Thoracic Assessment Overview Anatomy & Physiology History IPPA Developmental Considerations Nursing Diagnoses Teaching Opportunities Oro/naso pharynx and respiratory tree respiratory system extends from nares to diaphragm Anatomy & Physiology 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 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 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
