Respiratory Quiz -Health Assessment Lecture

The thorax or thoracic cavity

commonly called the chest, is a closed cavity of the body, containing structures needed for respiration.

• The thorax is surrounded by ribs and muscles and extends from the base of the neck to the diaphragm.

Mediastinum:

Contains the heart, trachea, esophagus, and major blood vessels of the body.

Right and left pleural cavity:

Contains a lung

external respiration

The exchange of oxygen and carbon dioxide at the alveoli level of the lung

internal respiration

Gases are transported from the lungs via the blood to the cells of the body. As the gases move across the systemic capillaries, exchange of oxygen and carbon dioxide occurs at the cellular level

The upper respiratory tract includes:

– Nose

– Mouth

– Sinuses

– Pharynx

– Larynx

– Proximal portion of the trachea

The lower respiratory tract includes:

The distal portion of the trachea

– Bronchi

– Lungs

– Pleural membranes, the muscles of respiration, and

the mediastinum complete the lower respiratory tract.

The trachea is located

in the mediastinum, and descends

from the larynx in the neck to the main bronchi at the

distal point.

The trachea is a

flexible and mobile structure, bifurcating

anteriorly at about the sternal angle and posteriorly at

about vertebrae T3 to T5.

The trachea contains

16 to 20 rings of hyaline cartilage

that help to maintain the shape of the trachea and

prevent its collapse during inspiration and expiration.

The carina

Just above the point of bifurcation, the last tracheal

cartilage, known as the carina, is expanded. The carina

separates the openings of the two main bronchi.

The trachea, like other structures of the respiratory tract,

is lined with

a mucus-producing membrane that traps

dust, bacteria, and other foreign bodies.

Anteriorly, the trachea bifurcates at about the level of the

sternal angle, forming the right and left main bronchi.

• The main bronchus enters each lung at the hilus (medial

depression) and maintains an oblique position in the

mediastinum

The right main bronchus

is shorter, wider, and more

vertical than the left main bronchus; therefore, aspirated

objects are more likely to enter the right lung

The bronchi and the many branches

continue to warm

and moisten air as it moves along the respiratory tract to

the alveoli in the lungs

The left lung

has two lobes (upper and lower) and tends

to be longer and narrower than the right lung

The apex and base of the lungs

The apex of each lung is slightly superior to the inner

third of the clavicle, and the base of each lung is at the

level of the diaphragm

The pleura

is a thin, double-layered, serous membrane

that lines each pleural cavity.A pleural fluid is produced by these membranes that acts

as a lubricant, allowing the lung to glide during the

respiratory cycle of inspiration and expiration

The surface tension created by the fluid and the negative

pressure between the membranes

helps keep the lungs expanded.

• As the negative pressure changes, one is able to move air into and out of the lungs

The mediastinum

is the middle section of the thoracic cavity and is surrounded by the right and left pleural cavities.

• The mediastinum contains the heart, the trachea, the esophagus, the proximal portion of the right and left main bronchi, and the great vessels of the body.

Respiratory process

is a general term that encompasses the structures and activities of respiration.

• The respiratory process is dependent on the muscles of the thorax, the structures of the thoracic cage, and the ability of air to move in and out of the body

Respiratory Muscles

The muscles of the thoracic cage (internal and external intercostals) and the diaphragm assist in the breathing process.

• The accessory muscles of the neck (trapezius, scalenes,

and sternocleidomastoid), abdomen (rectus), and chest

(pectorals) assist the respiratory cycle as necessary.

• Accessory muscles play a major role in the respiratory

cycle during distress and pathology.

The thoracic cage

consists of the bones, cartilage, and

muscles of the thorax.

• The sternum (breastbone) is located in the anterior

midline of the thorax.

• The 12 pairs of ribs circle the body, form the lateral

aspects of the thorax, and are attached to the vertebrae

and sternum.

For air to enter the body,

the respiratory muscles contract, the chest expands, alveolar pressure decreases, and the negative intrapleural pressure increases. These combined activities allow air to enter the expanded lungs

During expiration

the passive phase of the process, the

activities reverse themselves: the lungs recoil, and air

leaves the body.

eupnea

The regular, even depth, rhythmic pattern of inspiration and expiration describes eupnea

dyspnea

A change in this pattern, producing shortness of breath or difficulty in breathing

The balance of gas exchange between oxygen and

carbon dioxide is influenced by

the nervous system, the

cardiovascular system, and the musculoskeletal system.

The respiratory system has a major role in helping the

body to maintain

acid–base balance.

• The concentration of carbon dioxide in the blood directly influences the blood concentration of carbonic acid and hydrogen ions.

• The respiratory system responds to the needs of the body to either retain or excrete carbon dioxide

The first bony landmark to be considered is the

sternum, commonly called the breastbone. It is a flat, elongated bone located in the midline of the anterior thoracic cage and consists of three parts: the manubrium, the body, and the xiphoid process.

The depression at the superior border

is called the suprasternal notch or jugular notch. This becomes a

primary landmark used to identify and locate other landmarks.

angle of Louis

As the clavicles and sternum meet, a horizontal ridge is formed,

referred to as the sternal angle or angle of Louis. The

second rib and the second intercostal space are at this

level of the sternum

costal angle.

The xyphoid process and the inferior borders of the

seventh ribs form a triangle

Bilaterally, the first seven ribs

attach to the sternum and are called true ribs

Ribs 8, 9, and 10 attach to

cartilage of the superior rib, and ribs 11 and 12 are free floating and do not articulate anteriorly

The seventh cervical vertebra (C7)

is most visible at the base of the neck.

• This prominent C7 vertebra is used to count and locate other spinous processes. When two spinous processes are equally prominent, they are C7 and T1

The midclavicular line

begins at the midpoint of the clavicle and descends to the level of the 12th rib. The

nipples of the breast are slightly lateral to this line. This line subdivides the right and left thoracic cage into two equal parts

The anterior axillary line (AAL)

is another line drawn parallel to the sternal line. It begins at the anterior fold of

the axillae and descends along the anterior lateral aspect of the thoracic cage to the 12th rib

landmarks on the posterior aspect of the thoracic cage

The vertebral line, the right and left scapular lines, and the right and left posterior axillary lines are used as landmarks

The vertebral or midspinous line

commences at C7 and descends through the spinous process of each thoracic vertebra. It divides the vertebral column in half, forming the posterior right and left thoracic cage

The posterior axillary line (PAL)

is parallel to the vertebral line. It starts at the posterior axillary fold and descends along the lateral aspect of the thoracic cage to the 12th rib

Three imaginary lines identify the lateral aspect of the

thoracic cage

he imaginary lines include the anterior axillary, posterior axillary, and midaxillary lines.

• The midaxillary line is parallel to the anterior and posterior axillary lines. This line descends from the middle of the axillae to the level of the 12th rib. It forms the frontal plane, dividing the thorax into the anterior and posterior portions

The trachea bifurcates

forming the right and left main bronchi. Anteriorly, this occurs at the level of the angle of Louis or sternal angle. Posteriorly, this bifurcation occurs between the third and fifth thoracic vertebrae

The apices of the lung extend

2 cm to 4 cm (0.78–1.57

in.) above the inner third of the clavicle anteriorly.

• Posteriorly, the apices of the lungs are located superior to

the scapula between the vertebral line and midscapular

line.

The base of the lung has three reference points.

The lung is cone-shaped, and the base of the lung is located at the sixth intercostal space at the midclavicular line.

• At the midaxillary line, the base of the lung is at the eighth intercostal space.

• At the scapular line on the posterior thorax, the base of the lung is at the 10th intercostal space.

This triangle, also known as

The clavicle, the scapula, and the lateral base of the neck form a triangle at the superior aspect of the thorax.

Kronig’s area is used for palpation of muscles and lymph nodes and for percussion and auscultation of the apex and the lungs

Patients with allergies or asthma should be encouraged

to explore

the possibility of allergens in their work or

home environment.

Secondhand smoke at home or work environment

can

also lead to respiratory distress

Exposure to large amounts of dust

in a granary or mine

may lead to the development of silicosis.

Workers in some industries may be exposed to

substances that are hazardous to their respiratory health,

such as caustic fumes, fungi, asbestos, coal tar, nickel,

silver, textile fibers, chromate, and vinyl chlorides.

• Coal miners are susceptible to pneumoconiosis, a form of

black lung disease.

People working in an office building may need to be

concerned with

air conditioners and forced hot-air heat.

The ducts of the cooling and heating systems can carry

airborne organisms, increasing the risk for respiratory

infections.

Newborns have a

high respiratory rate

Pediatric patients have

respirations that are abdominal in

nature.

In pregnant patients,

as the uterus enlarges, increasing pressure in the abdominal cavity limits diaphragmatic excursion and can result in more rapid and shallow respirations.

Stress, anxiety, pain, and fatigue may

exacerbate

respiratory problems

Patients experiencing acute or chronic respiratory

problems

will have a physiologic alteration with gas exchange.

• This alteration may limit or restrict the individual’s ability to independently perform the activities of daily living and to participate in activities, exercise, and sports.

Limitations that affect a patient’s ability to independently

function on a daily basis contribute to

social isolation,

changes role activities, lower self-esteem, and increases

the dependency factor with support systems

Certain drugs, such as bronchodilators

are used in the treatment of respiratory conditions and may cause the hands to tremble visibly. This is not to be confused with nervousness

Parents of young children who have experienced severe

asthmatic attacks in the past

may be extremely anxious

any time the child develops a cold, seasonal allergy, or

any other respiratory problem

The geographical location of an individual’s environment

will also influence respiratory health. Factors to be considered are temperature, moisture, altitude, and pollution.

• Factors within the home and social environment will influence respiratory health. Forced hot-air heat is very drying to the membranes of the body.

The focused interview for the respiratory system is

concerned with data related to the structures and

functions of that system.

• Subjective data related to respiratory status are gathered

during the focused interview.

• Be prepared to observe the patient and listen for cues

related to the function of the respiratory system.

What to consider when asking questions

age, gender, race, culture, environment, health

practices, past and concurrent problems, and therapies

when framing questions and using techniques to elicit

information

If a patient is experiencing dyspnea, cyanosis, difficulty

with speech, and the anxiety that accompanies any of

these problems

attention must focus on relief of

symptoms and restoration of oxygenation

Focused interview questions include:

– General Questions

– Questions related to illness or infection

– Questions related to symptoms, pain, and behaviors

– Questions related to age

Health records, the results of laboratory tests, and x-rays

are

important secondary sources to be reviewed and

included in the data-gathering process.

Equipment includes:

– Examination gown and drape

– Examination gloves

– Examination light

– Stethoscope

– Tissues

– Face mask for nurse, if indicated

Normal breath sounds include:

– Eupnea

– Eupnea with a sigh

Asthma

A chronic hyperreactive condition resulting in bronchospasm, mucosal edema, and increased mucus secretion. This condition usually occurs in response to inhaled irritants or allergens.

• Subjective findings:

– Dyspnea (shortness of breath)

– Anxiety

– Chest pain

Asthma

• Objective findings:

– Wheezing

– Diminished breath sounds

– Absent breath sounds (with severe asthma)

– Increased respiratory rate

– Increased use of accessory muscles

– Decreased oxygen saturation

Atelectasis

A collapse or impaired inflation of one or more areas of

the lung (NHLBI, 2013).

• During atelectasis, the alveoli or an entire lung may

collapse from airway obstruction, such as a mucous plug,

lack of surfactant, or a compressed chest wall.

Atelectasis

• Subjective findings:

– Absence of symptoms, if only a small portion of the lung is affected.

– Dyspnea, if significant portions of the lung are affected.

Atelectasis

• Objective findings:

– Decreased or absent breath sounds over the affected

area

– Increased respiratory rate

– Decreased oxygen saturation

– Cyanosis (if severe)

Chronic Bronchitis

Chronic inflammation of the tracheobronchial tree leads to increased mucus production and blocked airways.

• A productive cough is present.

Chronic Bronchitis

• Subjective findings:

– Dyspnea

– Fatigue (related to increased work of breathing)

Chronic Bronchitis

• Objective findings:

– Chronic productive cough

– Increased respiratory rate

– Use of accessory muscles

– Wheezes

– Rhonchi

Emphysema

A condition in which chronic inflammation of the lungs leads to destruction of alveoli and decreased elasticity of the lungs. As a result, air is trapped and lungs hyperinflate.

Subjective findings of emphysema

– Dyspnea, especially upon exertion

– Air hunger (related to hypoxemia, CO2 retention, and air trapping).

Emphysema

• Objective findings:

– Barrel chest and decreased chest expansion

– Cyanosis

– Hypercarbia (increased blood concentration of CO2)

– Clubbing of fingers

– Use of accessory muscles

– Diminished breath sounds

Lobar Pneumonia

An infection that causes fluid, bacteria, and cellular debris to fill the alveoli.

• Subjective findings:

– Dyspnea

– Fatigue

– Chills

Lobar Pneumonia

• Objective findings:

– Increased respiratory rate

– Fever

– Productive cough

– Decreased oxygen saturation

– Bronchial breath sounds and crackles

Pleural Effusion

A fluid accumulation in the pleural space. Pleural effusion may be asymptomatic, or it could present with common signs and symptoms.

• Subjective findings:

– Dyspnea

– Occasional sharp, nonradiating chest pain

Pleural Effusion

• Objective findings:

– Cough

– Diminished or absent breath sounds

– Decreased or absent tactile fremitus

– No voice transmission

Pneumothorax

A condition in which air moves into the pleural space and causes partial or complete collapse of the lung. Pneumothorax can be spontaneous, traumatic, or tension.

Subjective findings:

– Dyspnea

– Sharp chest pain with inspiration

– Anxiety

Pneumothorax

• Objective findings:

– Increased respiratory rate

– Decreased oxygen saturation

– Diminished or absent breath sounds over the affected area

– Decreased chest wall expansion on the affected side

– Tracheal deviation to the unaffected side

Left Heart Failure

Heart failure occurs when the heart is unable to effectively pump oxygen-rich blood.

• Heart failure may affect one or both sides of the heart. Most often, both the left and right sides of the heart are affected (NHLBI, 2014).

• Left heart failure typically produces respiratory symptoms as blood that is not ejected by the left ventricle backs up into the lungs.

Right heart failure typically produces

peripheral edema,

as well as other manifestations

with left heart failure

increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema of the bronchial mucosa.

left heart failure Subjective findings:

– Dyspnea, especially upon exertion

– Orthopnea (shortness of breath that happens when you lie flat and goes away when you sit or stand up)

– Anxiety

Left Heart Failure

• Objective findings:

– Increased respiratory rate

– Decreased oxygen saturation

– Pulmonary congestion with auscultation of wheezes or crackles in lung bases

– Pallor

– Decreased chest wall expansion on the affected side

– Tracheal deviation to the unaffected side

During development, the fetus receives

its nutrients and oxygen from its mother. The lungs are nonfunctional, and oxygen is carried in blood from the placenta to the right side of the heart.

Compared with adults, children have much

smaller, more compliant airways until early adolescence.

children are more prone to

airway collapse and blockage. Oxygen needs are higher in small children because their increased metabolic rates result in higher oxygen consumption.

The foramen ovale

The majority of this blood passes through the foramen ovale to the left side of the heart, then into the aorta to enter the systemic circulation. The foramen ovale is a passageway for blood between the right and left atria.

ductus arteriosus

The rest of the blood passes through the pulmonary artery and ductus arteriosus and enters the aorta (Figure 26.7). The ductus arteriosus is an opening between the pulmonary artery and the descending aorta.

The risk of respiratory failure is greatest in

infants, toddlers, and preschoolers, but children of all ages experience respiratory failure much more quickly than adults.

The foramen ovale closes shortly after

after birth because of increased pulmonary vascular return and decreased pressure in the right side of the heart.

The ductus arteriosus closes within

24 to 48 hours in response to multiple physiologic events, including decreased pulmonary resistance and decreased pressure in the right atrium versus increased pressure in the left atrium.

what happens if the foramen ovulae and the ductus arteriosus remain patent

Murmurs may be auscultated if these openings remain patent. However, if a ventricular septal defect is present, the murmur it causes may not be auscultated until week 4 to week 6 after birth.

As individuals age

The lungs lose their elasticity, the skeletal muscles begin to weaken, and bones lose their density. As a result, it becomes more difficult for the older adult to expand the thoracic cage and take a deep breath.

The appearance of a barrel chest and calcification of cartilage contribute to

the decrease in the circumference of the chest (thoracic excursion). Thus, the older adult inhales and exhales smaller amounts of air.