PN 158 Unit 10 Assessment of the Thorax and Lungs

PN 158 Unit 10: Assessment of the Thorax and Lungs ©2016 Keyano College Specific Learning Outcomes 1. Define terms related to assessment of the thorax and lungs. 2. Identify the major landmarks of the chest. 3. Describe the normal breath sounds according to location and characteristic sound. 4. Describe the examination (including rationale for exam) performed to assess the thorax and lungs, the normal range of findings, obvious deviations from normal and action to take when variations from normal are found. 5. Complete an assessment of the thorax and lungs using appropriate techniques. 6. Appropriately document and report the findings of an assessment of the thorax and lungs to the collaborative team. Structure and Function • Thoracic cage—borders • Anterior thoracic landmarks • Posterior thoracic landmarks • Suprasternal notch • Vertebra prominens • Sternum • Spinous processes • Sternal angle • Inferior border of scapula • Costal angle • Twelfth rib Reference Lines • Midsternal line • Midclavicular line • Vertebral (mid-spinal) line • Scapular line • Anterior, posterior, midaxillary lines Structure and Function Thoracic cavity • Mediastinum • Contains esophagus, trachea, heart, great vessels • Lobes of the lungs • Anterior • Posterior • Lateral • Pleurae • Trachea and bronchial tree • Location of trachea and bronchi • Dead space • Function of acinus 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) of arterial blood • Maintaining heat exchange (less important in humans) Mechanics of Respiration • Control of respiration • Changing chest size during respiration • Inspiration • Expiration Health Assessment: Subjective Data • Cough: Do you have a cough? When did it start? Gradual or sudden? • Shortness of breath: Any shortness of breath or hard-breathing spells? What brings it on? How severe is it? How long does it last? • Chest pain with breathing: Any chest pain with breathing? Exact location? • History of respiratory infections: Any past history of breathing trouble or lung diseases like bronchitis, emphysema, asthma, pneumonia? Health Assessment: Subjective Data (Cont.) • Smoking history: Do you smoke cigarettes or cigars? At what age did you start? How many packs per day do you smoke now? For how long? • Environmental exposure: Any environmental conditions that may affect your breathing? Where do you work? At a factory, chemical plant, coal mine, farming, outdoors in a heavy traffic area? • Self-care behaviors: Last tuberculosis skin test, chest radiographic study, pneumonia or influenza immunization? Health Assessment: Objective Data Preparation • Position • Draping • Timing during a complete examination • Cleaning stethoscope endpiece Equipment needed • Stethoscope • Alcohol wipe Health Assessment: Objective Data Anterior chest—Inspect •Shape and configuration of chest wall •Facial expression •Level of consciousness •Skin color and condition •Quality of respirations •Rib interspaces Health Assessment: Objective Data Accessory muscles Anterior chest—Palpate •Symmetrical chest expansion •Tactile (vocal) fremitus •Palpate the anterior chest wall Health Assessment: Objective Data Anterior chest—Auscultate •Breath sounds •Abnormal breath sounds •Adventitious sounds •Include lateral chest •10 different places Health Assessment: Objective Data • Breath sounds • Technique • Bronchial, Vesicular, Bronchovesicular breath sounds—characteristics • Adventitious sounds • Crackles – fine vs coarse • Wheezes – high vs low pitched • Atelectatic crackles – sounds like fine crackles but do not last and are not pathological, disappear after few breaths Health Assessment: Objective Data Anterior Breath sounds: • Bronchial: • High pitch, loud amplitude, inspiration is less than expiration, rustling, like the sound of the wind in the trees • Trachea and larynx • Bronchovesicular: • Moderate pitch, moderate amplitude, inspiration = expiration, mixed quality • Over major bronchi, where fewer alveoli are located: anterior, around upper sternum in first and second intercostal spaces Health Assessment: Objective Data • Vesicular: • Low pitch, soft amplitude, inspiration is longer than expiration • Over peripheral lung fields, where air flows through smaller bronchioles and alveoli Health Assessment: Objective Data Measurement of pulmonary function status •Pulse oximeter (>95%) -Values evaluated in context of patient’s hemoglobin level, acid–base balance, and ventilatory status •Count Respirations (10-20/minute) •Listen for adventitious sounds Health Assessment: Objective Data Posterior chest—Inspect • Thoracic cage • Shape and configuration of chest wall • Anteroposterior/transverse diameter • Position patient takes to breathe • Skin color and condition Health Assessment: Objective Data Posterior chest—Palpate • Symmetrical expansion • Tactile (or vocal) fremitus • Technique • Factors that affect normal intensity of tactile fremitus • Palpate the entire chest wall Health Assessment: Objective Data Posterior chest—Auscultate •Breath sounds •Abnormal breath sounds •Adventitious sounds •Include lateral chest •18 different places Health Assessment: Objective Data Posterior Breath Sounds: • Bronchovesicular: • Moderate pitch, moderate amplitude • Over major bronchi, where fewer alveoli are located: posterior: between scapulae especially on right • Vesicular: • Low pitch, soft amplitude, inspiration is longer than expiration. • Over peripheral lung fields, where air flows through smaller bronchioles and alveoli Additional Health History Questions For Infants and children •Illness—frequent colds •Allergy •Chronic respiratory illness •Safety—childproofing; inhalation of toxic substances •Environmental smoke For older adults •Activity intolerance •Level of activity •Lung disease •Pain Abnormal Findings Configurations of the thorax •Barrel chest •Pectus excavatum •Pectus carinatum •Scoliosis •Kyphosis Abnormal Findings Respiration patterns •Sigh •Tachypnea •Bradypnea •Hyperventilation •Hypoventilation •Cheyne-Stokes respiration •Biot’s respiration •Chronic obstructive breathing Abnormal Findings Adventitious lung sounds •Discontinuous sounds -Crackles: fine -Crackles: coarse -Atelectatic crackles -Pleural friction rub •Continuous sounds -Wheeze: high-pitched -Wheeze: low-pitched -Stridor Sample Charting Subjective: • No cough, shortness of breath or chest pain with breathing. No history of respiratory diseases. Has “one or no” colds per year. Stated never smoked. Works in well ventilated office. Last TB skin test: 4 years, negative. Objective: • Upon inspection, Respirations 16/min, relaxed and even. Chest expansion is symmetrical, tactile fremitus is equal bilaterally. No tenderness to palpation, no lumps, no lesions. Vesicular breath sounds, clear over lung fields. No adventitious sounds Developmental Considerations (Cont.) Infants and children: •Surfactant •Vulnerability related to small size and immaturity of pulmonary system •Flexibility in sequence of the exam •Crying enhances palpation of tactile fremitus •Thoracic cage soft and flexible •Apgar scoring system •Sternal or intercostal retractions indicates distress •Respiratory rate and pattern •On auscultation, localization of breath sounds more difficult Developmental Considerations Pregnant women: • Enlarging uterus elevates diaphragm; decreases vertical diameter of thoracic cage, compensated by increase in horizontal diameter Acutely ill patients: • Second examiner needed to support patient in upright position for exam Developmental Considerations Older adults: • Lungs more rigid and harder to inflate • Decrease in vital capacity • Increase in residual volume • Decrease in number of alveoli • Increased shortness of breath on exertion • Increased risk for postoperative complications • Round, barrel-shaped thoracic cage and kyphosis • Chest expansion somewhat decreased • Less mobile thorax Cultural and Social Considerations • New and re-emergent cases of TB in Canada (2010) at unprecedented national low • Variation in rates by jurisdiction; disproportionately high in Nunavut • Asthma rates down, but contributing factor in 10% of hospital admissions of children under 5 years • Preventable risk factors for respiratory disease: tobacco smoke, poor air quality • Lung cancer is leading cause of cancer death in Canada • Women incur greater lung damage from exposure to environmental tobacco than men Health Promotion: Environmental Tobacco Smoke • • • • Second-hand/third-hand smoke risk Sidestream vs. mainstream smoke Exposure to both increases risk of adverse health effects Especially harmful to young children • Increased - Respiratory infection - Inner ear infection - Aggravation of asthma Case Study: M.C. is a 69-year-old who presents to the outpatient office with a “hacking, raspy” cough. Subjective Data Objective Data Previous medical history (PMH): hypertension (HTN), diabetes mellitus (DM) Vital signs: T 37°C, P 72, R 14, BP 134/64 Cough is productive, bringing up green phlegm Lungs: + rhonchi bilateral upper lobes, wheeze Runny nose, sore throat Oxygen (O2) saturation = 98% Denies fever Ears = tympanic membrane (TM) bulging Sore throat pain when swallowing Nose = + erythema, yellow discharge No history of smoking or seasonal allergies Throat = + erythema – pustules Complains of fatigue Medications: metoprolol 12.5 mg per day; metformin (Glucophage) 500 mg twice a day Lab Activities • SLO 5: Complete an assessment of the thorax and lungs using appropriate techniques. • SLO 6: Appropriately document and report the findings of an assessment of the thorax and lungs to the collaborative team. Quick Quiz Increased tactile fremitus would be evident in an individual who has which of the following conditions? A. B. C. D. Emphysema Pneumonia Crepitus Pneumothorax The thoracic cage is defined by the A. B. C. D. sternum, ribs, vertebrae, and diaphragm. clavicle, scapula, and spinous processes. costochondral junctions and costal margin. xiphoid process. Which of the following correctly expresses the relationship to the lobes of the lungs and their anatomical position? A. B. C. D. Upper lobes—lateral chest Upper lobes—posterior chest Lower lobes—posterior chest Lower lobes—anterior chest. Reference Book: Jarvis, C., Browne, A. J., Macdonald-Jenkins, J., & Luctkar-Flude, M. (2024). Physical examination & health assessment (4th Canadian ed.). Elsevier. Chapter 19: Jarvis, C., & Macdonald-Jenkins, J. (2024). Thorax and lungs. In C. Jarvis, A. J. Browne, J. Macdonald-Jenkins, & M. Luctkar-Flude (Eds.), Physical examination & health assessment (4th Canadian ed., pp. 457501). Elsevier.