In this nursing lecture, you will be able grasp the lessons easily and adapt it in your nursing study.
- Outline
- Structure and Function
- Subjective Data
- Objective Data
- Abnormal Findings
- Structure and Function
- Thoracic Cage /Cavity
- Shape- bony, conical shape, narrower at top borders – it is defined by:
- Sternum – 3 parts: manubrium, body, xiphoid process
- Ribs – 12 pairs, 1 st seven attach to the sternum (costal cartilages) Ribs 8,9,&10 attach to the costal cartilage above, Ribs 11 & 12 are floating ribs
- 12 Thoracic vertebrae
- Diaphragm – the floor, separates the thoracic cavity from the abdomen
- Anterior Thoracic Landmarks
- Suprasternal Notch – U shaped depression
- Sternum – “breastbone” = 3 parts
- Manubrium
- Body
- Xiphoid process
- Angle of Louis – manubriosternal angle continuous with the 2 nd Rib
- Costal angle- usually 90 0 or <. (increases when rib cage is chronically overinflated)
- Posterior Thoracic Landmarks
- Vertebra Prominens – Flex head, feel most prominent bony projection at base of neck = C7 next lower one is T1
- Spinous Processes – spinal column-
- Scapula – symmetrical , lower tip at the 7 -8 th Rib
- 12 th Rib = midway b/t spine & side
- Reference Lines
- Anterior Chest
- Midsternal line
- Midclavicular line
- Posterior Chest
- Vertebral line – midspinal
- Scapular line
- Lateral Chest
- Anterior Axillary line
- Posterior Axillary line
- Mid–axillary line
- The Thoracic Cavity
- Mediastinum middle of the thoracic cavity & contains;
- Esophagus
- Trachea
- Heart
- Great Vessels
- Pleural Cavities on either side of the mediastinum contain the lungs
- Lung Borders
- Anterior Chest –
- Apex 3 -4 cm. ↑ inner 1/3 of the clavicles
- Base – rests on the diaphragm, 6 th rib, MCL
- Lateral Chest
- Extends from Axilla apex to 7 th –8 th rib
- Posteriorly
- Apex of lung is at C7 – Base T10 (on deep inspiration to T12)
- Lobes of Lung
- Right Lung
- 3 lobes, upper, middle , lower
- Shorter due to liver
- Left Lung
- LUL = Left Upper and Lower ( 2 lobes)
- Narrower due to heart
- Lobes
- Diagonal sloping segments
- Oblique fissures
- 3 Important Points
- Left Lung – no middle lobe
- Anterior chest contains upper & middle lobes with very little lower lobe
- Posterior chest has almost all lower lobe. Rt middle lobe does not project into the posterior chest
- Pleurae
- The Pleurae form an envelope b/t the lungs & chest wall
- Visceral pleura – lines outside of lungs
- Parietal pleura – lines inside of chest wall & diaphragm
- Pleural Cavity – the inside of the envelope- space b/t visceral & parietal pleura, lubrication. Normally has a vacuum or neg. pressure
- Tracheal & Bronchial Tree
- Trachea – anterior to esophagus-
- 10-11 cm.long, begins at cricoid cartilage
- Bifurcates just below the sternal angle ( AKA angle of Louis, manubriosternal angle) into the
- Right Main Stem Bronchus – shorter, wider, more vertical ( Intubation – listen to breath sounds bilaterally)
- Left Main Stem Bronchus
- Tracheal & Bronchial Tree
- The trachea & bronchi provide the passage for air to get into the lungs from the environment = Dead Space (no air exchange takes place here)
- Bronchi
- Secrete mucus – captures particles
- Cilia – moves the trapped particles up to be expelled or swallowed
- Acinus
- Functional respiratory unit consisting of,
- Bronchioles, alveolar ducts, alveolar sacs, & alveoli
- Gaseous exchange in alveolar duct & alveoli
- Mechanics of Respiration
- 4 Major Functions of the Respiratory System
- Supply O 2 for energy production
- Remove CO 2 , waste product of energy reactions
- Homeostasis, acid-base balance of arterial blood
- Heat exchange
- Respiration maintains pH ( acid- base balance) of the blood by supplying O 2 & eliminating CO 2 .
- Normal Range Values of Arterial Bld. Gases
- pH= 7.35- 7.45
- Pa CO 2 = 35-45mmHg
- PaO 2 = 80-100mmHg
- SaO 2 = 94-98%
- Lungs help to maintain the pH balance by adjusting the amt. of CO 2 through:
- Hypoventilation
- Hyperventilation
- Respiration = breathing
- Inspiration
- Expiration
- Control of Respiration
- Involuntary control by respiratory center in the brain stem consisting of the pons & medulla
- Hypercapnia is an ↑ in CO 2 in the Bld. And provides the normal stimulus to breath
- Hypoxemia
- Subjective Data
- Cough
- SOB
- Chest Pain
- Respiratory Infections
- Smoking
- Environmental Exposure
- Self-care behaviors
- Objective Data
- Inspect
- Palpate
- Percuss
- Auscultate
- After Posterior Thyroid Exam
- Posterior chest, Lateral chest, then Anterior chest
- Remember to clean stethoscope end piece and warm prior to use on client.
- Quiet environment conducive to hearing lung sounds
- Equipment for Exam
- Stethoscope
- Ruler – 15cm.
- Tape measure
- Washable marker
- Alcohol swabs
- Posterior Chest
- Inspect Thoracic Cage
- Shape and configuration
- Anteroposterior Diameter should be < diameter =" Ratio">
- Note Position of Person to breathe.
- ? orthopnea
- Skin Color & Condition, nail color
- Barrel Chest
- Pectus Carinatum (Pigeon)
- Pectus Excavatum (Funnel)
- Posterior Chest
- Palpate
- Symmetric Expansion- warmed hands – thumbs @ T9-T10- pinch sm. Fold of skin
- Posterior chest
- Tactile Fremitus – palpable vibration of sound from the larynx- use palmer base of fingers- “99” or Blue Moon
- Symmetry important – vibration should feel the same bilaterally.
- Avoid palpating over scapulae because bone dampens out sound
- ↓ fremitus = obstructed bronchi, pleural effusion, pneumothorax or emphysema
- Note any barrier that is b/t the sound and your hand will↓ fremitus
- ↑ fremitus occurs only with gross changes (Lobar pneumonia).
- Entire Chest wall – gently palpate. Note
- Tenderness, skin temp., moisture, lumps, lesions
- Crepitus = coarse crackling sensation palpable over skin surface. (Subcutaneous emphysema when air escapes from lung into S/C tissue)
- Posterior Chest
- Percuss start at the apices, across shoulders, then interspaces side to side (5cm. Intervals) Avoid scapulae & ribs
- Resonance predominates in healthy lung
- Hyperresonance – too much air, emphysema, pneumothorax
- Dull = abnormal density, pneumonia, tumor, atelectasis
- Expected Percussion notes
- Diaphragmatic Expansion
- Lower lung borders in expiration & inspiration
- 1 st Exhale & hold- percuss down the scapulae line until sound changes from resonant to dull. Mark with marker
- Estimates the level of the diaphragm separating the abd cavity. May be higher on Rt. Due to liver
- Diaphragmatic Expansion
- Now take deep breath & hold.
- Percuss from mark to dull sound and mark.
- Measure the difference. Should be + bilaterally 3-5cm in adult may be 7-8 cm in well conditioned person
- Note hold your own breath when conducting this test!!!!!!!!!
- Exhale Inhale
- Posterior Chest
- Auscultate
- Position client
- Instruct to breath through mouth, little deeper than usual
- Tell you if becomes light headed
- Use flat diaphragm & hold firmly on chest
- Must listen to at least 1 full respiration before moving stethoscope side to side
- Compare both sides (lung fields)
- Auscultation Sequence
- Normal Breath Sounds
- Bronchial – Anterior Chest only = over trachea & larynx
- Quality = harsh, hollow, tubular
- Inspiration <>
- Amplitude = Loud
- Breath Sounds
- Bronchovesicular both anterior & posterior
- Over major bronchi, posterior b/t scapulae, anterior upper sternum, 1 st & 2 nd ICS
- Pitch = high
- Inspiration = Expiration
- Moderate amplitude
- Vesicular – Anterior & posterior
- Quality = rustling, wind in trees
- Inspiration > Expiration
- Soft amplitude
- Location of Breath Sounds
- Decreased or Absent Breath Sounds
- Causes =
- obstruction of the bronchial tree by secretions, mucous plug, F.B
- ↓ lung elasticity, emphysema = lungs hyperinflated
- Pleurisy, pleural thickening, pneumothorax (air), pleural effusion (fld.) in the pleural space
- Increased Breath Sounds = dense lung tissue enhances sound transmission as in consolidation ie. pneumonia
- Silent chest = ominous
- Adventitious Sounds
- Not normally heard in the lungs. Caused by moving air colliding with secretions or by popping open of previously deflated airways
- Crackles (Rales)
- Fine – high pitched popping- not cleared by coughing. Simulate sound by rolling strand of hair b/t fingers near ear or moisten thumb& index finger & separate them near your ear
- Course crackles- (opening a velcro fastener)
- Pleural Friction Rub – coarse & low pitched, 2 pieces of leather rubbed together close to ear
- Adventitious Sounds
- Wheeze (Rhonchi)
- High pitched, musical squeaking = air squeezes - asthma
- Low pitched musical snoring, moaning, =obstruction
- Stridor – high pitched, inspiratory, crowing, louder in neck = croup, acute epiglottitis
- Coarse Crackles
- Fine Crackles
- Voice Sounds normal voice transmission is soft, muffled & indistinct. Pathology that ↑ lung density makes words clearer
- Bronchophony – “99”
- Egophony- ee-ee-ee if disease sounds like aa-aa-aa Record as “E -> A changes”
- Whisper pectoriloquy 1-2-3
- These tests are only done if lung pathology is suspected
- Anterior Chest
- Inspect
- Shape & Configuration
- Expression- relaxed
- LOC – alert & cooperative
- Skin color & condition
- Quality of Respirations – reg. & even, no retraction or use of accessory muscles
- Anterior Chest
- Palpate
- Symmetric Chest Expansion
- Tenderness, turgor, temp., moisture
- Tactile Fremitus
- Compare both sides
- Symmetric Expansion
- Sequence for percussion & auscultation
- Tactile fremitus
- Percussion
- Apices in Supraclavicular Areas
- Interspaces = Resonance
- Dullness
- Female breast tissue
- Liver – Rt. 5 th intercostal space midclavicular
- Heart – Lt. 3 rd intercostal space midclavicular
- Flat = muscle & bone
- Tympany = stomach (Lt. Side)
- Expected Percussion Notes
- Auscultate
- Apices (supraclavicular) to 6 th rib
- Bilateral moving down
- One full respiration
- Directly over chest wall – displace female breast tissue
- Location Of Breath Sounds
- Pulse Oximeter
- Noninvasive measurement of arterial oxygen saturation = SpO 2 by measuring the relative amt. of light absorbed by oxyhemoglobin and unoxygenated hemoglobin. It compares light emitted to amt absorbed. Normally 97 -98%
- Terms for Documentation
- Rate
- Eupnea 12 – 20 bpm normal
- Tachypnea > 24, rapid, shallow
- Bradypnea <>
- Apnea = No respirations for 10 sec. or more
- Pattern = breathing rhythm. Normal respirations are regular and even.
- Cheyne – stokes = resp wax & wane in reg pattern with periods of apnea(20sec)
- Biot’s or ataxisic Sim. To cheyne –stokes but pattern irreg.
- Depth – on inspiration the normal depth is nonexaggerated and effortless.
- Shallow
- Sighing – purposeful to expand the alveoli
- Symmetry – bilateral rise and fall of the chest with respiration
- Audibility – normally be heard by the unaided ear several centimeters from the patient’s nose/mouth
- Patient position – healthy person breathes comfortably in supine, prone or upright position
- Orthopnea
- Mode of Breathing – normally inhale/exhale through nose
- Sputum
- Sample
- Color
- Mucoid, yellow/green, rust/blood tinged, black, pink
- Odor
- Amount
- Consistency
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