Thorax and Lungs

What does the thorax contain and what does it make up?

lungs, trachea, and bronchi; constitutes the lower respiratory system

Coarse crackles upon late inspiration

pneumonia

Where is the sternal angle?

2nd pair of ribs & 2nd intercostal space

suprasternal notch

hollow U-shaped depression just above the sternum, in between the clavicles

Where is second intercostal space?

Inferior to second rib

What is the costal angle?

The right and left costal margins form an angle where they meet at the xiphoid process

xiphoid process

lower, narrow portion of the sternum

Which rib can be palpated easily on back when head is tilted downward?

Rib 7

Trachea

Flexible tube anterior to esophagus, begins at cricoid cartilage

Which bronchus is shorter, wider, and more vertical?

right bronchus

What acts as passageways for inspired and expired air and is considered dead space?

Trachea and bronchi

Apex of the lungs is located where?

Slightly above clavicle

How many lobes do the right and left lungs have?

R: 3 lobes; L: 2 lobes

pleural effusion

abnormal accumulation of fluid in the pleural space due to heart failure or inflammation

T/f: most foreign objects are found in left lung

False! Right bronchus is shorter and more vertical making it easier for objects to go in it

Changes in breathing can cause problems in:

Acid-base balance

Why do breathing patterns change?

Cellular demand for oxygen; hormonal regulation; changes in O2 or CO2 level in blood; pH level; increased CO2 levels in blood

Age-related changes in lungs

Loss of elasticity, fewer functional capillaries, and loss of lung resiliency

t/f: impaired gas exchange as seen in pulmonary disease is a priority nursing diagnosis

true

Which muscle controls breathing?

Diaphragm

What cartilage stops the trachea from collapsing?

cricoid

What is bifurcation and what does the trachea bifurcate into?

To divide into two parts like how the bronchi branch into bronchioles; right and left primary bronchi

Upper lobes of lungs are easier to hear on the ____ side of the chest

anterior

What is pleuritic pain?

Sharp, stabbing pain associated with breathing due to fluid buildup between two pleura

What drug helps with pleuritic pain?

NSAIDS like aspirin; pleural effusion treatment; chest tube or pleurX catheter to drain the fluid

What organ is responsible for respiration?

The brain (responds to CO2 levels in brain)

What is the strongest stimulus to breathe?

Increase in serum CO2 (blood CO2)

What is partial pressure of CO2 in body?

The measure of carbon dioxide within arterial or venous blood; a marker of sufficient alveolar ventilation within the lungs

t/f: the chest expands vertically and horizontally

true

Older adult considerations regarding lungs

May experience dyspnea with certain activities due to age-related changes of lungs; chest pain associated with pleuritis may be absent; ability to cough effectively may be decreased; kyphosis is common; thoracic expansion may be decreased but should still be symmetric; deep breathing may be difficult, may fatigue easily; tenderness or pain at costochondral junction of ribs seen with fractures, especially with osteoporosis

costochondral junction

where rib attaches to cartilage

kyphosis

an abnormal increase in the outward curvature of the thoracic spine as viewed from the side

What kinds of questions should you ask first about lungs during subjective data collection?

Life-threatening symptoms FIRST (chest pain and difficulty breathing)

If a patient is experiencing chest pain, what must we do first before collecting any other subjective data?

Rule out myocardial infarction

How to determine pack year history?

of packs per day x # of years smoked

What does a pack year history of 40 mean?

Patient is at high risk for developing lung cancer or emphysema

3 things to observe during general routine screening of lungs

1. Color of face, lips, and chest; 2. Use of accessory muscles and intercostal spaces; 3. Nasal flaring or pursed-lip breathing

3 things to inspect during general routine screening of lungs

1. Color and shape of nails; 2. Configuration of anterior and posterior thorax; 3. Client's positioning

What should we palpate during general routine screening of lungs?

Anterior and posterior thorax for tenderness, sensation, and surface masses; fremitus; crepitus

What do clubbed fingers indicate?

Long-standing hypoxemia

What does an anterior-posterior thorax diameter of 1:1 indicate?

The chest is as wide as it is deep because ribs will be fixed in inspiratory position and have a hard time pushing out air

What is the purpose of purse-lipped breathing?

Deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse

What is fremitus?

A palpable vibration from the spoken voice felt over the chest wall

What is crepitus in the lungs?

Subcutaneous emphysema; occurs when air leaks into subcutaneous tissues due to pneumothorax or leaking chest tube

What two things are included on the focused specialty assessment of lungs?

1. Percuss for diaphragmatic excursion; 2. Auscultate voice sounds

How do we prepare the client for a physical examination?

Remove clothing from waist up, put on gown or drape; explain procedure before starting; client to sit upright position with arms at side; ensure room temperature is comfortable

Physical examination of posterior thorax includes

Inspection of configuration, use of accessory muscles, and client's position; palpation for tenderness, sensation, crepitus, surface characteristics, fremitus, and chest expansion; percussion for tone, diaphragmatic excursion; auscultation for breath sounds, adventitious sounds, voice sounds: bronchophony, egophony, whispered pectoriloquy

Physical examination of anterior thorax includes

Inspection of shape and configuration, position of sternum, sternal retractions, slope of ribs, quality and pattern of respiration, intercostal spaces, use of accessory muscles; palpation for tenderness, sensation, and surface masses; percussion for tone; auscultation for anterior breath sounds, adventitious sounds, and voice sounds

consolidation in lobe

Trachea in center, dull sound in affected lobe, increased tactile fremitus

tactile fremitus

Abnormal vibration of the chest wall during speaking that is palpable on physical examination

obstructive atelectasis

Due to blocked airway resulting in collapse of the lung tissue distal to the blocked airway; ipsilateral tracheal shift; greatly decreases gas exchange

pneumothorax

Collapsed lung; contralateral tracheal shift

hemothorax

Bleeding in the lungs

pleural effusion can cause

Contralateral tracheal shift

bronchial breath sounds

Normal breath sounds, air moving through the bronchi

Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.

bronchovesicular breath sounds

Normal breath sounds over the mainstem bronchus; moderate blowing sounds, inspiration equal to expiration

vesicular breath sounds

Normal soft, low-pitched sounds, primarily when a person breathes in

heard over most of the lungs

fine crackles

Short high-pitched sounds during inspiration, may clear with cough

coarse crackles

Low-pitched, bubbling or gurgling sounds, start early in inspiration and extend into the first part of expiration; caused by fluid in lungs from pulmonary edema and fibrosis

pleural friction rub

Continuous, dry grating sound caused by inflammation of pleural surfaces and loss of lubricating pleural fluid

wheeze (sibilant)

Musical/squeaking/high-pitched, continuous sounds; auscultated during inspiration and expiration; air passing through narrowed airways

What breath sound would you hear for patient with asthma?

Sibilant wheezes

What are sonorous wheezes?

Low-pitched snoring or moaning sounds heard primarily during expiration but may be heard throughout the respiratory cycle; may clear with coughing

Which breath sounds occurs due to an airway obstruction or chronic bronchitis?

Sonorous wheezes

Tachypnea is over ___ bpm and bradypnea is under ___

Shallow, over 24; regular, under 10

Kussmaul respirations

Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body

Causes of hypoventilation

Overdose of opioids or anesthetics

Cheyne-Stokes respiration

Pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea; regular pattern

Causes of Cheyne-Stokes respiration

Endocranial pressure or congestive heart failure

Biot respirations (and causes)

Irregularly interspersed periods of apnea in a disorganized sequence of breaths caused by meningitis or severe brain damage

Ataxic respirations

Irregular, unpredictable respiratory rate and tidal volume; more extreme than Biot respirations

What is air trapping?

Increasing difficulty in getting air out

COPD includes

Emphysema and chronic bronchitis

Risk factors for COPD

1. Cigarette smoke; 2. Asthma; 3. Occupational exposure to dust and chemicals; 4. Exposure to fumes from burning fuels; 5. Age of 35-40 years and older; 6. Rarely genetics

What should you educate a client about COPD?

1. To avoid smoking; 2. Teach about pursed-lip breathing, tripod positioning, and energy-conserving methods

emphysema

Collapse of alveoli resulting in impaired gas exchange

What is barrel chest caused by?

Increased functional residual capacity due to air trapping from small airway collapse

Second leading cause of death in US

Lung cancer

small cell lung cancer

A type of lung cancer in which the cells appear small and round when viewed under the microscope; also called oat cell lung cancer

non-small cell lung cancer

A group of lung cancers that includes squamous cell carcinoma, adenocarcinoma, and large cell carcinoma; less aggressive than SCLC