Ch. 30 Thorax, Lungs, Breasts

Page 1: Introduction

Health Assessment Overview

• Focus: Thorax, Lungs & Breasts

• Presented by: Dr. Brenda Chan

• Class: N266

Page 2: Anatomy and Physiology

Thoracic Structures

• Bony Structures of the Thorax

• Anterior Landmarks

• Posterior Landmarks

• Lateral Anatomical Lines

• Anteroposterior (AP) Diameter

• Lungs

• Lobes, Trachea, Bronchi

• Mediastinum

Page 3: Key Thoracic Landmarks

Anatomical Markers

• Sternal notch

• Angle of Louis

• 2nd Costal Cartilage

• Lung Lobes

• Upper lobes, Middle lobe, Lower lobes

• Anatomical Lines

• Midsternal line, Midclavicular line, Anterior axillary line

• Resources: RnCeys.com, Paul & Barb Bauer, RNs

Page 4: Health History

Presenting Problems

• Cough

• Onset, nature, production (color, timing), pattern, severity

• Shortness of Breath (SOB)

• Onset, pattern, severity, wheezing, dyspnea on exertion (DOE), paroxysmal nocturnal dyspnea (PND)

• Chest Pain

• Exposure to Respiratory Infections

• Influenza, Tuberculosis (TB)

• Review of Systems (ROS)

• Respiratory, cardiac, musculoskeletal, gastrointestinal (GI) systems

• Past Medical History (PMH)

• Tobacco and medication (inhalers, OTC decongestants)

• Use ASPTIM approach

Page 5: Risk Factors for Respiratory Disability

• Gender

• Age

• Family History

• Asthma, Cystic Fibrosis (CF), Tuberculosis (TB)

• Smoking

• Sedentary Lifestyle

• Forced immobilization

• Occupational Exposure

Page 6: Inspection

Key Areas of Focus

• Skin

• Inspect skin and nipples

• Bony Structures

• Assess AP diameter, anterior/posterior deviations

• Respiratory Rate and Pattern

• Normal vs. unusual patterns, accessory muscle use

• Skin Color, Lips, Nailbeds

Page 7: Palpation

Techniques and Findings

• Tracheal Placement

• Anterior “Tug” estimate

• Paraspinous Muscles

• Thoracic Expansion

• Tactile Fremitus

• Assess increased vs. decreased fremitus

• Crepitation

• Subcutaneous emphysema

Page 8: Percussion

Techniques and Types of Tones

• Percussion Tones

• Tympany, hyper-resonance, resonance, dullness, flatness

• Techniques

• Direct vs. indirect techniques

• Diaphragmatic Excursion

• Techniques and sequence

Page 9: Auscultation

Exam Techniques

• Without Stethoscope

• Sounds

• Identify vesicular, bronchovesicular, and bronchial sounds

• Adventitious Sounds

• Crackles, wheezes, pleural friction rub

Page 10: Lung Lobes Overview

Right Lung Lobes

• Right Upper Lobe

• Right Middle Lobe

• Right Lower Lobe

• Left Lung Lobes

• Lung Mapping

• Illustrative details of lobes

Page 11: Breath Sounds

Types of Sounds

• Tracheal Sound

• Bronchovesicular Sounds

• Vesicular Sounds

• Anatomical Areas

• Anterior vs. Posterior assessments

Page 12: Adventitious Sounds

Types of Sounds Described

• Stridor: Upper airway obstruction; sounds over trachea.

• Rales (Crackles)

• Associated with fluids in lungs, smaller airways

• Rhonchi

• Larger airways obstructed by fluids

• Wheezing

• High-velocity airflow through narrowed bronchi

Page 13: Adventitious Sounds Continued

Sound Characteristics

• Crackles: Disruptive air passage due to fluid, mucus, or pus in small airways.

• Rhonchi: Produced by air through obstructed airways with thick secretions or spasms.

• Wheezes: Continuous, high-pitched sound from narrowed airways.

Page 14: Common Abnormalities in Adults

Respiratory Conditions

• Asthma

• Atelectasis

• Pneumothorax

• Bronchitis

• Emphysema

• Pleural Effusion

• Pneumonia

• Lung Cancer

Page 15: Respiratory Diseases Overview

Conditions Described

• Pulmonary Fibrosis: Fibrous tissue in lungs reduces elasticity.

• Pneumonia: Alveoli fill with thick fluid, complicating gas exchange.

• Pulmonary Tuberculosis: Bacteria encapsulated in tubercles, lowering lung elasticity.

• Emphysema: Alveoli destruction reduces gas exchange surface.

• Asthma: Inflammation and constriction of airways from irritants.

• Bronchitis: Infection or irritants cause inflammation and mucus production.

Page 16: Additional Abnormalities

Factors Influencing Respiratory Health

• Extreme Obesity

• Difficulty Swallowing

• Weakened Chest Muscles

• Frequent Respiratory Infections

Page 17: Dyspnea of Rapid Onset - 10 P’s

Causes of Rapid Dyspnea

• Pneumonia

• Pneumothorax

• Pulmonary Constriction/Asthma

• Foreign Body Aspiration

• Pulmonary Embolus

• Pericardial Tamponade

• Heart Failure

• High Altitudes

• Psychogenic Factors

• Poison Exposure

Page 18: Understanding Cardiac Tamponade

Cardiac Complications

• Definition: Fluid build-up in pericardial sac affecting heart function.

• Consequences: Impaired pumping ability due to pressure from fluid accumulation.

Page 19: Rate and Depth of Breathing

Factors Influencing Breathing Patterns

• INCREASED:

  • Acidosis (metabolic), CNS lesions, anxiety, aspirin poisoning, hypoxemia, pain.

• DECREASED:

  • Alkalosis, CNS lesions, myasthenia gravis, narcotic overdose, extreme obesity.

Page 20: Airway Assessment

Signs of Upper Airway Obstruction

• Symptoms:

  • Inspiratory stridor, hoarse cough, nasal flaring, suprasternal retraction.

Page 21: Signs of Severe Obstruction

Advanced Symptoms

• Stridor: Inspiratory and expiratory.

• Barking Cough

• Retractions: Involvement of subcostal and intercostal spaces.

• Cyanosis: Visible even with supplemental oxygen.

Page 22: Sputum Characteristics

Analyzing Sputum

• Viral Infection:

  • Mucoid, blood-streaked (less common).

• Bacterial Infection:

  • Yellow, green, rust (bloody), clear, purulent, or mucoid.

Page 23: Sputum Findings Continued

Sputum Observations

• Chronic Infectious Diseases:

  • Variable, with intermittent blood streaking.

• Carcinoma:

  • Persistent blood streaking.

• Infarction:

  • Clotted blood, large amounts.

• TB Activity:

  • Large amounts of blood.

Page 24: Other Considerations

Patient Assessments

• Oxygen Use:

  • Nasal cannula (NC) vs. mask.

• Suction Patient:

  • Encourage coughing prior to assessment.

• Ventilator/Tracheostomy Management:

• Smoking History Calculation:

  • Pack years = Packs per day X Years smoked.

Page 25: Special Considerations for Elderly

Elderly Patient Focus

• Infection Exposure

  • Frequency of respiratory infections and influenza immunity.

• Weather Effects

• Sedentary Lifestyle & Immobilization

• Risk Factors:

  • Smoke exposure, cough, dyspnea, fatigue, significant weight change, fever.

Page 26: Breast Health History

Key Topics

• Breast Issues to Consider:

  • Discomfort, lumps, nipple discharge.

• PMH:

  • Birth control pills (BCPs), hormonal medications, smoking history.

• Family History (FH):

  • Family history of cancer is significant; 73% of breast cancer patients have no family history.

Page 27: Review of Systems (Breast)

Breast-Specific Review

• Cyclical Changes:

  • Lumps with menstrual cycle.

• Lactation and Breast Self-Exams (BSE)

• Menstrual History

• Obstetric History (OB Hx)

• Dermatologic Issues

Page 28: Signs of Breast Changes

Physical Changes to Note

• Lump/Thickening:

  • Different from surrounding breast tissue.

• Nipple Changes:

  • Inversion or shape change.

• Skin Texture Changes:

  • Dimpling.

• Nipple Discharge:

• Skin Rashes:

• Swelling in Axilla or Collarbone

Page 29: Breast Cancer Risk Factors

Key Risk Indicators

1. Old Age and Obesity

2. Nulliparity

3. Family History of Cancer

4. Duct Papilloma:

• Associated with bleeding.

5. Physical Changes:

• Enlargement, asymmetry, nipple retraction, Paget disease (eczema-like)

Page 30: Anatomy & Physiology of Breasts

Overview of Breast Structure

• Mammary Glands:

  • Paired structures on anterior chest wall.

• Nipple and Areola:

  • Nipple is surrounded by areola; size varies greatly.

• Tissue Density:

  • Variability by age and reproductive history.

Page 31: Breast Tissue Composition

The breast is made up of three types of tissue:

1. Glandular Tissue

• Responsible for milk production.

• Organized into 15-20 lobes, which contain smaller lobules with acini cells (milk-producing cells).

• Lactiferous ducts drain milk from each lobe to the nipple.

2. Fibrous Tissue

• Provides support and structure to the breast.

• Cooper’s ligaments are fibrous bands that help maintain breast shape.

3. Retromammary Fat

• Fatty tissue that surrounds and cushions the breast.

• The amount of fat determines breast size, but does not affect function.

Why Is This Important?

• Knowing the tissue structure helps detect abnormalities (e.g., lumps, tumors, cysts).

• Changes in Cooper’s ligaments may cause dimpling of the skin, which can be a sign of breast cancer.

Page 32: Physical Exam of Breasts

Examination Techniques

• When assessing the breasts, nurses check for size, shape, and skin changes to detect possible abnormalities.

  1. Inspect the Breasts for:

  • Size & Symmetry – Is one breast significantly larger than the other?

  • Contour – Look for swelling, dimpling, or abnormalities in shape.

  • Skin Appearance – Check for redness, rashes, thickening, or visible veins.

  2. Inspect the Nipples for:

  • Size, shape, and direction – Do they point in the same direction?

  • Rashes or ulcerations – Could indicate skin conditions or infection.

  • Discharge – Unusual discharge may suggest infection, hormonal changes, or cancer.

  3. Additional Positions for Breast Inspection:

  • Raise arms above the head – This helps reveal changes in shape or hidden masses.

  • Press hands against hips – Helps check for dimpling or skin retraction, which can indicate underlying disease.

  Why Is This Important?

  • Early detection of breast changes improves outcomes in breast cancer diagnosis.

  • Changes in contour, skin texture, or nipple position may indicate an underlying issue.

Page 33: Breast Palpation

Palpation Techniques

• Palpation (feeling the breast with hands) is done to check for lumps, tenderness, or other abnormalities.

  1. What to Look for During Palpation:

  • Consistency – Is the tissue soft, firm, or lumpy?

  • Tenderness – Is there any pain when pressing on the breast?

  • Nodules (Lumps) – If a lump is found, note:

    • Location – Where is it in the breast?

    • Size & Shape – Is it round, irregular, or fixed?

    • Consistency – Is it hard or soft?

    • Tenderness – Does it hurt when touched?

    • Mobility – Does it move or feel stuck in place?

  Why Is This Important?

  • Most lumps are benign (non-cancerous), but some can indicate serious conditions like breast cancer.

  • Regular breast exams help with early detection and better treatment outcomes.

Page 34: Nipple and Areola Palpation

Special Focus Areas

Palpating the Nipple

• Check for tenderness or masses beneath the nipple.

• Gently compress the areola to see if there is any discharge (note the color, consistency, and amount).

  • Bloody or persistent discharge may indicate a serious condition like infection or cancer.

2. Examining the Male Breast

• Inspect and palpate the nipple and areola for lumps, swelling, or discharge.

• Though rare, men can also develop breast cancer, so any abnormalities should be checked.

3. Checking the Axillary (Underarm) Lymph Nodes

• Palpate the central axillary nodes to feel for swelling, tenderness, or lumps.

• Enlarged lymph nodes may indicate infection or cancer spread.

Why Is This Important?

• Nipple discharge, lumps, or changes in lymph nodes can be early signs of disease.

• Breast cancer can spread to lymph nodes, so checking them is crucial for staging the disease.

Page 35: Abnormal Findings in Breast Exam

Characterizing Abnormalities

• If a mass (lump) is found, it is important to assess specific characteristics to determine if it could be cancerous or benign.

  1. How to Describe a Mass:

  • Location – Where is the lump? (Use a clock-face method, e.g., "2 o’clock position").

  • Size – Measure in centimeters.

  • Shape – Is it round, oval, or irregular?

  • Mobility – Does it move freely, or is it fixed in place?

  • Tenderness – Is it painful when touched?

  • Consistency – Is it soft, firm, or hard?

  • Borders – Are the edges well-defined or unclear?

  • Retractions/Dimpling – Skin pulling inward can suggest cancer.

  2. Malignant (Cancerous) Mass Characteristics:

  • Usually non-tender

  • Hard and irregular in shape

  • Fixed (doesn’t move easily)

  • Poorly defined borders

  • More common in women over 40

  Why Is This Important?

  • Early detection is key – A lump can take 3-8 years to grow before becoming noticeable.

  • Regular breast exams and mammograms help find abnormalities early.

Page 36: Facts on Breast Cancer

Key Statistics

1. Key Facts About Breast Cancer

• Discovery of BRCA1 & BRCA2 genes – These genetic mutations increase breast cancer risk.

• 80% of breast lumps are benign (non-cancerous).

• 1 in 6 women will develop breast cancer in their lifetime.

• 75% of breast cancer cases occur in women over 50.

• The 5-year survival rate for localized breast cancer is over 90%, but it drops to 60% if cancer spreads.

2. Health Promotion & Prevention

• Breast Self-Exams (BSE):

  • Perform monthly to check for lumps or changes.

• Clinical Breast Exams:

  • Done by a healthcare provider regularly.

• Mammograms:

  • Baseline at age 40 (earlier if high risk).

  • Every 1-2 years between 40-50.

  • Annually after 50.

Why Is This Important?

• Early detection improves survival rates.

• Regular screening helps find cancer before symptoms appear.

Page 37: Staging of Breast Cancer: Stage IA

Description

• Tumor: 2 cm or smaller.

• Lymph Nodes: Absence indicated other than small clusters.

Page 38: Staging of Breast Cancer: Stage IIA

Description

• Staging of Breast Cancer: Stage IIADescription:

  • In Stage IIA, the tumor (the lump of cancer) is larger than 2 centimeters but up to 5 centimeters in size. This is about the size of a small egg or a big grape.

  • At this stage, the cancer may have spread to nearby lymph nodes, which are small, bean-shaped structures that help your body fight infections.

  • Specifically, 1 to 3 lymph nodes in the armpit area (axilla) or near the breastbone can be affected by the cancer.

  • This spread to a few lymph nodes shows that the cancer is serious but not as advanced as later stages.

  • Treatments for Stage IIA may include surgery to remove the tumor and affected lymph nodes, chemotherapy (medicine to kill cancer cells), or radiation therapy (using high-energy rays to target cancer).

  • It's important for patients to talk to their doctors about the best treatment options and how to manage the disease effectively.

Page 39: Staging of Breast Cancer: Stage IIB

Description

• Staging of Breast Cancer: Stage IIB

• Description:

  • In Stage IIB, the tumor is larger than 2 centimeters but not bigger than 5 centimeters. This means the tumor is about the size of a grape or a little smaller than a lime.

  • A tumor can also be bigger than 5 centimeters, which is like the size of a large lemon or more.

  • This stage means that cancer has spread to the lymph nodes, which are small, round structures found in places like the armpit (axilla) or near the breastbone.

  • When cancer affects the lymph nodes, it indicates that the cancer is more serious and could grow or spread further.

  • At this stage, doctors will look for ways to treat the cancer effectively, which could involve surgery, chemotherapy (using medicine to kill cancer cells), radiation (using high-energy rays to kill cancer cells), or other treatments.

  • It's important to work closely with healthcare providers to understand the best options for treatment and to monitor how the cancer is responding.

Page 40: Staging of Breast Cancer: Stage IIIA

Description

• Staging of Breast Cancer: Stage IIIA

• Description:

  • In Stage IIIA, the tumor can be any size, which means it can be small or large.

  • This stage of cancer affects the lymph nodes, which are small, bean-shaped structures in your body that help the immune system fight infections.

  • Specifically, cancer has spread to the lymph nodes in the armpit area (called the axilla) or those located near the breastbone.

  • This spreading means that the cancer is more serious compared to earlier stages.

  • Treatment for Stage IIIA may be more complex and could involve a combination of surgery, chemotherapy, radiation, or other therapies.

  • Understanding this stage is important for patients and doctors to plan the best course.

Page 41: Staging of Breast Cancer: Stage IIIB

Description

• Staging of Breast Cancer: Stage IIIBDescription:

  • In Stage IIIB, the breast cancer has spread to the chest wall, which is the part of your body underneath the breasts.

  • This spread can cause swelling and may lead to ulcers, which are open sores on the skin.

  • It means that the cancer is more serious and may need more advanced treatment than earlier stages.

Page 42: Staging of Breast Cancer: Stage IIIC

Description

• taging of Breast Cancer: Stage IIICDescription:

  • In Stage IIIC of breast cancer, the tumor can be any size. This means the tumor can be very small or very big.

  • The important thing about Stage IIIC is that cancer has spread (metastasized) to multiple lymph nodes.

  • These lymph nodes are small structures in the body that help fight infections, and they can be affected if the cancer spreads.

  Affected Areas:

  • In Stage IIIC, cancer may spread to:

    • 10 or more lymph nodes in the armpit area (axilla) or near the collarbone (above or below).

  • Understanding Stage IIIC is important because it affects the treatment options a doctor may suggest. It may require more complex treatments, and the focus may shift to managing the disease and improving the patient's quality of

Page 43: Staging of Breast Cancer: Stage IV

Description

• Description: In Stage IV breast cancer, the tumor may be any size. This means it can be very small or very large. What makes Stage IV special is that the cancer has spread from the breast to other parts of the body. This spreading is known as metastasis.

  Lymph Node Involvement: In Stage IV, the cancer can spread to many lymph nodes. Lymph nodes are small structures in the body that help fight infection. In this stage, the cancer may affect lymph nodes in areas like the armpits or above and below the collarbone.

  Affected Organs: The cancer can also move to important organs, including:

  • Brain: This can cause headaches, confusion, or other neurological symptoms.

  • Lungs: If the cancer spreads to the lungs, it may lead to breathing problems or a persistent cough.

  • Liver: This can affect how the liver works and may cause symptoms like jaundice (yellowing of the skin and eyes) or pain in the upper abdomen.

  • Bone: When the cancer spreads to the bones, it can cause pain or fractures.

  Importance: Understanding Stage IV breast cancer is crucial because treatment options may be more complex, and the focus may change to managing the disease and improving quality of life.

Breast Assessment Summary (Slides 30-36)

1. Breast Anatomy (Slide 30-31)

📌 Example: Think of the breast like an orange:

• Peel (Skin) – Covers and protects.

• Fibrous Tissue (White Pith) – Supports the shape.

• Glandular Tissue (Juicy Segments) – Produces milk.

• Lactiferous Ducts (Straws) – Carry milk to the nipple.

• Cooper’s Ligaments (Thin Strings Inside the Orange) – Keep the breast in place.

2. Breast Inspection (Slide 32)

What to look for:
✅ Size & Shape – One breast is slightly bigger? That’s normal! But sudden changes may not be.
✅ Skin Texture – Any dimples or thickening (like an orange peel) could be a problem.
✅ Nipple Changes – Is one suddenly pulled inward or leaking fluid?

📌 Example: Imagine looking at an apple. If there’s a dent, a color change, or a deep spot, you’d check if it’s bruised. The same applies to breast changes!

3. Breast Palpation (Slide 33-34)

✅ Feel for lumps, tenderness, or unusual textures using the pads of your fingers.
✅ Use a circular motion to cover the whole breast.
✅ Don’t forget to check the underarm (axilla) for swollen lymph nodes.

📌 Example: Think of feeling for a pea under a blanket—it may be small, but you can still find it with gentle pressure.

4. Abnormal Findings (Slide 35)

🚩 Warning signs of a lump that might be cancerous:
❌ Hard & Fixed (Doesn’t move when touched)
❌ Irregular Shape (Not round, but jagged)
❌ Painless (Most cancerous lumps don’t hurt)
❌ Skin Changes (Dimpling, redness, or nipple retraction)

📌 Example: Imagine pressing on a grape (soft & movable = normal cyst) vs. pressing on a raw almond (hard & fixed = concerning lump).

5. Breast Cancer Facts & Prevention (Slide 36)

✅ 80% of lumps are benign (not cancer).
✅ Mammograms detect cancer early – Start screening at 40 (earlier if high risk).
✅ Self-exams help detect changes early!

📌 Example: Think of checking your car’s tires—if you check them monthly, you’ll catch small issues before they turn into a flat tire. The same goes for breast exams—early detection saves lives!

Final Takeaway: Why Does This Matter?

👩‍⚕ As a nurse, you’ll be helping patients detect and prevent breast cancer early.
💡 **Knowing what’s normal vs. abnormal helps you educate