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Lungs and Thorax

Health Assessment

Anterior Thoracic Landmarks: Suprasternal Notch, Sternum, Sternal Angle, Costal Angle
Suprasternal Notch: U-shaped depression above sternum between clavicles.
Sternum: the breast bone, manubrium, the body, xiphoid process.
Sternal Angle: (Angle of Louis) articulation of the manubrium and the body of the sternum.
Costal Angle: angle at the xiphoid process.
Posterior Thoracic Landmarks: vertebra prominens, spinous processes, inferior border of scapula, twelfth rib
Vertebra Prominens: the most prominent bony spur protruding at the base of the neck C7-T1
Spinous Processes: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 3-4 coccygeal vertebrae
Inferior Border of Scapula: scapula are located symmetrically at 7th or 8th rib
Twelfth Rib: located midway between the spine and the patient’s side.
Reference Lines: Midsternal line, Midclavicular line, Vertebral line, Scapular line, Anterior axillary line, Midaxillary line, Posterior axillary line
The Thoracic Cavity: Mediastinum, Pleural Cavities, Lung Borders.
Mediastinum: middle section of the thoracic cavity containing the esophagus, trachea, heart, and great vessels.
Pleural Cavities: located on either side of the Mediastinum containing the lungs.
Lung Borders: apex-anterior chest at the highest point base-lower border.
The Lungs: Right and Left Lungs.
Right Lung: shorter than the left because of the underlying liver. Right lung has three lobes.
Left Lung: Narrower than the right because the heart bulges to the left. Left lung has two lobes.
Pleurae: thin and slippery forms an envelope between lungs and chest wall.
Visceral Pleura: lines outside of lungs.
Parietal Pleura: lines inside of the chest wall and diaphragm.
Costodiaphragmatic Recess: the pleurae extend 3 cm below the level of the lungs, if this potential space fills with air, lung expansion is compromised.
Trachea: lies anterior to the esophagus, beginning at the cricoid cartilage in the neck and bifurcates just below the sternal angle into the R & L bronchi. It is about 10-11 cm long.
Bronchi: two main branches leading from the trachea to the lungs.
Functions of Respiration: Supplying oxygen to the body for energy production. Removing carbon dioxide as a waste product of energy reactions. Maintaining homeostasis (acid-base balance).
Control of Respirations: Breathing pattern changes without our awareness in response to cellular demands. This involuntary control is mediated by the respiratory center in the brainstem. Normal stimulus to breathe is an increase of CO2 in the blood.
Changes in the Aging Adult: Thorax less mobile. Respiratory muscle strength declines. Decrease in elastic properties within the lungs. The aging lung is a more rigid structure that is harder to inflate.
Subjective Data: History Questions Dyspnea/Shortness of breath, Wheezes, Cough, Chest pain while breathing, Past history of respiratory infections, Past history of respiratory conditions
Subjective Data: History Questions (cont) Lifestyle/Personal Habits: Smoking history, Environmental exposures, Medications – RX, OTC, herbal, Oxygen use or other breathing treatments
Additional History for the Aging Adult: Have you noticed any SOB or fatigue with your ADL’s? What is your usual amount of activity? How’s your energy level? Are you finding that you tire more easily?
Additional History for Pedi: Subjective Data: Frequent colds? Coughing Wheezing? Smokers in the home? Bottle feeding?
Physical Exam - Objective Information: Thoracic cage, Respirations, & Skin color
Inspect Thoracic Cage: shape and configuration, AP to transverse diameter, neck and trapezius muscles
Inspect Respiration: rate, effort, use of accessory muscles
Inspect Skin Color: Person’s position & Facial expression
Palpation: Feel for lumps, masses, tenderness. Assess for any observed abnormalities.
Confirm Symmetric Expansion: hands placed posterior chest wall with thumbs at T9-T10 level (bottom of the rib cage).
Tactile Fremitus: increased=consolidation ex: pneumonia, decreased=obstruction ex: pneumothorax, emphysema
Percussion - Percuss over lung fields: resonance is what you hear in healthy lung. hyperresonance= too much air & dull=abnormal density.
Estimate Diaphragmatic Excursion: percuss to map out the lower lung border both with inspiration and expiration.
Auscultation: Assess normal Breath sounds. Identify adventitious sounds.
Characteristics of normal breath sounds: Bronchial, Bronchovesicular, Vesicular
Bronchial (Tracheal): Inspiration < Expiration
Bronchovesicular (major bronchi): Inspiration = Expiration
Vesicular (peripheral lung fields): Inspiration > Expiration
Note: any adventitious (added) sounds.
Discontinuous sounds (rales/crackles): may indicate pneumonia, fibrosis, early heart failure, bronchitis.
Fine Crackles: soft, high pitched, brief.
Coarse Crackles: louder, lower pitched, longer.
Listen: in dependent areas, re-eval after cough.
Continuous Sounds: wheezes, rhonchi.
Wheezes: narrowed airways (asthma, COPD) high pitched, shrill.
Rhonchi: secretions in large airways low pitched, snore-like.
If there are any abnormal sounds and it is indicated assess for transmitted voice sounds: suggests consolidation.
Bronchophony: “99”
Whispered Pectoriloquy: whisper “1,2,3”
Egophony: “ee” changes to “ay”
Bronchophony: have patient say 99 while listening with stethoscope over the chest wall. Normal= muffled and indistinct. Abnormal= clear (increased lungdensity/pathology).
Whispered Pectoriloquy: whisper phrase 1,2,3. Normal= muffled and indistinct. Abnormal-clear (increased lung density/pathology).
Egophony: auscultate chest while patient phonates ee-ee-ee.
Normal sound is: ee-ee-ee
Abnormal sound is: aa-aa-aa
Objective Data: Pediatric Round chest cavity in infants.Nose breathers until 3 months old. 30-40 breaths per minute for infants. Infants are belly breathers…diaphragm is main muscle used.
Objective Data: Pediatric (cont) Look for nasal flaring, sternal and intercostal retractions as signs of respiratory distress. Remember: BACK TO SLEEP
Pulse Oximetry: Measures the arterial oxygenation saturation or SpO2.
Pulse Oximetry: (cont) Oxygen saturation refers to the level of oxygen carried by red blood cells through the arteries and delivered to internal organs. While red blood cells travel through the lungs, they are saturated with oxygen.
Pulse Oximetry: (cont) A low saturation level could indicate a respiratory illness or other medical condition. Normal range for healthy person 97%-100%
Created by: mr209368