Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Thorax and Lungs
Health Assessment
| Question | Answer |
|---|---|
| thorax | extends from base of neck superiorly the level the diaphragm inferiorly |
| thoracic cage | - outer structure of the thorax= structure and support contains sternum, 12 pairs ribs,12 thoracic vertebrae, muscles, and cartilage |
| thoracic cavity | - contains respiratory components lungs, distal portion of trachea, bronchi=lower respiratory system |
| sternum | lies in the center of the chest anteriorly, manubrium, body, xiphoid process |
| Sternal Angle (Angle of Louis) | -Bony ridge joining manubrium to the body of the sternum -1 inch below sternal notch corresponding with 2nd ribs |
| costal angle | formed by right and left costal margins where they meet at the xiphoid process - if >90 degrees=. barrel chest |
| ribs. 1-7 | true ribs attach directly to the sternum by costal cartilage |
| Ribs 8-10 | attach to sternum thru costal cartilage of rib 7 |
| ribs 11-12 | floating ribs |
| which side can you hear lung sounds better on posteriorly? | right side |
| vertebral line | A line running vertically down through the spinous processes of the spine |
| scapular line | A vertical line from the inferior angle of scapula |
| vertical axis of thorax | must count ribs and interspaces, ICS named by rib above |
| horizontal axis of thorax | around circumference of chest. must know anterior, posterior, and lateral landmarks (imaginary lines) |
| mediastinum | middle section of thoracic cavity containing esophagus, bronchi, trachea, heart, and great vessels |
| Pleural cavity contains | right pleural cavity: R lung with 3 lobes left pleural cavity: left lung with 2 lobes pleura: visceral, parietal - lines the thoracic cavity, trachea, and bronchial tree |
| respiratory process | Diaphragm descends, creating negative pressure in thorax, air enters mouth & nose to post nasopharynx & pharynx > larynx > trachea> R & L main bronchi > bronchioles > alveoli > 02 diffuses through capillary > C02 diffuses from capillary to alveoli |
| lobes of lungs | superior more anterior, inferior more posterior R middle lobe must be assessed from anterior and center lateral surfaces alone(cannot do this posteriorly) |
| functions the respiratory system | provide oxygen, remove carbon dioxide, acid-base balance, temp control |
| stimulus for breathing | CO2 levels, Hypoxemia (low blood oxygen): hypoxic drive |
| muscles | - diaphragm and intercostals used during normal inspiration - accessory muscles used during increased respiratory effort: scalenes, sternomastoid, trapezius |
| expiration is a ___ process | passive |
| as air rushes in, the diaphragm pushes organs... | down and forward |
| Subjective Data Collection | chief complaint, COLDSPA, cough, GI symptoms, weight loss, night sweats, fever, clubbing, edema, dspnea, CHF, anxiety, COPD, etc. |
| dyspnea | difficulty breathing |
| causes of dyspnea | - asthma, pulmonary COPD, pneumonia, pneumothorax, pulmonary embolism, CHF, CHD, MI, anxiety gradual onset: COPD sudden onset: infections, asthma exacerbation, PE, MI |
| orthopnea | difficulty breathing while supine, associated with heart failure |
| paroxysmal nocturnal dyspnea | sudden awakening from sleeping with shortness of breath, associated with heart failure |
| sleep apnea | breathing cessation during sleep, snoring/gasping sounds, causes fatigue, irritability, depression, memory loss leads to high BP, heart disease, stroke, accidents |
| chest pain | - emergency because risk of cardiac ischemia |
| cough in early morning | chronic bronchial inflammation or smoking |
| Cough in the late evening | irritant exposure during the day |
| cough during the night | postnasal drip or sinusitis |
| continuous cough | acute infection |
| White sputum indicates? | cold, viral infection, bronchitis |
| Green sputum indicates | bacterial infection |
| Brown/black sputum indicates | blood (more serious) |
| rust colored sputum indicates | TB, pneumococcal pneumonia |
| Pink frothy sputum indicates | pulmonary edema |
| objective data general approach | - move from top to bottom, compare side to side, visualize underlying structures |
| general inspection | look for nasal flaring, pursed lip breathing, color of skin, color/shape of nails |
| nasal flaring could be a sign of | hypoxia- labored breathing |
| normal chest AP to lateral ratio | 1:2 ratio |
| Barrel chest AP/lateral ratio | 1:1 ratio |
| precuts excavatum | funnel chest, sunken sternum inherited but can be surgically repaired |
| pectus carinatum | pigeon chest, extra cartilage making chest go forward more common in males with vit D deficiency |
| tripod position | An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward seen in COPD pts |
| angle of ribs | 45 degrees <45 degrees = barrel chest |
| normal chest configuration | AP<transverse |
| barrel chest configuration | AP >/= transverse |
| Normal spinal alignment | 3 curves: cervical, thoracic, lumbar |
| scoliosis | abnormal lateral curvature of the spine, usually during a growth spurt |
| kyphosis | hunchback, more common in women after osteoporosis |
| lordosis | swayback, increased lumbar curvature |
| palpating tenderness | use fingers, start over apex of left lung moving side-to-side and downward/out to cover all lung portions |
| crepitus | a crackling sensation(like hairs rubbing) occurring when air passes through fluid |
| fremitus | vibrations of air in bronchial tubes, use ulnar edge while pt says 99 on both sides to check chest expansion aka subcutaneous emphysema |
| checking chest expansion | place hands with thumbs at T9-T10, pressing together. As client takes a deep breath, thumbs should move 5-10cm apart |
| resonance | low-pitched, normal over the lungs |
| tympany | drum-like, normal over abdomen |
| dullness | fluid or solid, normal over heart and liver |
| dullness in lungs from | fluid or solid in lungs: pneumonia, pleural effusion, tumor |
| hyper resonance in lungs from | emphysema, pneumothorax, asthma |
| tympany in lungs from | pneumothorax |
| Percuss for diaphragmatic excursion | normal should be 3-5cm; can be 7-8cm in well-conditioned clients; measures contraction of the diaphragm Ask pt to exhale and hold it, percuss until sound changes to dull (solid organ), mark spot |
| percuss for diaphragm excursion continued | Ask patient to inhale and hold it, repeating percussion and marking this second spot then calculate distance between two ** will be higher on right d/t liver** |
| Bronchiovesicular breath sounds | medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration = expiration |
| vesicular breath sounds | Normal breath sounds made by air moving in and out of the alveoli. |
| normal respiratory rate | 12-20 breaths per minute |
| rhythm can be | regular or irregular |
| bradypnea | <10 for adults |
| tachypnea | >24 for adults |
| cheyne strokes | periods of apnea and hyperapnea (heart failure, drug OD, brain damage) |
| Kussmaul respirations | increased rate and depth (metabolic acidosis) |
| adventitious breath sounds | Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles. if you hear this, have pt cough then listen again |
| vesicular-diminished | heard more with elderly (normal break sounds but less) |
| crackles(rales) | - fine-like fire burning coarse-like rolling strands of hair between fingers next to ear |
| rhonchi | sonorous wheeze-snoring |
| wheezes | sibilant wheeze-musical |
| stridor | can hear without stethoscope |
| pleural friction rub | walking through snow |
| Bronchophony | - with clear lungs "99" should sound slightly muffled with fluid or mass becomes more clear |
| Egophony | - with clear lungs should remain eee eee sounds like aye or a with fluid/mass |
| whispered pectoriloquy | (whisper 1-2-3) normal sounds faint, muffled vs abn clear and distinct |
| anterior chest expansion | thumbs along costal margins and pointing toward xiphoid |
| breast tissue, heart and liver sound: | dull |
| muscles and bones sound | flat |
| stomach sounds | tympanic |
| atelctasis | collapsed lung |
| pleural effusion | fluid surrounding lung, sounds dull |
| pneumothorax | air between lungs and chest wall, hyperresonance |
| hemothorax | blood in thoracic cavity |
| pulmonary embolus | clot in lungs, chest pain, dyspnea, restlessness, tachypnea, hypoxia, crackles/wheezes |
| tuberculosis | bacteria spread via droplet, night sweats are very characteristic |
| asthma | chronic inflammation and narrowed airways, wheezes is the main characteristic >30 min = go to hospital resonance when percussing |
| pneumonia | infection inflames alveoli(fluid or pus), coughing and spirometer help prevent this |
| bronchitis | increased mucous in airways (inflammation) cough for more than 3 months elevated hemoglobin, overweight, cyanotic |
| emphysema (COPD) | permanently enlarged air sacs, no elastin, tripod position, easily fatigued |
| older adult considerations | dyspnea, pain at costochondreal junction of ribs=fracture, coughing ability decreases, hypnosis is common, deep breathing difficult, sternum/ribs more prominent |
| The leading cause of death in the United States and Europe is | lung cancer |
| which population does lung cancer tend to affect more? | men more than women, specifically African American men |
| risk factors of lung cancer | smoking, genetic predisposition, exposure to toxins, workplace pollutants, poor diet |
| respiratory symptoms that could have non-respiratory etiology: | cough (CHF, side effects of ace-inhibitors), chest pain (angina, musculoskeletal pain), kussmual respirations (diabetes), and apnea (drug overdose) |
Created by:
AV25
Popular Nursing sets