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Chest Examination Overview

Discussion in 'Pulmonology' started by Dr.Scorpiowoman, Jan 6, 2017.

  1. Dr.Scorpiowoman

    Dr.Scorpiowoman Golden Member

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    Thoracic Assessment Overview

    • Anatomy & Physiology
    • History
    • IPPA
    • Developmental Considerations
    • Nursing Diagnoses
    • Teaching Opportunities

    [​IMG]

    Oro/naso pharynx and respiratory tree
    respiratory system extends from nares to diaphragm

    Anatomy & Physiology

    92836f3daff8763420b53dce167f3f20.jpg

    Thoracic cavity
    • two distinct pleural cavities
    • separated by mediastinum
    • Pleural cavities lined by serous membranes
      • parietal pleura
      • visceral pleura
    • parietal pleura lines chest wall and diaphragm
    • visceral pleura lines the lungs
    • potential space between, small amount of lubricating fluid
    Lungs

    • R has 3 lobes
    • L has 2 lobes
    Topography

    • 2nd rib articulates with sternum at the Angle of Louis
    • Suprasternal notch
    • Costal Angle
    • Midsternal line
    • Midclavicular line
    • Anterior Axillary line
    Note:
    Intercostal space - named for rib above

    Lung Borders

    • anterior thorax
      • apices extend 2-4 cm ABOVE clavicle
    • posterior thorax
      • apices extend to T1
    • lower borders
      • T 10 on exhalation
      • T12 on deep inspiration
    Physiology of respiration

    • Specifically ventilation ("breathing")
    • inspiration/expiration
      • inspiration- air from atmosphere ® lungs
      • expiration - outflow, passive
      • accomplished by movement of
        • diaphragm
        • muscles - intercostal and neck
        • change in intrathoracic pressure
    • Inspiration accomplished by movement of
      • diaphragm
      • muscles
      • change in intrathoracic pressure
      • diaphragm moves down, flattens
      • intercostal and neck muscles expand
      • diameter and length of thoracic cavity
      • pressure in lungs ¯ below atmospheric
      • air rushes in
    Breathing

    Exhalation
    • nearly opposite
    • passive event
    • diaphragm relaxes
    • chest wall and lungs recoil (elastic)
    • air is expelled
    Pulmonary pressures

    Intrapulmonic (within lungs)
    Intrapleural (around lungs)

    • Boyles law - volume of gas varies inversely with P
    • intrapleural pressure ALWAYS NEGATIVE
      (unless chest cavity open)
    • essential - creates suction
      holds visceral and parietal pleural tog.
    Health History

    • Any risk factors for respiratory disease
    • smoking
      • pack years ppd X # years
      • exposure to smoke
      • history of attempts to quit, methods, results
    • sedentary lifestyle, immobilization
    • age
    • environmental exposure
      • Dust, chemicals, asbestos, air pollution
    • obesity
    • family history
    Present health status
    • URI
    • Allergies
    • Recent screening or diagnostic assessments, last CXR
    • Medications
      • Rx or OTC
    • Use of aerosols or inhalants for any purpose
    • Exercise tolerance
    How soon do vital signs return to NL after exercise

    HPI - Cough
    • Type
      • dry, moist, wet, productive, hoarse, hacking, barking, whooping
    • Onset
    • Duration
    • Pattern
      • activities, time of day, weather
    • Severity
      • effect on ADLs
    • Wheezing
    • Associated symptoms
    • Treatment and effectiveness
    HPI - sputum
    • amount
    • color
    • presence of blood (hemoptysis)
    • odor
    • consistency
    • pattern of production
    HPI - SOB
    • Onset - sudden or gradual
    • Frequency- intermittent or persistent
    • Pattern- when/where condition occurs
      • relationship to exercise
      • time of day
      • eating
    • Wheezing
    • Severity- effect on activity
    • COPD
    • Response to treatment
    Other terms for SOB
    • orthopnea
      • "2 pillow"
    • paroxysmal nocturnal dyspnea - PND
    Past Health History
    • Respiratory infections or diseases (URI)
    • Trauma
    • Surgery
    • Chronic conditions of other systems
    Family Health History

    • Tuberculosis
    • Emphysema
    • Lung Cancer
    • Allergies
    • Asthma
    Other considerations

    • Employment
    • place
    • exposure
    • Current or past residence/travel
    • Hobbies
    Thoracic Assessment

    • Privacy
    • Warm
    • Well lit
    Assessment

    Inspection
    • Skin
      • color and nutritional state
      • lips - color
      • nail beds - color and shape
    • posture
    Thoracic contour
    • shape, symmetry
    • developmental:
    Pigeon chest

    Funnel chest

    Spinal Deformities

    Kyphosis

    facafe3632170441131ff852883f55ff.jpg
      • AP to Lateral diameter
        • till age 6 - 1:1 (equal)
        • 1:2 in normal adult
        • barrel chest - 1:1 in adult
          • presence of chronic pulmonary disease
    • Ribs and interspaces
      • retraction of interspaces indicative of obstruction
      • bulging during exhalation result of air outflow obstruction: tumor, aneurysm, cardiac enlargement
      • slope of ribs, costal angle
    • Respiratory Pattern
      • Rate
      • Rhythm
      • Depth
      • Effort
      • Respiratory movement

    • Rate
      • adult NL: 12 - 20 resting
      • tachypnea = > 20
      • bradypnea= <10
    Rhythm


    Depth: shallow, deep
    • Hyperventilation
    deep and rapid
    20 anxiety
    drug OD
    CNS disease
    acid/base imbalance

    • Hypoventilation
    20 post op pain
    CNS drugs
    neuro impairment
    obstruction

      • Effort/Quality
      • unlabored
      • labored- dyspnea, orthopnea
      • shallow
      • grunting
      Respiratory movement
      • thoracic or abdominal
        • Men & children - abdominal breathers
        • Women- thoracic
    Normal rate, rhythm, quality termed eupnea

    • rhythmic
    • effortless
    • quiet
    • symmetrical
    • Also inspect for
      • cyanosis of
        skin
        MM
        lips, earlobes, nail beds
        soles, palms
      • flaring of nares
      • use of accessory muscles
        • supraclavicular retraction
      • cough
    Palpation

    assess for lesions
    thoracic expansion
    tactile fremitus
    tracheal position

    Thoracic Expansion
    • Posteriorly- level of 10th rib
    • Thumbs should separate 3 - 5 cm
    • Feel during quiet I & E
    • Palpate during deep inspiration
    • Should be symmetrical
    • If not - ? Fx ribs
    • atelectasis (lung collapse)
    Tactile Fremitus
    • palpable vibrations of chest wall over lung fields from speech or sounds
    • Use palmar or ulnar surface
    • Palpate vocal sounds
    • Systematically palpate side to side in same area
    • Normal, increased or decreased
    Locations for feeling fremitus

    4615b40d1ce7b15e57285acd33d76b8a.jpg

    What doesincreased or decreased tactile fremitus mean ?

    • Tactile Fremitus Increased- conditions that increase density of thoracic tissue
      • consolidation of pneumonia
      • some lung tumor
    • Tactile Fremitus Decreased - obstruction of transmission of vibrations-
    • pleural effusion
    • pleural thickening (fibrosis)
    • pnemothorax
    • bronchial obstruction
    • COPD/emphysema
    Percussioncheck underlying area for
    • air
    • fluid
    • solid
    Percussion sounds -
    flat
    dull - @ heart, liver
    resonant - NL
    hyperresonant - COPD, hyperinflation
    tympany

    Why would sounds be dull ?

    • Diaphragmatic excursion
    • done when breathing is shallow
    • when suspect something is limiting diaphragmatic movement
    • percuss to mark level of diaphragm at full exhalation, then full inhalation
    • should be 3 -6 cm difference
    Auscultation
    • How is respiratory sx working?
    • What lung areas are not working?
    • Are secretions, fluid, an obstruction blocking air passages?
    • Hold stethoscope firmly but not tightly over ICS
    • Use diaphragm or bell ??
    • Ask pt to breathe normal/deeply with mouth open (Tell pt to tell you if dizzy, lightheaded)
    • Listen for entire cycle inhale/exhale
    • Tune out heart sounds
    • Systematic
    Don't confuse sounds over chest hair with breath sounds

    Auscultate
    • Normal breath sounds

    • Adventitious breath sounds

    • Voice sounds (vocal resonance) (if abnormalities are suspected)
    Normal breath sounds

    Note

    • Pitch

    • Intensity

    • Quality

    • Duration
    Vesicular-

    heard over most of lung

    • I>E

    • low pitch

    • soft intensity


    Bronchovesicular-over bronchi

    • I=E
    • moderate pitch and intensity, breezy
    Bronchial/Tracheal
    • I<E
    • high pitched, loud, blowing
    Documenting NL breath sounds:

    Vesicular breath sounds audible all lung fields bilaterally.

    Adventitious Breath Sounds

    • Abnormal sounds imposed on top of normal
    • Crackles
      • due to air passing thru moisture in airway
      • usually heard R and L lung bases
      • best heard during inspiration
        • fine (in small airways, alveoli)
        • medium (in bronchioles)
        • coarse (larger airway, "gurgle", thick secretions, coughing may affect)

    • Rhonchi and wheezes
    • continuous sounds produced by movement of air thru narrowed areas in larger airways (tracheobronchial tree)
    • narrowed 20
      fluid, secretions
      COPD

      mass
    • Predominate in exhalation

    • wheeze
      high pitched
      suggests COPD or bronchitis
    • rhonchi
      lower pitched
      whistle, rumble, snore
      suggests secretions in large airways
    Clearing of crackles, wheezes or rhonchi by coughing suggests that they are caused by secretions

    • Pleural Friction Rubs
    Caused by inflamed visceral and parietal pleura rubbing together

    • Creaking, grating, leather-like quality
    • Can be heard over lungs (pleurisy)
    also heart (pericardial friction rub) (usually heard over anterolateral chest)

    • Very painful
    • not cleared by coughing
    Documenting variation from NL breath sounds:

    Fine crackles R and L lung bases bilaterally.

    Voice sounds

    • Vocal Resonance
      • Advanced technique
      • » Tactile fremitus but auscultated
      • Client says or whispers "99",
    NL sounds muffled

    • Abnormal if increased 20 consolidation (pneumonia)
    (air-filled lung has become airless)

    • THINK! If vocal resonance is increased
    Tactile fremitus will be �?
    Percussion sound will be � ?
    Breath sounds - may hear...?

    Difference between tactile fremitus and vocal resonance

    Tactile fremitus- sound vibration of spoken or whispered voice through lung fields on palpation

    Vocal resonance- sound vibration of spoken or whispered voice through lung fields on auscultation

    Source
     

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    Last edited: Jan 26, 2019

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