thorax and lungs.330.ss.09
TRANSCRIPT
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Thorax and Lungs
Nursing 330
Governors State University
Shirley Comer
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Posterior Chest
Inspect- observe shape and configuration– Spinous process in straight line
Scoliosis= s shaped curve Kyphosis= outward curvature
– Thorax symmetrical– Ribs slope downward– Scapulae placed symmetrically
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Chest Diameter
Anteroposterior diameter less than transverse diameter
– Barrel Chest- diameter equal to transverse diameter /c horizontal ribs and costal angles greater then 90 degrees.
Occurs in chronic emphysema r/t lung hyperinflation
Neck and Trapezius muscles- normal development– Hypertrophy /c COPD
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Chest diameter image
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Observe
Body position– Tripod position /c COPD so ancillary muscles can
aid breathing– Orthopnea- inability to lie flat r/t SOB- rib cage
cannot expand fully while lying-Some pt may report using several pillows in bed or sleeping sitting up
Skin color and condition Resp rate and character
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Palpate the Posterior Chest
Symmetric chest expansion- place hands at T9-chest should expand evenly during inspiration. – Unequal may be present in:
Atelectasis Pnuemonia Trauma/fractured ribs Pnuemothorax
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Chest expansion image
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Tactile Fremitus
Is a palpable vibration– Use palms– Pt repeats phrase “99 or blue moon”
Palpate over apices to bases Vibrations should be equal bilaterally Decreased fremitus = pleural effusion, thickened chest wall,
Pnuemothorax, emphysema Increased fremitus= consolidation of lung tissue, pneumonia,
tumor, fibrosis Crepitus = crackling sensation over skin surface = SQ
emphysema
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Tactile Fremitus image
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Palpate
Palpate the entire chest wall– Note
Tenderness Change in skin temp Moisture Lumps Masses Skin lesions
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Percuss
Percuss from apices to bases Percuss at 5cm intervals Avoid the ribs, clavicle and scapulae
– Resonance is heard over healthy lung tissue Heavily muscled or obese pt may sound duller
– Dullness is heard over bone or abnormal lung = pneumonia, pleural effusion Atelectasis or tumor
– Lungs are hyper inflated /c COPD=hyper resonance
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Percussion/Auscultation pattern
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Diaphragmatic Excursion
Percuss the position of the diaphragm during inspiration and expiration and mark.
Measure the difference should be equal Normal is 3 to 5 cm but may be as high as 8 in
athletes Excursion will be decreased in COPD, pleural
effusion and Atelectasis
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Diaphragmatic Excursion
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Auscultate the Posterior chest
Normal breath sounds– Bronchial aka tracheal or tubular-
heard close to larger airways (trachea, main bronchi)
– Bronchovesicular- heard over medium sized airways
– Vesicular- heard over lung periphery
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Decreased/ Diminished Breath Sounds
Occur when– Bronchial tree is obstructed by secretions, mucous
plug or foreign body– Emphysema r/t loss of elasticity in lung and
decreased force of inspired air– Sound transmission is obstructed- pleurisy, pleural
thickening, Pnuemothorax, pleural effusion– Absent breathing
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Adventitious Sounds
Crackles AKA fine rales– Short popping sounds at the end of inspiration– Caused by fluid collapsing the alveoli during
expiration– Common /c pneumonia, CHF, Atelectasis
Coarse Rales– Similar to crackles but more bubbling sounds earlier
in inspiration– Caused by more fluid than crackles
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Adventitious Sounds cont
Rhonchi– Snoring sound heard during expiration– Caused by secretion in bronchial tree
Wheezes– Musical whistling sounds heard mainly on expiration
but can be through our cycle– Present in asthma, emphysema, bronchitis or
bronchospasm
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Anterior Chest
Observe shape and configuration of chest Costal angle less than 90 degrees Position of ribs Observe
– Facial expression- COPD may have tense or tired faces– LOC- Cerebral hypoxia = drowsiness, irritability confusion– Skin color and condition– Quality of respirations-noisy, use of ancillary muscles
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Auscultate the Anterior chest
Listen for 1 full respiratory cycle over the entire anterior chest.
Will hear vesicular lung sounds over most of anterior chest.
Pt should take deep breath in and out through mouth.
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Vocal Fremitus
Egophony– Pt says “E”
Bronchophony– Pt says “99 or blue moon”
Whispered Pectoriloquy– Pt says “1-2-3”
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Age Specific Considerations
Infants and Children– Resp rate will be irreg during feeding or sleeping in
neonate.– Broncho vesicular sounds heard over entire lung
field r/t thin chest wall– Crackles heard in upper fields /c cystic fibrosis.– Stidor is a high pitched inspiratory sound heard
audibly /c croup epiglottis or foreign body aspiration
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Age Specific Continued
Pregnant women– Thoracic cage widens– Apical pulse displaced laterally– Orthopnea may be present– Change in resp character
Elderly– Kyphosis-Barrel chest– Marked bony prominences r/t decreased subcutaneous fat.– May fatigue during exam or hyperventilate– More likely to have disease present-pneumonia,` Atelectasis
ect
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Practice Exam Question
Your client has a 20 year history of cigarette smoking and a productive cough. What adventitious breath sound are you most likely to hear during your assessment?– A. Stridor– B. Rhonchi– C. Coarse Rales– D. Vesicular
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Rationale
B is the correct answer. A productive cough and history of cigarette smoking indicate the possible presence of secretions in the bronchial tree.
A is a condition seen in children C is caused by fluid D is not an adventitious breath sound