Health Assessment Week 4: Respiratory, breast, & axilla

right lung

has 3 lobes

• right upper lobe

• right middle lobe

• right lower lobe

left lung

has 2 lobes

• left upper lobe

• left lower lobe

anterior reference lines

• midsternal line (center of chest)

• midclavicular line (dropping from midpoint of clavicle)

• anterior axillary line

posterior reference lines

• vertebral line (spine)

• scapular line

lateral reference lines

• anterior axillary

• midaxillary

• posterior axillary lines

key landmarks

• sternal angle (angle of louis)

• costal angle (normally <90 degrees)

ventilation

is the flow of air in and out of the alveoli

diffusion

is the exchange of oxygen and CO2 between the alveoli and RBCs in the bloodstream

perfusion

is the exchange of oxygen and CO2 between those RBCs and the body’s tissue

main function of respiratory system

is the gas exchange, provides oxygen to the body cells and removes CO2 from the body

upper respiratory components

1. nose

2. mouth

3. pharynx

4. larynx

5. trachea

function is to warm, humidify, and filter the air we breathe

lower repiratory components

1. bronchi

2. bronchioles

3. alveolar ducts

4. alveoli

function is gas exchange, alveoli are the functional units for gas exchange

parietal pleura

linees chest cavity

visceral pleura

encloses the lung

pleural cavity

the space between two layers of pleura

• cavity can have build up of air, blood, or fluid in that cavity (which compress the lungs and makes the lungs at risk for collapse)

blood flow in and out of lungs

deoxygenated blood from the body goes to the right atrium through the pulmonary artery and then to the right ventricle and then to the lungs where it becomes oxygenated blood, then it is returned to the left atrium

• blood coming into the right ventricle and it passes through the alveoli and the passage is where diffusion takes place

diffusion cycle

• blood coming into the right ventricle and it passes through the alveoli and the passage is where diffusion takes place

• oxygen is diffused from the alveoli into the capillaries and then CO2 moves the opposite direction back into alveoli for us to breath out CO2

• then remaining oxygenated blood returns to the left atrium

mechanics of respiration

• supply oxygen to the body

• remove carbon dioxide from maintain acid base balance

• maintain heat exchange

• hypercapnia stimulates body to take a breath

• Hypoxemia is secondary trigger to take a breath

how breathing works

diaphragm contracts and moves downward increasing the chest space and decreasing the pressure in lungs for air to move into lungs = inhalation (negative pressure breathing)

diaphragm relaxes and moves back up, pushing the air out during normal breath = exhalation (passive pressure breathing)

dyspnea

shortness of breath

objective assessment sequence

1. inspection

2. palpation

3. percussion

4. auscultation

inspection (what you see)

look at…

1. neurological / level of consciousness

2. position and breathing effort

3. skin and nails

4. thoracic configuration

5. respirations

neurological / level of consciousness

early signs of hypoxia (low oxygen intake) or hypercapnia (high CO2) presents as restless and irritability = progression to somnolence and drowsiness

hypercapnia

is too much CO2 in the body

• too much CO2 in the body tells the body to take a breath and exhale the CO2 out

position and breath effort

if patient assumes tripod position (leaning forward supported by arms to aid expiration) or uses pursed lipped breathing = look for increased work of breathing and accessory muscle use (intercostals or rectus abdominis)

skin and nails

inspect for cyanosis, pallor, delayed capillary refill or clubbing of nail beds (associated with chronic hypoxia)

cyanosis

bluish / grayish discoloration

pallor

paleness

thoracic configuration

normal anterior - posterior (AP) : transverse diameter ratio is 1:2 or (0.7), an AP:T ration approaching 1:1 is known as barrel chest = occurs with chronic lung hyperinflation

respirations

labored, unceasing work of breathing (WOB), uneven breathing, accessory muscle use

palpation (what you feel)

• symmetric chest expansion

• tactile fremitus

• palpate chest for lumps, masses, tenderness

symmetric chest expansion

place thumbs @ the chest wall level, thumbs should move outwards symmetrically during deep inhalation

tactile fremitus

palpate the chest wall while the patients repeats a phrase (“ninety nine”) to feel for vocal resonance vibrations, which should be equal bilaterally

• decreased vibration

• increased vibration

decreased vibrations

vibrations are blocked or prevented from reaching nurse’s hands

• = obstruction due to pleural effusion (fluid around the lungs), pneumothorax (air around the lungs), emphysema (too much airrr and destruction of lung tissue)

increased ventilation

• vibrations travel better through something solid

= consolidation of tissue ie. pneumonia (normally air filled lung becomes filled with inflammatory fluid / cells making it more solid)

percussion (what you tap)

percuss systematically in intercostal spaces (never over bone or ribs) and compare side to side

• resonance

• hyper resonance

• dullness

resonance

clear, hollow sound hardcover normal, healthy lung tissue

hyper resonance

booming, lower pitched sound indicating an abnormal excess of air (ex. pneumothorax)

dullness

a thud like sound heard over dense tissue or fluid accumulation (ex. pneumonia consolidation or pleural effusion)

auscultation (what you listen to)

auscultate lung fields using diaphragm of the stethoscope directly on skin, moving side to side in a systematic ladder / zig zag pattern (listening to the sounds made by air moving through lungs)

expected sounds:

1. bronchial

2. broncho vesicular

3. vesicular

bronchial

loud, high pitched, hear expiration longer / louder than inspiration (heard over trachea)

broncho vesicular

moderate sound, hear inspiration = expiration equally, (heard over areas where large bronchi are located)

vesicular

low, soft pitched sounds, hear inspiration louder than expiration, (heard over most of the lungs)

normal voice transmission

soft, muffled and indistinct; you can hear sound through stethoscope but cannot distinguish exactly what is being said (increased lung density or fluid consolidation, like lobar pneumonia, enhances sound transmission, making spoken words sound loud and clear)

broncophony

ask the patient to saying “ninety-nine”, normally muffled: abnormal becomes clear and distinct over consolidated areas

egophony

ask the patient to say “ee-ee-ee”, normally heard as “ee”": abnormal finding turns into an “A” sound over consolidated tissues

whispered pectoriloquy

ask patient to whisper “1-2-3”, normally heard faint or inaudible: abnormal yields clear, distinct whispered words through stethoscope

adventitious breath sounds (abnormal)

1. crackles: discontinuous, high pitched popping sounds, created when air pops open fluid filled or collapsed alveoli from fluid in the alveoli (like pneumonia, heart failure0

2. wheezes: continuous, high pitched, musical sounds from narrowed airways, air squeezed through narrowed or constricted airways (like asthma)

3. rhonchi: continuous low pitched snoring or rumbling sounds caused by mucus or secretions in the airways (clears or changes after coughing)

4. stridor - continuous, very high pitched, loud crowing or barking heard without stethoscope, usually indicating upper airway obstruction and represents medical emergency

adventitious lung sounds (discontinuous)

1. fine crackles

2. coarse crackles

3. pleural friction rub

fine crackles

• high pitched, short cracking or popping

• during inspiration

• not clear by coughing

• due to air entering deflated airways and popping them open

coarse crackles

• loud, low pitched bubbling or gurgling

• start in inspiration, may extend to expiration

• may improve with suctioning or coughing

• due to air moving through secretions or fluid

pleural friction rub

• superficial sound, coarse, low pitched, rubbing

• due to pleural inflammation causing tissues to rub together during inspiration

adventitious lung sounds (continuous)

1. wheeze

2. rhonchi

3. stridor

wheeze

• high pitched, musical squeaking

• usually on expiration, can be inspiration

• due to air moving through narrowed airways

rhonchi

• low pitched wheeze, snoring sound

• heard throughout cycle, may clear somewhat with coughing

• due to airflow obstruction, often secondary to secretions

stridor

• high pitched, inspiratory sound louder in neck than in chest

• narrowing of upper airway due to inflammation or foreign body

peak flow meter (spirometry)

Measures forced expiratory volume to evaluate airway constriction and monitor asthma management at home

6 minute walk test

Evaluates functional capacity and mobility in chronic lung disease; goal distance is >300 meters without severe desaturation

chest x ray

Radiographic imaging used to visualize lung fields, infiltrates, pleural effusions, or pneumothorax

scoliosis

sideways/side-to-side curvature of the spine.

Instead of the spine being relatively straight when viewed from behind, it curves to one side

pectus excavatum

the breastbone (sternum) is pushed inward.

The chest looks sunken in, especially around the sternum.

pectus carinatum

the breastbone sticks outward

The chest has a more protruding/rounded appearance.

kyphosis

an exaggerated forward curve of the upper spine.

It causes the upper back to appear rounded or hunched.

(hunchback appearance)

respiratory patterns (normal adult)

• rate: 10-20 breaths per minute

• depth 500-800 mL

• pattern: even, regular

• ration of HR:P = 4:1

respiratory patterns

1. tachypnea

2. hyperventilation

3. bradypnea

4. hypoventilation

5. cheyne-stokes

6. biot respirations

tachypnea

• Rapid, shallow breathing

• Rate >24 breaths per minute

• Can be a normal response

• Can be respiratory insufficiency, pneumonia, alkalosis, CNS

hyperventilation

• Rapid, deep breathing

• Can be extreme exertion, fear, anxiety, CNS

• Blows off CO2 can lead to respiratory alkalosis

bradypnea

• Slow breathing, normal depth

• Rate < 10 breaths per minute

• May be drug induced, increased intracranial pressure, diabetic coma

hypoventilation

• Irregular, shallow breathing

• Can be caused by overdose of narcotics or anesthetics

• May be a/w prolonged bed rest, pain

• leads to CO2 retention (respiratory acidosis)

cheyenne stokes

• Abnormal respiratory cycle with waxing and waning respirations

• Causes; heart failure, meningitis, drug overdose, increased ICP

• Can be normal in infants & older adults during sleep

• Abnormal in adults while awake

A cycle of breathing that gradually waxes (increases) and wanes (decreases) in depth, followed by a period of apnea

biot respirations

• Similar but with irregular pattern

• 3-4 normal respirations then period of apnea

• Trauma, brain abscess, heat stroke, meningitis, encephalititis

An irregular pattern consisting of 3 to 4 normal breaths followed by a sudden period of apnea

expected finding for normal respiratory condition

• Inspection: AP:T diameter 1:2, relaxed posture, RR 10-20, regular even respirations, no cyanosis or pallor, SpO2 >95% on RA

• Palpation: symmetric chest expansion, tactile fremitus present and equal bilaterally, no lumps, masses, or tenderness

• Percussion: resonance throughout lung fields

• Auscultation: clear lung sounds throughout

Common respiratory conditions

1. atelectasis

2. pleural effusion

3. heart failure

4. pneumothorax

5. asthma

6. tuberculosis

7. lobar pneumonia

8. acute bronchitis

9. chronic bronchitis

10. emphysema

11. lung cancer

atelectasis

Collapse of individual alveoli or an entire lung segment, commonly seen postoperatively due to shallow breathing or airway obstruction

• inspection - cough, may note slightly elevated RR, mild cyanosis, AP:T diameter WNL, SpO2 may be slightly decreased

• palpation - Decreased chest expansion and decreased or absent tactile fremitus on the affected side

• percussion - Dullness over the collapsed lung tissue, remainder of lung fields resonant or may be hyper-resonant

• auscultation - Decreased or absent breath sounds over the area; fine crackles may be present

pleural effusion

Accumulation of excess fluid (serous, purulent, or blood) in the interpleural space

• inspection - Dyspnea, tachypnea, and dry cough, decreased SpO2, cyanosis

• palpation - Decreased or absent tactile fremitus and chest expansion on the affected side

• percussion - dull over affected area

• auscultation: crackers over affected area

heart failure

Left-sided heart pump failure causes increased blood pressure in pulmonary capillaries, backing up fluid into alveoli (lungs)

• subjective - dyspnea on exertion (DOE), edema, cough

• inspection - tachypnea, increased WOB, orthopnea, PND, nocturia, dependent edema, pallor; severe may have pink, frothy sputum

• palpatation - skin moist, clammy, tactile fremitus WNL

• percussion - resonance throughout

• auscultation - crackles especially at bases, may note extra heart sounds

pneumothorax

Free air in pleural space, destroying negative pressure and causing partial or complete lung collapse

• inspection - unequal chest expansion, if severe may have tachypnea, cyanosis, decreased SpO2, anxiety, tracheal deviation to unaffected side, tachycardia, hypotension

• palpation - Decreased or absent tactile fremitus and chest expansion on the affected side

• percussion - Hyper-resonance on the affected side

• auscultation - Decreased or completely absent breath sounds on the affected side

asthma

Allergic hypersensitivity causing bronchospasm, airway inflammation, and mucosal edema

• inspection - Tachypnea, acute shortness of breath, prolonged expiration, and accessory muscle use

• palpation - decreased tactile fremitus

• percussion - resonant

• auscultation - Bilateral high-pitched wheezing, predominantly during expiration

silent chest

air can’t get in or out , obstruction is bad

tuberculosis

Prolonged infectious process secondary to tubercle bacilli

• subjective - Initially asymptomatic but may be noted on CXR, progresses with weight loss, fatigue, weakness, low grade fever, night sweats

• inspection - cough nonproductive progresses to purulent yellow-green blood-tinged, dyspnea, orthopnea

• palpatation - chest expansion equal

• percussion - resonates, dull over areas of effusion

• auscultation - crackles that persist even after coughing

orthopena

shortness of breath when lying down

lobar pneumonia

Infection causes alveoli to be edematous and porous and become inflamed and filled with fluid, exudate, and blood cells (consolidation)

• subjective - fever, cough, pleuritic chest pain, chills, SOB, fatigue, malaise

• inspection - Tachypnea, increased work of breathing, fever, chills, and pleuritic chest pain

• palpation - Increased tactile fremitus over the consolidated lobe (dense tissue transmits sound waves better) and decreased chest expansion on the affected side

• percussion - dull over the infected area

• auscultation - fine to medium crackles

acute bronchitis

Infection of trachea and larger bronchi, usually viral

• subjective - cough lasting up to 3 weeks, may have fever, sore throat, fatigue

• inspection - productive or nonproductive cough, AP:T diameter WNL, no increased WOB

• palpation - no pain, tactile fremitus WNL, equal chest expansion

• percussion - resonant

• auscultation - clear and equal bilaterally

chronic bronchitis

Type of COPD – proliferation of mucus in airways (barrel chest, clubbing, increased air in lungs)

• subjective - SOB, recurrent productive cough

• inspection: hacking rasping cough with thick mucoid sputum, dyspnea, fatigue, decreased SpO2, finger clubbing

• palpation - tactiel fremitus normal

• percussion - may be hyper resonant

• auscultation - may note crackles, prolonged expiration, wheeze especially during exacerbation

emphysema

Type of COPD – destruction of pulmonary connective tissue (barrel chest)

• subjective - SOB worse with activity, chest tightness,cough, history of cigarette smoking

• inspection - (AP:Transverse ratio approaching 1:1), tripod positioning, accessory muscle use, and prolonged expiration, decreased SpO2

• palpation - Decreased tactile fremitus and decreased chest expansion bilaterally

• percussion - hyper resonant

• auscultation - decreased breath sounds with prolonged expiration

lung cancer

different types

• Subjective: fatigue, nausea/vomiting, persistent cough, SOB, poorly localized chest pain; may be asymptomatic

• Inspection: weight loss, clubbing, hoarseness, anemia, hemoptysis

• Palpation: WNL

• Percussion: resonant, may note dullness if large tumor

• Auscultation: may note wheezing, decreased lung sounds