bronchovesicular and Bronchi

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Vesicular Breath Sounds

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-low-pitched, low-intensity sounds heard over healthy lung tissue **low-pitch, soft and short expiration; heard over most lung fields; accentuated in a thin person or child, diminished in overweight and muscular individuals

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Bronchovesicular Breath Sounds

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-heard over the major bronchi and are typically moderate in pitch and intensity **combination bronchial and vesicular heard over main bronchus area and over right posterior lung field; medium pitch; expirations equal inspirations

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Bronchial Breath Sounds

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-highest in pitch and intensity -ordinarily heard only over the trachea **coarse, loud and long expirations; heard over trachea; high pitched expirations somewhat longer than inspirations

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Bronchovesicular and Bronchial Breath Sounds

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-sounds abnormal if they are heard over the peripheral lung tissue

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Adventitious Breath Sounds

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-Crackles -Rhonchi (sonorous wheezes) -Wheezes -Friction rub

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Crackles

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-formerly called rales -abnormal respiratory sound heard most often during inspiration and characterized by discrete discontinuous sounds -fine: high-pitched, and relatively short in duration -coarse: low-pitched, and relatively longer in duration **crackles; loud, high pitched bubbly or crackly noise heard during inspiration; not cleared by cough

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Rhonchi (sonorous wheeze)

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-deeper, more rumbling, more pronounced during expiration, more likely to be prolonged and continuos and less discrete than crackles -caused by the passage of air through an airway obstructed by thick secretions, muscular spasm, new growth or external pressure **loud, low, coarse sounds like a snore; often heard continuously during inspiration or expiration; cough may clear

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Wheeze (sibilant wheeze)

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-continuous, high-pitched, musical sound (almost a whistle) heard during inspiration or expiration -caused by a relatively high-velocity airflow through a narrowed or obstructed airway -may be caused by the bronchospasm of asthma (reactive airway diseases) or acute or chronic bronchitis **musical noise sounding like a whistle; most often heard during inspiration or expiration; usually louder during expiration

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Friction Rub

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-occurs outside the respiratory tree -dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration -caused by inflamed, roughened surfaces rubbing together **dry, rubbing or grating sound usually caused by inflammation of pleural surfaces; heard during inspiration or expiration

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Vocal Reasonance

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-spoken voice transmits sound through the lung fields that may be heard with the stethescope - the following auditory changes changes may be present any condition that consolidates lung tissue --->Bronchophony --->pectoriloquy --->Egophony -conversely,vocal resonance diminishes and loses intensity where there is loss of tissue within the respiratory tree (e.g. with the barrel chest of emphysema)

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Vocal Resonacne

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-Bronchophony -Pectoriloquy -Egophony

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Bronchophony

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-greater clarity and increases loudness of spoken sounds

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Pectoriloguy

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-Extreme Bronchophony where even a whisper can be heard clearly through the stethoscope

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Egophony

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-intensity of the spoken voice is increased and there is a nasal quality - e's become stuffy broad a's

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Physical Examination Preview 1

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-Inspect the chest; front and back, noting thoracic landmarks, for the following -->size and shape (anteroposterior diameter compared with the lateral diameter) -->symmetry -->color -->superficial venous pattern -->prominence of ribs

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Physical Examination Preview 2

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-evaluate respiration for the following -->rate -->rhythm or pattern -inspect chest movement with breathing for the following -->symmetry -->use of accessory muscles -note and audible sounds with respiration

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Physical Examination Preview 3

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-Palpate the chest for the following --> symmetry --> thoracic expansion --> sensations such as crepitus, grating vibrations --> tactile fremitus

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Physical Examination Preview 4

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-Perform direct or indirect percussion on the chest, comparing sides for the following --> diaphragmatic excursion --> percussion tone intensity, pitch, duration, and quality

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Physical Examination Preview 5

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-Auscultate the chest with the stethoscope diaphragm, from the apex to base; compare sides for the following --> intensity, pitch, duration, and quality of breath sounds --> unexpected breath sounds (crackles, rhonchi, wheezes friction rubs) --> vocal reasonace

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Cough

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-Describe -->dry or moist -->onset -->frequency of occurrence -->regularity -->pitch and loudness -->postural influences -->quality

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Sputum

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-The production of sputum is generally associated with cough -Describe -->Color -->Consistency -->odor

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Older Adults

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-Chest expansion decreased --->respiratory muscle weakness --->generally physical disability --->sedentary lifestyle --->calcification of rib articulations -Bony prominences marked -kyphosis with flattening of lumbar curve -increased anteroposterior diameter -hyper reasonance common

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Abnormalities

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-Asthma -Atelectasis -Bronchitis -Pleurisy -Pleural effusion -Emphysema -Pneumonia -Influenza -Tuberculosis -Pneumothorax -Hemothorax -Lung Cancer -Cor pulmonale -Pulmonary Embolism Diaphragmatic hernia

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Asthma

answer

-reactive airways disease -->small airways obstruction due to inflammation and hyperactive airways

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Atelectasis

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-incomplete expansion of the lungs at birth or the collapse of the lung at any age

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Bronchitis

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-inflammation of the large airways --acute --chronic

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Pleurisy

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-inflammation process involving the visceral and parietal pleura, which becomes edematous and fibrinous

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Pleural Effusion

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-excessive non purulent fluid in the pleural space

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Empyema

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-purulent exudative fluid collected in the pleural space

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Pneumonia

answer

-Inflammatory response of the bronchioles and alveoli to an infective agent (bacterial, fungal , or viral)

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Influenza

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-viral infection of the lung -normally an upper respiratory infection, but due to alterations in the epithelial barrier, the infected host is more susceptible to secondary bacterial infections

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Tuberculosis

answer

-Chronic infectious disease that most often begins in the lung but may then have widespread manifestations

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Pneumothorax

answer

-presence of air or gas in the pleural cavity

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Hemothorax

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-presence of blood in the pleural cavity

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Lung Cancer

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-Generally refers to bronchogenic cancer, a malignant tumor that evolves from bronchial epithelial structures

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Cor Pulmonale

answer

-acute or chronic condition involving right-sided heart failure

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Pulmonary Embolism

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-embolic occlusion of pulmonary arteries -relatively common condition -difficult to diagnose

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Diaphragmatic hernia

answer

-result of an imperfectly structured diaphragm , occurs once in slightly more than 2000 live births

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Older Adults: COPD

answer

Chronic Obstructive Pulmonary disease -is a nonspecific designation that includes a group of respiratory problems in which cough, chronic and often excessive sputum production and dyspnea are prominent features -is not limited to older adults; smokers at greatest risk -emphysema, bronchiectasis and chronic bronchitis are the main conditions that are included in this group

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Older Adults: Emphysema

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-condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function

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Older adults: Bronchiectasis

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-chronic dilation of the bronchi or bronchioles is caused by repeated pulmonary infections and bronchial obstruction

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Older Adults: Chronic Bronchitis

answer

-large airway inflammation, usually a result of a chronic irritant exposure, more commonly a problem for patients older than 40

Health Assessment Nursing 307 chest and lungs chapter 13 – Flashcards

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