Thorax and Lung Assessment Flashcards

The Thorax

• Thoracic Cage
  • Sternum, clavicle, scapulae, 12 vertebrae, 12 pairs of ribs
  • Three main compartments: airways, blood vessels, interstitinum
  • Mediastinum: heart, great vessels, lymph nodes, nerves, fat
• Additional structures
  • Thymus, trachea, esophagus
• Thoracic muscles
  • Intercostals/(interspaces), transverse thoracic, subcostal, others
• Blood Supply
  • Arterial: Thoracic aorta, subclavian, brachial, axillary
  • Venous: various veins
  • Pulmonary arteries, pulmonary veins (understanding which carries oxygenated vs. deoxygenated blood).

Anterior Thorax

• Key anatomical landmarks and structures:
  • Suprasternal (jugular) notch
  • Clavicle
  • Scapula
  • Ribs: True (1-7), False (8-12), Floating (11, 12)
  • Costal margin
  • Sternum: Manubrium, Sternal angle, Jugular notch, Body, Xiphisternal junction, Xiphoid process
  • Costal cartilages
  • Transverse process
  • Superior thoracic aperture (thoracic inlet)
  • Vertebrae T1, T11, T12, L1

Posterior Thorax

• Key anatomical landmarks and structures:
  • Clavicle
  • Vertebra prominens of C7
  • Spinous process of T3
  • Scapula
  • Inferior angle of scapula

Reference Lines

• Anterior Thorax
  • Midsternal line
  • Midclavicular lines
  • Anterior axillary lines
• Posterior Thorax
  • Vertebral line
  • Midscapular lines
• Axillary Region
  • Anterior axillary line
  • Posterior axillary lines
  • Midaxillary lines
• Other Areas
  • Supraclavicular
  • Suprascapular
  • Subscapular

Lobes of the Lungs

• Apex of lung
• Horizontal fissure
• Oblique fissure
• RLL (Right Lower Lobe)
• LUL (Left Upper Lobe)
• RUL (Right Upper Lobe)
• Spinous process of T3
• RML (Right Middle Lobe)
• LLL (Left Lower Lobe)
• Inspiratory descent

Anterior Lung Lobes & Right Lateral

• Horizontal fissure
• 4th rib
• RUL (Right Upper Lobe)
• LUL (Left Upper Lobe)
• 5th rib
• Fight oblique fissure
• midaxillary line
• RML (Right Middle Lobe)
• RLL (Right Lower Lobe)
• Right oblique fissure
• LLL (Left Lower Lobe)
• Spinous process of T3
• AUL
• 4th rib oblique
• 5th rib at midaxilary
• Horizontal fissure
• oblique fissure
• RLL (Right Lower Lobe)
• 6th rib at midclavicular
• Right 6th rib midclavicular line

Anterior Lung Lobes & Left Lateral

• 4th rib
• Horizontal fissure
• RUL (Right Upper Lobe)
• LUL (Left Upper Lobe)
• 5th rib midaxillary line
• RML (Right Middle Lobe)
• RLL (Right Lower Lobe)
• Right oblique fissure
• LLL (Left Lower Lobe)
• 6th rib midclavicular line
• Left oblique fissure
• Left oblique fissure
• LLL (Left Lower Lobe)
• midclavicular
• Spinous process of T3
• Left

Posterior Lung Lobes & Right Lateral

• Oblique fissure
• LUE RUL
• T3
• LLL (Left Lower Lobe)
• RLL (Right Lower Lobe)
• Right oblique fissura
• Spinous process of T3
• RUL (Right Upper Lobe)
• 4th rib
• T10
• 5th rib at midaxitary
• RML (Right Middle Lobe)
• Horizontal fissuro
• 100
• RLL (Right Lower Lobe)
• T12
• 6th rib at midclavicular
• Right lateral view

Posterior Lung Lobes & Left Lateral

• Oblique fissure
• LUE RUL
• T3
• LLL (Left Lower Lobe)
• RLL (Right Lower Lobe)
• Left obilque fissure
• LUL (Left Upper Lobe)
• T10
• 6th rib at midclavicular
• LLL (Left Lower Lobe)
• T12
• ne
• Spinous process of T3
• Left latoral view

Fluid Pools

• Fluid pools down via gravity, leading to diminished lung sounds at the bases.

The Respiratory Tract

• Components:
  • Pharynx (Nasopharynx, Oropharynx, Laryngeal pharynx)
  • Nasal cavity
  • Frontal sinus
  • Sphenoidal sinus
  • Epiglottis
  • Larynx and vocal cords
  • Esophagus
  • Trachea
  • Mediastinum
  • Right and left lungs
  • Right and left bronchus
  • Terminal bronchiole
  • Alveolar duct
  • Alveoli
  • Capillaries
  • Thoracic vertebra
  • Wall of thorax
  • Diaphragm
  • Sternum
  • Parietal pleura
  • Pleural space
  • Visceral pleura

Mechanics of Respiration

• Automatic process initiated by pons and medulla (compromised with brain injury).
• Main trigger: ↑ CO_2 levels.
• Other triggers: ↓ O_2 levels, ↑ acidity, certain medications, anxiety, brain injury.
• Inspiration
  • Diaphragm contracts and flattens, pulls lungs down.
  • Thorax and lungs elongate, ↑ vertical diameter.
  • External intercostal muscles open ribs, lifts sternum.
  • ↑ anteroposterior diameter of thorax (left and right).
• Expiration
  • Diaphragm, internal intercostal muscles, abdominal muscles relax, pressure in lungs > atmosphere.
  • Air pushed out, chest and abdomen return to relaxed position.
• Effective breathing depends on sufficient nerve innervation, muscle excursion, strength.

Question 1

• The nurse caring for a patient diagnosed with a 2nd rib fracture should know the location of the sternal angle is also called what?
  • A. Apex
  • B. Angle of Louis
  • C. Base
  • D. 2nd ICS
• Answer: B. Angle of Louis
  • Rationale: The sternal angle (Angle of Louis or sternomanubrial angle) is found approximately 4-5 cm (1.5 inches) down from the suprasternal notch. It's a bony ridge that joins the manubrium to the sternum and is continuous with the 2nd rib

Older Adults

• Respiratory strength declines.
• Lungs lose elasticity.
• Decreased flexibility in rib cartilage.
• Bone density decreases.
• Decreased AP ratio.
• Diminished respiratory volume.
• Risk for atelectasis, reduced air exchange, hypoxia, hypercapnia, acidosis; reduced gag and cough reflexes; impaired cough reflex, weaker muscles, decreased inspiratory capacity.

COPD

• COPD is a general term for “chronic obstructive pulmonary disease” from multiple conditions, including emphysema, chronic bronchitis, etc.
• Results in irritation, swelling, and impaired gas exchange.
• Emphysema causes CO_2 retention leads to a barrel chest (seen on a general survey).

ABC Assessment

• Airway
  • Throat swelling
  • Anaphylactic shock
  • Foreign object
  • Trauma (motor vehicle accident, etc.)
  • Epiglottitis (infection)
  • Facial, mouth, or tongue swelling
• Breathing
  • Shortness of breath (SOB)
  • Fast or slow respiratory rate
  • Low PaO_2 %
  • Labored breathing / increased work of breathing
  • Poor lung sounds (crackles, wheezing, etc.)
  • Nasal flaring
  • Abdominal breathing
  • Intercostal retractions
  • Poor coloring (cyanosis)
  • Chest rise and fall and is it symmetrical
  • Do their symptoms match their diagnosis?
• Circulation
  • High or low blood pressure
  • Fast or slow heart rate
  • Poor coloring (pallor, cyanosis, gray)
  • Diminished or absent pulses (any extremity)
  • Capillary refill >3 seconds (any extremity)
  • Cool, clammy skin
  • Abnormal or irregular heart rhythm

Priority Urgent Assessment

• Must accurately prioritize assessments and interventions.
• ABC: airway, breathing, circulation.
• Acute shortness of breath
  • Assess airway, respiratory and heart rate, BP, oxygen saturation
  • Auscultate lungs for possible abnormalities
  • Administer oxygen or bronchodilator as ordered
  • Elevate head of bed
• Short of breath to Anxiety increases to Becomes anxious to Increased work of breathing
  • Remain with client, encourage relaxation techniques.
  • Can lead to ↓ oxygen levels leading to ↑ dyspnea, cyanosis, confusion, LOC.
  • May need to alert emergency response team.
• May be unable to fully cooperate with assessment
  • Auscultate lungs (and when turning client*)
  • Prioritize subjective data à how are they saying they feel? What do you ask them?
  • Ask only pertinent questions related to the situation
  • Cluster interventions
  • Assess when the client is more relaxed
  • Take advantage of positioning changes and listen to posterior lungs during the “turn q2,” bed bath, etc.

Subjective Data Collection

• Assessment of risk factors
  • Past medical history
  • Lifestyle and personal habits
  • Occupational history
  • Environmental exposures
  • Medications
  • Family history
• Common Symptoms
  • Chest pain
  • Dyspnea
  • Orthopnea and paroxysmal nocturnal dyspnea (PND)
  • Cough
  • Sputum (color, amount, consistency, when)
  • Wheezing
  • Functional abilities
  • Older adults
  • Cultural considerations
• Teaching and Health Promotion
  • Smoking cessation
  • Prevention of occupational exposure
  • Prevention of asthma
  • Immunizations

Basic and Advanced Techniques

• Inspection of client (general survey).
• Inspection of chest.
• Palpation of chest.
• Chest expansion.
• Tactile fremitus.
• Percussion of chest.
• Auscultation of lungs.
• Diaphragmatic excursion.
• Auscultation of voice sounds.

Comprehensive Physical Examination

• General appearance à do they look like they’re having difficulty breathing?
• Posterior chest
  • Inspection (See Table 16.4)
  • Palpation
    • Tactile fremitus
  • Percussion
  • Auscultation (See Tables 16.1; 16.2)
  • See Figures 16.11, 16.12, 16.13, 16.14, 16.15
• Anterior chest
  • Inspection (See Table 16.4)
  • Palpation
  • Percussion
  • Auscultation (See Tables 16.1; 16.2)
  • See Figures 16.16, 16.17

Making Clinical Decisions

• Analyze laboratory and diagnostic testing (Lab data; radiography; pulmonary function tests).
• Prioritize hypotheses and take action.
• Analyzing changing findings: progress note.
• Interprofessional collaboration with respiratory therapy.
• Plan the care.
• Evaluating outcomes.
• Did we just ADPIE??
• See Tables 16.3; 16.7

Question 2

• Acute shortness of breath is a medical emergency. Immediate assessments are necessary. What is the priority assessment the nurse would make with a client who has acute shortness of breath?
  • A. Administer inhalers à intervention
  • B. Administer oxygen à intervention
  • C. Raise the head of the bed à intervention
  • D. Auscultate lungs à assessment ADPIE
• Answer: D. Auscultate lungs
  • Rationale: Auscultate lungs for objective information before intervention.
• ADPIE
  • Assessment: You’ve assessed difficulty breathing, so you auscultate lungs.
  • Diagnose: SOB (you may not know why, but you know they have SOB).
  • Plan: Make the patient breathe easier so plan what you’re going to do (within seconds).
  • Intervention: “Do the things” à oxygen, inhaler/neb treatment, sit them up.
  • Evaluation: Did those things work? Do you need to do anything else?

Assessing the Patient

• By Looking
  • General survey à What does the patient look like? Breathing well? Struggling?
    • Respiratory rate
    • Shallow? Are they working hard? Pursed lip breathing?
    • Accessory muscle use?
  • Is the diaphragm working hard? (diaphragmatic breathing)
  • Do you see intercostal retractions?
  • Are they struggling sitting up? Leaning forward in the tripod position?
  • Has their coloring changed? Cyanosis to mucous membranes? Skin?
• By Listening
  • Evaluate the presence and quality of normal breath sounds.
  • Instruct the person to breathe through the mouth, a little bit deeper than usual.
  • Use the flat diaphragm of the stethoscope and hold it firmly on the person’s bare chest wall; listen to at least one full respiration in each location.
  • Side-to-side comparison is most important.
  • Do not confuse background noise with lung sounds.
    • Examiner’s breathing on stethoscope tubing
    • Stethoscope tubing bumping together
    • Patient shivering
    • Patient’s hairy chest; the movement of hairs under the stethoscope sounds like crackles (rales); minimize this by pressing harder or by wetting the hair with a damp cloth.
    • Rustling of paper gown
  • As you listen, think…
    • “What am I hearing over this spot?”
    • “What should I expect to be hearing?” Know your anatomy!!

Auscultation Pattern

• Anterior
• Posterior

Types of Breath Sounds

• You should expect to hear three types of normal breath sounds in an adult or older child:
  • Bronchial (bronchi)
  • Bronchovesicular (bronchioles)
  • Vesicular (alveoli)

Adventitious Lung Sounds

• Crackles
  • High-pitched, popping sound caused by air being forced through an airway. Heard during inspiration.
  • Fine crackles sound like hair rubbing together.
  • Coarse crackles are a low gurgling sound.
  • Disorders: Pneumonia, pulmonary edema, ARDS, heart failure
• Wheeze
  • High-pitched continuous musical sound
  • May occur during inspiration and/or expiration
  • Airway obstruction/narrowing/constriction
  • Disorders: Asthma
• Rhonchi
  • Deep, low-pitched rumbling sound (sounds like a snore)
  • Caused by respiratory secretions
  • Clears with cough
  • Disorders: COPD, Bronchitis
• Pleural Friction Rub
  • Low, deep, harsh grating sound
  • Caused by friction of inflamed and roughened pleural surfaces against one another during movement of the chest wall
  • Disorders: Pleuritis
• Stridor
  • High-pitched, inspiratory wheezing
  • Obstruction of upper airway
  • Disorders: Croup, Epiglottitis, Foreign body aspiration

Assessing by Palpating

• Tactile fremitus
  • Tactile refers to the hands
  • Fremitus is a palpable vibration
  • Sounds are transmitted through bronchi and lung tissue to the chest wall where you feel them as vibrations.
  • Use either the palmar base (ball) of fingers or the ulnar edge of one hand, and touch the person’s chest while he or she repeats the words “ninety-nine” or “blue moon.”
  • These are resonant phrases that generate strong vibrations.
• Density = tightly compacted/thick
  • Conditions that increase the density of lung tissue (fluid, pneumonia) make a better conducting medium for sound vibrations and increase tactile fremitus
  • Uniformly dense areas conduct sound better than porous (air-filled) tissue (lungs during respiration, pneumothorax etc.).
    • Increased density = better/deeper sound = increased fremitus
    • Decreased density = more difficult to hear = decreased fremitus

Palpating Tactile Fremitus

• Areas and sequence of palpating tactile fremitus
• Assessing tactile fremitus

Assessing PaO_2 %

• A healthy person with no lung disease and no anemia normally has an SpO_2 above 92% (COPD 88-92%).
• Conditions that affect the reading include:
  • Temperature of fingers (cool/cold lowers it) – common!!
  • Nail polish/artificial nails
  • Anemia (low hemoglobin level)
  • Acid-base imbalances
  • Ventilatory status (hypo/hyperventilation)
  • Poor oxygen tube connection (or not turned on)
• If the number seems “off,” switch fingers and try again. Pulse ox readings are frequently inaccurate the first time. Check your patient