Nursing 1145 Thorax & Lungs + Breasts & Regional Lymphatics

THE ASSESSMENT ORDER = Always the Same (THORAX & LUNGS)

Inspect → Auscultate → Palpate → Percuss (for lungs, auscultation is routine; palpation/percussion are less common but testable)

NORMAL INSPECTION (THORAX & LUNGS)

1.Non-labored, quiet breathing 2.Rate WNL for age (~12–20/min) 3.Skin warm and dry 4.Color consistent with ethnicity 5.Patient calm

ABNORMAL (Warning Signs) INSPECTION (THORAX & LUNGS)

1.Nasal flaring (trying to get more air) 2.Retractions (skin pulling in between ribs) 3.Pursed lip breathing (COPD) 4.Tripod position (leaning forward to breathe) 5.Accessory muscle use (neck, trapezius) 6.Anxious / altered consciousness

Clubbing of nails (Key Inspection Findings)

Chronic hypoxia (COPD, heart complications, inflammatory GI disease)

Barrel chest (Key Inspection Findings)

Increased AP diameter → chronic air trapping (emphysema/COPD)

Tripod position + pursed lip breathing (Key Inspection Findings)

COPD patient struggling to breathe

Cachectic (very thin) + short of breath (Key Inspection Findings)

COPD burns 8,000–10,000 calories/day vs. normal 3,000

Trail sign (Key Inspection Findings)

Sternocleidomastoid prominence indicating trachea deviation

Trachea is normally MIDLINE.

Any deviation is a BIG clinical clue.

Trachea moves TOWARD problem (Tracheal Position)

1.Atelectasis (small collapse, lung pulling it) 2.Post-surgery

Trachea moves AWAY from problem (Tracheal Position)

1.Pneumothorax (air pushing it away) 2.Large mass / tumor

Tension Pneumothorax

Entire lung collapsed. Trachea deviates to GOOD side. EMERGENCY = chest tube in minutes.

Eupnea (Breathing Patterns)

1.Normal = slow, regular, 10–20/min 2.Associated with = Healthy

Tachypnea (Breathing Patterns)

1.Rate > 20/min, shallow 2.Associated with = Infection, anxiety, SOB

Bradypnea (Breathing Patterns)

1.Rate < 8–10/min 2.Associated with = Opioids, fentanyl OD

Cheyne-Stokes (Breathing Patterns)

1.Fast → slow → STOPS → repeats 2.Associated with = Brain injury, end of life, sedatives

Kussmaul's (Breathing Patterns)

1.Deep, sighing, fast 2.Associated with = Acidosis, diabetic ketoacidosis (DKA)

Agonal (Breathing Patterns)

1.Gasping, irregular 2.Associated with = End of life → call family

A 5-year-old with Kussmaul's breathing patterns and diabetic with pH 6.9 and blood sugar 543 from a tooth infection

The infection caused the hyperglycemia. Treatment: insulin + fluids. Key smell: sweet/acetone breath.

Barrel Chest (Chest Shapes)

Air trapping from COPD/emphysema — AP diameter = transverse

Pectus Excavatum (Chest Shapes)

Sunken sternum = may be isolated or part of syndrome (e.g., Marfan's — Lincoln)

Pectus Carinatum (Chest Shapes)

Protruding sternum = pigeon chest

Kyphosis (Chest Shapes)

Hunched upper back = osteoporosis, age-related

Scoliosis (Chest Shapes)

Sideways spinal curve = affects lung expansion

Central cyanosis

Blue/gray on lips, tongue, gum, nail beds → low oxygen centrally

Peripheral cyanosis

Blue on fingertips, nail beds → poor perfusion

Pallor

Pull lower eyelid = check subconjunctival space → anemia → also causes SOB + fast HR

Hemoglobin 6.0 (normal 12–16)

Pale nail beds + SOB + tachycardia = chronic kidney disease causes this

Flail Chest (Chest Injuries)

1.4–7+ rib fractures → paradoxical movement 2.Inspiration → chest moves IN (wrong way) 3.Expiration → chest moves OUT (wrong way) 4.Cause: trauma (car accident, bicycle accident)

Subcutaneous Emphysema (Crepitus) = Chest Injuries

1.Air leaks from lung into subcutaneous tissue 2.Feel it on palpation = like bubble wrap popping 3.Takes weeks to dissipate

Subcutaneous Emphysema (Crepitus) Example

Prof's neighbor story: 6–7 rib fractures, not recognized → pneumothorax missed in ER → ICU + ventilator

Normal Sounds (Lungs Auscultation)

1.Vesicular: Soft, normal throughout lung fields (you'll chart as 'clear to auscultation' / CTA) 2.Bronchovesicular: Medium = near major airways 3.Bronchial/Tracheal: Loud = near trachea

Fine Crackles (Rales) = Adventitious (Abnormal) Lung Sounds

1.Like rubbing hair near ear = high-pitched pops on inspiration 2.Causes = Pneumonia, heart failure, atelectasis / do NOT clear with cough

Coarse Crackles (Adventitious (Abnormal) Lung Sounds)

1.Loud, bubbling, gurgling 2.Causes = Pneumonia, secretions / may temporarily decrease with cough/suction

Atelectatic Crackles (Adventitious (Abnormal) Lung Sounds)

1.Like fine crackles but disappear after a breath or two 2.Causes = Early atelectasis / common post-op

Wheeze (Sibilant) = Adventitious (Abnormal) Lung Sounds

1.High-pitched musical, like a flute = continuous 2.Causes = Asthma (tight airways), heart failure

Rhonchi (Sonorous) = Adventitious (Abnormal) Lung Sounds

1.Low-pitched, snoring sound = continuous 2.Mucus in airways, COPD, bronchitis

Stridor (Adventitious (Abnormal) Lung Sounds)

1.Loud, high-pitched crowing = heard from doorway (EMERGENCY) 2.Causes = Upper airway obstruction = croup, post-extubation

Pleural Friction Rub (Adventitious (Abnormal) Lung Sounds)

1.Creaking, like leather rubbing = 2 phases at end inspiration/early expiration 2.Causes = Inflamed pleura (pleurisy, pneumonia, cancer)

DECREASED / ABSENT sounds (Lungs)

1.Emphysema (big barrel chest, sound travels poorly) 2.Pneumothorax (collapsed lung, no air movement) 3.Obstruction / pleurisy

INCREASED sounds (Lungs)

Consolidation = pneumonia

Egophony, Bronchophony, Whispered Pectoriloquy (voice sounds)

SAME abnormal cause: consolidation (fluid/mucus = pneumonia)

Egophony

1.Patient says 'EEE' 2.Normal: hear 'ee' (beet) 3.Abnormal: hear 'AAA' (goat sound = egophony)

Bronchophony

1.Patient says '99' in normal voice 2.Normal: muffled 3.Abnormal: clear and loud

Whispered Pectoriloquy

1.Patient whispers '1-2-3' 2.Normal: barely audible 3.Abnormal: clearly heard

Tactile Fremitus (Palpation)

1.Feel chest vibrations while patient speaks = use ulnar OR palmar surface 2.Compare right vs. left symmetrically = should be equal, lesser at bases

INCREASED fremitus

Pneumonia (consolidation/solid)

DECREASED fremitus

Pleural effusion (fluid in pleural space), large AP diameter, or pneumothorax

Symmetric Expansion (Palpation)

1.Hands on back, thumbs at spine → patient breathes → thumbs should spread ~equally

Asymmetric expansion

Suspect pneumothorax or atelectasis on less-moving side

Clear / White (Sputum)

Allergy, viral = normal-ish

Yellow / Green (Sputum)

May be bacterial BUT not always! (46% had no infection in study)

Rust colored (Sputum)

Blood (TB, pneumonia, cancer, capillary rupture from coughing)

Pink & Frothy (Sputum)

Pulmonary edema (heart failure, severe hypertension) = seen when intubating

Yellow/green does NOT automatically mean bacterial infection.

A study showing 46% with yellow/green had NO infection. Don't fall for that question.

Smoking History/Pack Years Formula

Packs per day × number of years = pack years

1 pack/day × 20 years

= 20 pack years (threshold for lung cancer screening)

2 packs/day × 30 years

= 60 pack years (heavy)

0.5 packs/day × 30 years

= 15 pack years

Average American smoker

= 20 pack years

Lung cancer risk increases

Around 15–20 pack years

Smoking History

Ask: 'Do you CURRENTLY smoke?' AND 'Did you EVER smoke?' = many quit on hospital admission

Chronic cough

= 3 months per year for 2 consecutive years

Chronic cough (Common Causes)

1.Post-nasal drip = MOST COMMON 2.Asthma 3.GERD (acid reflux) 4.Bronchitis 5.Bronchiectasis

ATELECTASIS

1.Small collapse of alveoli 2.Cause: immobility, post-op, opioids 3.Sounds: atelectatic crackles (clear with breaths) 4.Fremitus: decreased 5.Treatment: get up, incentive spirometer 10x/hour, reduce over-sedation

PNEUMONIA

1.Full consolidation = fluid, bacteria, WBCs 2.Can develop FROM untreated atelectasis 3.Sounds: increased lung sounds, crackles, rhonchi 4.Fremitus: INCREASED 5.Treatment: antibiotics, positioning, spirometer

Patient got atelectasis in under 12 hours post-surgery because she wasn't moving (over-using PCA).

Her docs stopped the Dilaudid, switched to Motrin, pulled her catheter, and got her walking. Lesson: mobility prevents atelectasis.

Count respiratory rates for a full minute (Key Clinical Pearls)

Never assume 16. A student who counted 32, found pneumonia the doctor missed.

Always listen to the POSTERIOR lungs (Key Clinical Pearls)

Bases are where most problems hide. Doctors often skip the back.

RRT (Rapid Response Team) = Key Clinical Pearls

Call if patient has signs of respiratory failure. Families can call it too.

Incentive spirometer (Key Clinical Pearls)

10 times per hour (or every commercial on TV) to prevent atelectasis.

Stridor (Key Clinical Pearls)

Emergency. Heard from the doorway. Upper airway obstruction.

Pink/frothy sputum (Key Clinical Pearls)

Pulmonary edema. You'll see it when intubating.

Axillary tail of Spence (Breast & Regional Lymphatics Anatomy)

Breast tissue extending into the armpit = must be palpated!

Cooper's ligaments (= suspensory ligaments) = Breast & Regional Lymphatics Anatomy

Hold breast up. When shortened by cancer → DIMPLING

4 Quadrants (Breast & Regional Lymphatics Anatomy)

Upper Outer, Upper Inner, Lower Outer, Lower Inner = Location of any mass is reported by quadrant

Lymph nodes (Breast & Regional Lymphatics Anatomy)

Axillary (central, pectoral, subscapular, lateral) mostly NOT palpable normally

Subjective History Questions

1.Pain = constant or intermittent? 2.Lump = location, how long, changes with cycle? 3.Discharge = bloody? clear? white? Are they breastfeeding? 4.Rash or swelling = one side or both? 5.Trauma = hematoma can feel like a mass for months 6.Last mammogram, self-breast exam routine 7.Axilla: tenderness, lump, rash

Before menopause (When to do breast self exam)

ONE WEEK after menstruation (less swelling, easier to feel)

After menopause (When to do breast self exam)

Once a month, any consistent day

Palpation Technique (Breast Exam)

1.Use 3 fingers (not 1) = spreads pressure, holds tissue together, allows depth 2.Cover ENTIRE breast tissue including up into the axilla (tail of Spence) 3.Any pattern is fine (circles, lines, wedges) = as long as all tissue is covered

Three Levels of Pressure (Breast Exam Palpation Technique)

1.Light = superficial tissue 2.Medium = mid-tissue 3.Firm = near chest wall / ribs

Breast Normal Finding

A firm ridge at the lower curve of the breast is NORMAL = do not mistake it for a lump.

BENIGN (Good sign) = Describing a lump

1.Consistency = Soft 2.Mobility = Moves freely 3.Shape = Smooth, round 4.Edges = Distinct, clear 5.Tenderness = May be tender 6.Skin changes = None

CANCEROUS (Bad sign) = Describing a lump

1.Consistency = Hard 2.Mobility = Fixed / stuck 3.Shape = Irregular 4.Edges = Indistinct, blurry 5.Tenderness = Often non-tender 6.Skin changes = Dimpling, peau d'orange

ABNORMAL FINDINGS = SIGNS OF CANCER

1.Dimpling = Cooper's ligaments shorten due to mass → skin dimples 2.Fixation = breast attached to chest wall (tumor has grown through) 3.Peau d'orange = 'orange peel' skin appearance → edema from lymph blockage 4.Nipple retraction = NEW inward pulling of nipple (if always been that way, may be normal) 5.Nipple deviation = nipple pointing in different direction than usual 6.Lymphedema = arm swelling after lymph node removal

NORMAL lymph node

Not palpable, OR < 1 cm, soft, mobile, non-tender

ABNORMAL lymph node

Enlarged, hard, fixed, non-tender = suspect malignancy

Most common cause of enlarged node

INFECTION (from area drained by that node)

Modifiable (Can Change) = Breast Cancer Risk Factors

1.Alcohol = 'appears on every body system' 2.Overweight / obesity 3.Physical inactivity 4.Not having children 5.Not breastfeeding

Non-Modifiable (Cannot Change) = Breast Cancer Risk Factors

1.Age, Sex (female) 2.Race = Black women more likely to get triple-negative type 3.Dense breast tissue 4.Early menses (before age 12) 5.Late menopause (after age 55) 6.BRCA1 or BRCA2 gene mutation

Hormone therapy after menopause was listed as a risk factor. Is this correct?

It was based on a FLAWED STUDY. Do not mark hormone therapy as a confirmed risk factor.

Ages 40–44 (Mammogram screening schedule = ACS guidelines)

Optional yearly mammogram

Ages 45–54 (Mammogram screening schedule = ACS guidelines)

Yearly mammogram

Ages 55+ (Mammogram screening schedule = ACS guidelines)

Every 1–2 years (but Prof still does yearly)

High risk (Mammogram screening schedule = ACS guidelines)

Yearly mammogram + MRI starting ~age 30

High risk breast cancer

Prior breast cancer, BRCA mutation, first-degree relative with gene mutation

Can implants do standard mammogram

No → use breast MRI (every 6 months if reconstructed)

Gynecomastia (Male Breast)

Enlarged breast tissue in males

Gynecomastia Causes

Adolescent obesity, Aldactone (spironolactone = potassium-sparing diuretic), antipsychotics