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Chapter 18: Thorax and Lungs (pg. 413)
1. Position and Surface Landmarks
a. Anterior Thoracic Landmarks: Signposts for underlyingrespiratory structures.i. Suprasternal Notch:Hollow Ushaped depression
!ust a"o#e the sternum$ "etween cla#icles.ii. Sternum:%&"reast"one'( Has three parts: the
manu"rium$ the "ody$ and the )iphoid process.1. *alk your +ngers down the sternum until you
feel a distinct "ony ridge$ the sternal angleiii. Sternal Angle: %&Angle of Louis'( The articulation of
the manu"rium and the "ody of the sternum%continuous with the second ri"(.
1. Also marks the site of tracheal "ifurcation intothe right and left main "ronchi,. -orresponds with upper "order of the atria of
the heart. Lies a"o#e the fourth #erte"ra on the "ack
i#. Costal Angle: /ight and left costal margins form anangle where they meet at the )iphoid process.%Usually 0 degrees or less(
1
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1. Angle increases when ri" cage is chronicallyo#erin2ated %i.e. emphysema(
". Posterior Thoracic Landmarks: 3ore di4cult to countri"s and intercostal spaces "ecause of the surroundingmuscles.
,
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i. erte!ra "rom#nens: %-5( 6 the most "onyprominence when you 2e) your head.
1. 7f two #erte"ra seem e8ually prominent$ theupper on is -5
ii. Sp#nous "rocesses:9ote: -5T the spinous
process points outward$ after T the spinous processpoints downward o#erlying the ne)t #erte"ral "odyand ri" "elow.
iii. $n%er#or &order o% the Scapula:symmetrical ineach hemithora). Lower tip is usually at the 5thor ;thri".
i#. T'el%th #!:The tip is usually midway "etweensomeone
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erte!ral
%midspinal( =Scapular
Anter#orax#llar+,
#dax#llar+, ="oster#orax#llar+
,. The Thoracic -a#ity:i. 3ediastinum: 3iddle sectionii. Pleural -a#ities: right a left of the mediastinum
iii. Lung &orders: 7n the anterior chest$ the apex of thelung tissue is or cm a"o#e the inner third of thecla#icle. The !aserests on the diaphragm at a"outthe >thri" in midcla#icular line
1. Laterally: lung tissue e)tends from ape) ofa)illa to 5thor ;thri"
,. Posteriorly: -5 marks ape)$ T1 corresponds to"ase.
". Lo"es of Lungs: ?oth lungs are 9@T precisely symmetrical.1. /ight lung: shorter than left %"c Underlying
li#er on the right($ TH/BB lo"es %separated "y
+ssures(,. Left lung: narrower than the right %"c heart
"ulges to the left($ T*@ lo"esii. Anter#or: -ontains mostly upper and middle lo"es
1. -!l#ue (the ma/or or d#agonal) 0ssure:crossed the Cthri" in the mida)illary line andends at the >thri" in midcla#icular line
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,. or#2ontal (m#nor) 0ssure: Di#ides rightupper and middle lo"e. B)tends from Cthri"%right mida)illary( to rdintercostal space$ or th
ri" at the right sternal "order
iii. "oster#or: Almost ALL lower lo"es. Upper lo"es endat a"out T or T$ then lower lo"es "egin$ reachingall the way to T1 %e)piration( and T1, %inspiration(.
a. Right Middle Lobe (RML):does notpro!ect on the posterior chest.
,. Lo"es pro!ected in the posterior chest include:
Left upper lo"e$ Left Lower Lo"e$ /ight UpperLo"e$ /ight Lower Lo"e.
i#. Lateral: Lunges e)tend from ape) of a)illa to 5thor ;th
ri".
C
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#. TAEB A SPB-7AL 9@TB: points that often confuse"eginning e)aminers.
1. The left lung has no middle lo"e,. The anterior chest contains mostly upper and
middle lo"e with #ery little lower lo"e.
. The posterior chest contains almost all lowerlo"ec. "leurae: serous mem"ranes that form and en#elope
"etween the lungs and chest walli. #sceral pleurae: lines the outside of the lungs$
dipping down into the +ssures.1. -ontinuous with parietal pleurae
ii. "ar#etal pleurae: lines the inside of chest wall anddiaphragm
iii. Costod#aphragmat#c recess: pleurae e)tendappro)imately cm "elow the le#el of the lungs. This
is the potential spaceF when it a"normally +lls withair or 2uid it compromises lung e)pansion.
d. Trachea and ?ronchial Tree:i. Trachea: anterior to esophagus. 111 cm long in and
adultii. Trachea and "ronchi G ead Space%1C mL(
1. Transport gasses "etween en#ironment andlungs
iii. Ac#nus: unctional respiratory unit that consists ofthe "ronchioles$ al#eolar ducts$ al#eolar sacs$ andal#eoli
. 3echanics of /espiration:a. 4 ma/or %unct#onsof the respiratory system.
1. Supply o)ygen to the "ody for energyproduction
,. /emo#ing car"on dio)ide as a waste product ofenergy reactions
. 3aintaining homeostasis %acid"ase "alance( ofarterial "lood %maintains pH(
. 3aintaining heat e)change %less important inhumans(
". Control o% esp#rat#ons: controlled "y respiratory center
in the "rain stem %Pons and 3edulla( 6 normal stimulus to"reath is and increase car"on dio)ide in the "lood.
i. +percapn#a: increased car"on dio)ide in the "lood%increased respirations(
ii. +poxem#a: decreased o)ygen in the "lood %alsoincreases respirations$ "ut is less eIecti#e thanhypercapnia(
c. -hanging -hest SiJe:
>
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1. 7nspiration: inhale,. B)piration: e)hale
ii. B)pansion and -ontraction of the chest ca#ity$ altersthe siJe of the thoracic container in , dimensions:
1. The #ertical diameter lengthens or shortens$
which is accomplished "y downward or upwardmo#ement of the diaphragm,. The anteroposterior %AP( diameter increases or
decreases$ which is accomplished "y ele#ationor depression of the ri"s.
4. L-"NTAL C-"TNC:a. $n%ants and Ch#ldren:
i. /espiratory De#elopment in the etus.
Age e*elopmentur#ng the 0rst 5
'ee6s
Primiti#e lung "ud emerges
17 'ee6sThe conducting airways reach thesame num"er as the adult
3 'ee6sSur%actantis present in ade8uateamounts
&+ rthThe lungs ha#e 5 millionprimiti#e al#eoli ready to startrespiration
ii. /espiratory AL@9B does not function until "irth.iii. /espiratory de#elopment continues throughout
childhood1. 7ncreases in:
a. Diameter of airways". Length of airwaysc. SiJe of Al#eolid. 9um"er of Al#eoli % million "y
adolescence(i#. -onsider: -hildren
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c. Low "irth weightd. /isk of nicotine addictione. S7DS %"oth prenatal and
postnatal e)posure(f. Lower respiratory
illnessesg. Acute and chronic otitismedia$
h. ?reathlessnessi. Asthma!. Ad#erse lung function
throughout childhoodk. 7ncrease risk for ADHDl. 7ncrease risk for Depression in childhood
and adolescence". The "regnant 9oman: enlarging uterus ele#ates
diaphragm cmi. Decrease #ertical diameter of thoracic cageii. 7ncrease horiJontal diameter of thoracic cage %,cm(
1. 7ncrease BST/@KB9 le#els rela)es the chestcage ligaments to allow for trans#erse)pansion
,. -ostal angle widens. Total circumference of the chest cage increase
"y >cm. increase in Tidal Molume %e#en though
diaphragm is ele#ated$ it mo#es e#en more
during pregnancy(iii. Krowing fetus increase demand for o)ygen on the
mother %this is met easily "y increase in tidal#olume(
i#. 9o change in //#. "h+s#olog#c d+spnea%5C of women(: increased
awareness to "reath$ does 9@T alter ADLs$ and is9@T associated with cough$ wheeJing or e)ercise.
c. The Ag#ng Adult: more rigid and hard to in2atei. -ostal cartilages "ecome calci+es %thora) less
mo"ile(
ii. /espiratory muscle strength declines after age C1. Also a Decrease in elasticity in lungs,. Small airway closure
a. Decreased #ital capacity %ma) air on cane)pel(
". 7ncrease residual #olume %air left "ehindafter forceful e)piration(
;
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iii. Histologic -hanges: %i.e. gradual loss of intraal#eolarsepta and decreased num"er a al#eoli( 6 less surfacearea for gas e)change
1. 7ncreased risk for:a. Postoperati#e pulmonar+
compl#cat#ons". Postoperati#e atelectas#sc. $n%ect#onfrom a decrease a"ility to
cough$ loss of protecti#e airway re2e)es$and increased secretions
i#. Lung "ase "ecome less #entilated as a result ofclosing oI a num"er of airways
1. 7ncreased risk for d+spneaC. CLT AN ;NT$CS:
a. Tu"erculosis %T?(: 9um"er of cases declined for , years inthe U.S.
". Asthma: most common chronic disease in childhood with apre#alence of 0.C in children ages 15.
i. -ases ha#e increase in the U.S. since ,1.1. ;. %,11(,. 3ost common in lower income families. Pre#alence according to Bthnicity %,1(
ethnicity wide increase in pre#alence ofAsthma
a. *hite: 5.;". ?lack: 11.0c. Hispanics: 5.,
>. 79TB/M7B*: Health History and Su"!ecti#e Assessmenta.Cough:
i. Nuestions to askThings to Eeep in 3ind in aninter#iew:
1. Do you ha#e a coughO,. *hen did it startO Kradual or SuddenO
a. Acute #s. -hronic. How long ha#e you had a coughO
a. Acute Cough: , weeks". Chron#c Cough: o#er , months
. How often do you coughO Any special time ofdayO Does it wake you up at nightO
a. -ontinuous throughout the day: Acuteillness %e.g. respiratory infection(
". Afternoon e#ening %may"e e)posure toirritants at work(
c. 9ight: Post nasal drip %sinuses(
0
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d. Barly morning: -hronic "ronchialin2ammation of smokers
C. Do you cough of phlegm or sputumO HowmuchO *hat colorO
i. Chron#c &ronch#t#s: producti#e
cough$ months of a year$ lasts ,years". 9h#te or Clearmucoid: colds$
"ronchitis$ #iral infectionsc.
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,. B#er had any shortness of "reath or hard"reathing spellsO *hen did it STA/TO *hat"rings it onO Se#erityO How long does it lastO
. 7s it aIected "y positionOa. -rthopnea: di4culty "reathing when
supine. @ccur at speci+c timeO 9ightDayOa. "arox+smal nocturnal d+spnea
("N):awakening from sleep with S@?%Shortness @f ?reath( and needing to "eupright to achie#e comfort
C. S@? episodes associated with night sweats%diaphoresis(O
>. -ough$ chest pain or "luish color around lips ornails$ wheeJing soundO
5. Bpisodes seem to "e related to food$ pollen$
dust$ animals$ season$ emotion$ or e)erciseOa. Asthma aattacks occur with a speci+c
allergen$ e)treme cold$ an)iety%Descri"ed at &chest tightness'(
;. *hat do you do during an episodeO Takespecial position or purse lip "reathingO @)ygen$inhalers$ medicationO
0. How does S@? eIect your acti#itiesO Ketting"etter or worse or neitherO %Assessing ADLs(
ii. People with smoking history$ dyspnea$ and cough$you can use the short Citem 8uestionnaire to
identify who should "e asses with spirometry forchronic o"structi#e pulmonary disease %-@PD(. %pg.,(
9e#er
/arely
Sometimes
@ftenMery@ften
Score
o' o%ten do +ou cough=
C , 1
o' o%ten does +ourchest sound no#s+
('hee2+, 'h#stl#ng,
rattl#ng) 9hen +ou!reathe=
C , 1
o' o%ten do +ouexper#ence shortness o%!reath dur#ng ph+s#cal
act#*#t+=
C , 1
o' man+ +ears ha*e+ou smo6ed=
C , 1
11
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9hat #s +our age=
C , 1
c. Chest "a#n '#th &reath#ng:-aused "y musclesoreness from coughing$ or from in2ammation of pleurao#erlying pneumonia.
1. Eeep in mind: distinguish from cardiac pain orheart "urn of stomach acid
ii. Nuestions to Ask1. Any chest pain with "reathingO Point to
location.,. *hen did it startO -ontinuous$ intermittentO. ?urningO Sta""ingO. ?rought on "y respiratory infection$ coughing$
or traumaO Associated with fe#er$ deep"reathing$ une8ual chest in2ationO
C. *hat ha#e you done to treat it medication orheatO
d. #stor+ o% resp#rator+ #n%ect#ons: -onsiderseuelae %a condition that is the conse8uence of apre#ious disease or in!ury(after these conditions
i. Nuestions to askThings to consider:1. Any past history of "reathing trou"le or lung
diseases such a "ronchitis$ emphysema$
asthma$ pneumonia.,. Any unusually fre8uent or unusually se#erecoldsO
a. 3eaningful to ask a"out e)cess num"eror se#erity %"ecause e#eryone gets acold here and there(
e.Smo6#ng #stor+.i. Nuestions to AskThings to consider:
1. Do you smokeO *hat age did you startO Howmany packs a dayO
,. Ha#e you e#er tried to 8uiteO *hat happenedO
*hy do you think it didn
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,. Ad*#se.Ki#e clear$ non!udgmental$ andpersonaliJed suggestions for 8uitting.
. Assesseach person
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constriction(. Usuallycaused "y smoking.
%crackles o#er de2atedareas$ may ha#ewheeJe(
C-" S@? %e): after 2ightof stairs($ Barly
morning -ough %wsputum($
S: Hypertension$afe"rile$ H/ *DL$
ele#ated respirations%resting($ under weight$nspect#on: ?arrel-hest$ Tripod$ regularshallow respirations%accessory muscles($prolonged e)piration$S@? am"ulation$"alpat#on: minimal%symmetric( cheste)pansion$ Tactil
fremitus %"ilaterally($Auscultat#on:?Sdiminished$ wheeJe%e)piration$
mph+sema
-aused "y destructionof Pulmonaryconnecti#e tissueFcharacteriJed "ypermanentenlargement of airsacts distal to terminal"ronchioles andrupture ofinteral#eolar calls.7ncrease airwayresistance.Hyperin2ated lung$increase lung #olume.Smokers: ;0 ofcases
$nspect#on: 7ncreasedAP diameter$ ?arrelchest$ Acessorymuscles used$ Tripod$position$ S@?%especialyon e)ertion( resp.distress$ Tachypnea
"alpat#on: DecreaseTactile remitus andchest e)pansionAuscultat#on:Decreased ?reathsounds$ 3ay ha#eProlonged e)piration.3ued heart sounds$Ad#entitious Sounds%occationally a wheeJ(
Atelectas#s
-ollapsed shrunkensection of a#eoli orentire ung as a resultof:1( airway o"structionF
7nspection: -ough. Lagon e)pansion onaIected side increasedrepiratory rate andpulse. Possi"lecyanosisPalpation: -hest
1
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al#eolar air "eyondthe o"struction isgradually a"sor"ed"y the pulmonarycapillaries and
al#eolar walls ca#ein,( -ompression on
lung( Lack surfactant
e)pansion on aIectedside. Tactile remitusdecreased or a"sento#er area. Largecollapse could mean
tracheal shift towardaIected sideAuscultation ?reathsounds Decreased#esicular or a"sento#er aIected area.Ad#entitious sounds%none if "ronchuso"struction$ occasional+ne crackles if"ronchus is patent(
"neumon#a
Pneumocystis jiroveci%P. carinii( 6 #irulentform of pneumonia.ProtoJoal infection%associated with A7DS(
$nspect#on:An)iety$S@?$ dyspneaone)ertion$ malaise%common($ tachypnea$fe#er$ drynonproducti#e cough$intercostal retraction inchildren$ cyanosis"alpat#on:Decreasedchest e)pansionAuscultat#on:?S
decreased$ad#entitious sounds%crackles may "epresent 6 often a"sent(
Tu!erculos#s
-aused frominhalation of tu"ercle"acilli into the al#eolarwall:1( Acute
in2ammatoryresponse 6macrophagesengulf "acilli%don
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,( Scar tissue forms$lesion calci+es andshows on )ray
( /eacti#ation ofpre#iously healed
lesion. Dormant"acilli nowmultiply$producingnecrosis$ ca#iation$and caseous lungtissue %cheeselike(
( Destruction aslesion erodes into"ronchus$ formingair+lled acity
%ape) usually mostdamaged(
lo"es common persistfollowing full ecpirationand cough
Hyperresonance: Lower pitched$ "ooming sound %too much air ispresent(Anteroposterior %AP( diameter Q Trans#erse diameter %.5:.5C(3ore -onditions:
Cond#t#on e0n#t#on
"neumothorax
ree Air in Pleural space %causes hyperresonance(
"ulmonar+
emo!l#sm
Undissol#ed materials %throm"us$ air "u""les$ fat
glo"ules( origninating in legs or pel#is detach andtracel #ia #enous system$ return#ng !lood tor#ght heart,and lodge to occlude pulmonar+*essels.
;. Techni8ues for -ollecting -!/ect#*e ataa"out the Thora)%anterior and posterior(:
a.Anter#or:#. $nspect#on:
1. Shape and Con0gurat#on: ri"s sloping
downward$ symmetric interspaces$ costal anglewithin 0 degrees$ de#elopment of a"dominalmuscles %consistant with age$ weight$ andathletic condition(
,. @ac#al express#on: /ela)ed indicatesunconscious "reathing eIorts %that
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. Color and Cond#t#on: assess lipsnail"eds%look for cyanosis or unusual pallor($ nails%con+guration($ skin %lesionsO(
C. esp#rat#ons: 9ormal rela)ed "reathing$ nonoise$ symmetry$ note any localiJed lag on
inspirationa. 9ote use of accessory muscles to "reatheis a"normal$ unless in e)ercise$ one mayuse calene$ sternomastoid$ trapeJiusmuscles to enhance respiration.
>. esp#rator+ rate: occasional sighs normallypunctuate "reathing
##. "alpat#on:1. Symmetric -hest B)pansion: place hands along
costal margins$ point thum"s toward )iphoidprocess$ Ask person to "reathe deep$ watch
your thum"s mo#e apart,. Tactile %#ocal( remitus: Mi"rations
a. ?egin at lung apices %su"cla#icular areas(". -aompar #i"rations one side to the other
while patient say &00'c. A#oid female "reasts. The "reast tissue
damps the sound. "alpate anter#or chest 'allfor tenderness:
none should "e present###. Auscultat#on
1. Listen from apices to >thri"
,. 3easurement of Pulmonary unction Status:a. orced e)piratory time:
15
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". Handheld Sp#rometer: measures lunghealth in chronic conditions such asasthma.
i. Forces vital capacity%M-( 6 thetotal #olume of air e)haled
ii. Forced expiratory volume in 1second%BM1( the #olume e)halein the +rst measure second
iii. BM1M- ratio 5C or greater Gno o"struction
c. Pulse oximeter: Sp@,: 0500i. 3ust "e ele#ated in conte)t of
hemoglo"in le#el$ acid"ase"alance$ and #entilator staus
d. 6-minute walk test%> 3*T(: safer$simpler$ ine)pensi#e clinical measure of
gunctional status in aging adultsi. used in pulmonary reha"ilitationii. +nd a hallway with little tra4c and
make sure patient is wearingcomforta"le shoes and pulse o).
iii. Assess @,saturation as they arewalking
i#. ST@P if "elow ;C to ;; or upone)treme "reathlessness
!."oster#or:#. $nspect#on:
1. 9ote the shapeand con0gurat#on of chestwall
,. Spinous processes should "e in a straight line. Thora) is symmetric. Thora) elliptical shape$ downward sloping ri"s
%C degrees from spine(C. Scapulae symmetrical in each hemithora)>. AP diameter should "e less than trans#erse
diameter5. The neck and trapeJius muscles$ de#eloped
normally for age and occupation;. 9ote: position the person takes to "reathe
%including a rela)ed position(0. Skin -olor and condition
A?9@/3AL 79D79KS in 7nspection.
Skeletal deformities may limit thoracic cage e)cursion: scol#os#s$
6+phos#s %pg. ,(
AP is e8ual to Trans#erse Diameter %&arrel Chest(
o /i"s horiJontal$ chest appears as if held in continuous
inspiration
o ound 7n -@PD
C+anos#s
1;
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ii. "alpat#on:1. Assessing Symmetric -hest B)pansion: Place
hands sideways on the posterolateral chestwall with thum"s pointing together at the le#elof T0 or T1. Slide hands medially to pinch up a
small fold of skin "etween your thum"s
a. Ask the person to take a deep "reath
%9ote any lag in e)pansion(,. Assessing Tact#le %#ocal( @rem#tus%palpa"le
#i"ration(: Use palmar "ase of the +ngers orthe ulnar edge of one hand and tough theperson
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A?9@/3AL 79D79KS in Palpation:
Une8ual chest e)pansion: sign of atelectasis$ lo"ar pneumonia$ pleural
eIusion$ thoracic trauma %fractured ri"s or pneumothora)(o Asymmetry suggest dysfunction$ can "e assessed further with
the stethoscope ecreased @rem#tus: any "arrier that comes "etween the
sound and your palpating hand decreases fremitus %i.e.o"structed "ronchus$ pleural eIusion$ or thickening$pneumothora)$ or emphysema(
$ncreased @rem#tus: -ompression or consolidation of lung
tissue %i.e. lo"ar pneumonia( honchal @rem#tus:Palpa"le with thick "ronchial
iii. %Apparently we are skipping percussion(i#. Auscultat#on: Air that passes through the
tracheo"ronchial tree is an audi"le sound through
the chest wall.1. ?reath Sounds: B#aluate the presence and
8uality of 9ormal ?reath Soundsa. "os#t#on o% "at#ent: sitting$ leaning
forward slightly$ with arms restingcomforta"ly across the lap
". Tell patient to "reathe deep through themouth$ assure them they can stop if theystart to feel diJJy
%pg,0(
,
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,. 73P@/TA9T to "e aware of. There are C-ommon "ackground noises that are oftenconfused with lung sounds. They are:
a. B)aminer
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A?9@/3AL 79D79KS in Auscultation:
?reath sounds changed "y o!struct#onin the passageways or "y
d#seasein the lung parenchyma$ the pleura$ or the chest wall
Decreased or A!sent &reathsounds:
o *hen "rochial tree is o"structed %"y secretions$ mucus$ plug$ orforeign "ody(
o Bmphysema: loss of elasticity in lung +"ers and decreased force of
inspired air Lungs also already hyperin2ated 6 inhaled air does notmake
as much noiseo Anything %in the pleural space( that o"structs transmission of sound
"etween lung and stethoscope i.e. pleurisy$ leural thickening$ airRpheumothora)$ 2uid Rpeural eIusion
-rackles %Sign of Pulmonary edema$ pneumonia$ pulmonary$ +"rosis$ and
the terminally ill who ha#e a depressed cough re2e) Ad#entitious Sounds: added sounds that are not normally heard in the
lungs. Heard as "eing superimposed on the "reath soundso -aused "y mo#ing air colliding with secretions in the
tracheo"ronchial passageways or "y popping open of pre#iouslyde2ated airways
o Crac6les%rales( and'hee2e%rhonchi( are terms commonly used
"y most e)aminers. There are also sounds called str#dor%heard inthe lungs of children with the -roup( and @r#ct#on u!s%the soundof the plurae ru""ing together(.
-rackles: discontinuous popping sounds heard o#er inspiration
*heeJes: continuous musical sounds heard mainly o#ere)piration
0. /espiratory Patterns
,,
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1. 9ormal *o#ce sounds:-an "e auscultated o#er the chestwall %same pattern used for tactile fremitus(
a. Moice Sounds: not elicited routinely 6 only if you suspectlung pathology %"ased on earlier data(
i. Testing for: &ronchophone+$ egophone+$ and'h#spered pector#lou+
A?9@/3AL 79D79KS:1. ?ronchophoney: &00' is more distinct than normal,. Bgophoney: &e' sounds like &a' %in Say(
. *hispered pectorilo8uy: a whispered &1,' sounds #ery clearand close
. -onsolodation of lung tissue will enhance the #oice sounds$
11. De#elopmental -ompetence:a. 7nfants and -hildren
i. 7nspection:
,
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1. ?arrel -hest after > years lead to chronicasthma or cystic +"rosis
,. Apgar Scoring System
Card#o*ascular S+stem (ear Nec6 essels) "er#pheral ascular S+stem: Chapter 1B?("age 45B)
a. -ool acts:i. ?lood MolumeG C leters G >C 8uarts G1.C gallonsii. 1 hear "eat pumps >; ml %1 cup(iii. Heart pumps a"out ,$ gallons a day %>
litersmin(
,. "os#t#on and Sur%ace Landmar6s: -ardio#ascular system: theheart %muscular pump($ "lood #essels
a. "record#um: Area on anterior chest directly o#erlying theheart
". Heart and Kreat Meins located "etween lungs and in themiddle third of the thoracic cage %med#ast#num(
c. Heart e)tends from the ,ndto the Cthintercostal space
,
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i. /ight "order of sternum %?ase(Left mid cla#icularline
Descri"e where each heart sound is heard "est 6APBT3 %All Pigs Bat Too3uch(
1( Aort#c%/ight sternal "order$ ,nd 7-S(,( "ulmon#c %Left sternal "order$ ,nd 7-S(( r!>s %Left sternal "order$ rd 7-S(( Tr#cusp#d %Left sternal "order$ th 7-S(
C( #tral %Left midcla#icular line$ Cth 7-S(
,C
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"$ ("o#nt o% ax#mum $mpulse):Apical Pulse 6 at the Ape)%landmarks: midcla#icular line$ +fth intercostal space(.
Anatom+ and "h+s#olog+ o% C s+stem
d. Heart Mal#es
,>
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i. A (Atr#o*entr#cular):prevent return of blood toatrium chamber of the heart.
1. Tricuspid %right side( and mitral"icuspid %leftside( &Try "efor you ?uy'
a. @pen with Diastole %allow #entricles to +ll
from Atrium(". -losed with Systole %Pumping phase sono "ack2ow(
ii. Sem#lunar al*e: heart Mal#e$ shaped like halfmoonsFprevents blood from owin! back into theheart.
e. Card#ac C+cle: The rhythmic mo#ement of "lood throughthe heart %pg.>( 6 know when #al#es are open and whenthey are closed
i. #astole: The +lling phase 6 Mentricles are rela)ed 6AM open$ SL closed
1. , of cycle is +lling %longest(ii. S+stole: Pumping PhaseDMentricular contractionD
AM open$ SL closed1. Mentricular pressure is higher than atrial". AM #al#es swing shut %S1(: "eginning of systole
a. Pre#ents regurgitation into atria duringcontraction
#. All #al#es closeda. Mentricular walls contract %isometric
contraction( to "uild pressure inside the#entricles to a high le#el
b. Mentricle P V Aortai. Aortic #al#es open
iii. #astole%again(:Atria +lls with "lood1. All four #al#es closed$ #entricles rela)
%isometric rela)ation(a. Atria +lls with "lood deli#ered from lungsb. Atria Pressure V Mentricular Pressure
iv. $vents in the %i!ht and Left &ounds'1. S1: AM #al#es close+rst Heart sound %"egin
systole(a. 31: 3itral closes
b. T1: Tricuspid closesc. S1 is loudes at Ape)
". S: semilunar #al#es close %end systole(a. A,: Aortic closesb. P,: Pulmonic closesc. S, is loudest at ?ase
,5
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. B)tra Heart Sounds: ?ell is "est %pg. >(a. Third Heart Sound %S3(:in Diastole 6
comes after S,
i. Mentricles resistant to +lling%#olume too much$ "acking up andde#eloping Heart ailure or Mal#eregurgitation(
ii. Lu" du" da %&Een Tuck EBW'(". Diastole B)tra Heart Sound %S4(:in
Diastole 6 comes "efore S1i. Later resistant sound %#entricle too
full$ still wall$ heart damage 63yocardial infarction %37((
ii. Lu" Du" %&TB99 a see'(
. 3urmurs: Tu"ulent "lood 2owa. Kentle$ "lowing$ wishing sound". 3U/3U/S 6 documented
i. "#tch or @reuenc+%high$ low(ii. Loudness Kraded 1> loud or
soft %intensity(iii. T#m#ng%systolic or diastolic(i#. "attern%grows louder$ tapers$
peaks(#. Eual#t+%rum"ling$ musical$
"lowing harsh(
c. -onditions that cause 3urmurs: Don
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B)ample 3urmurB)ercise$ thyroto)icosis Melocity of "lood increases
Anemia Miscosity fo "lood decreases
A stenotic or narrowed #al#e$ anincompetent or regurgitant #al#e$dilated cham"er$ septal defect
Structural defects in the #al#es %astenotic or narrowed #al#e$ anincompetent or regurgitant #al#e($or unusual openings occure in thecham"ers %dilated cham"er$septal defect(
. BEK %-ham"er depolariJation and repolariJation(
. Su!/ect#*e ata%pg.51(a. -hest Pain: -@LDSPA
a. Ang#na: -hest Pain 6 7mportant cardiac symptom$occurs when heart
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i. -hest Pain @rigin my "e found in diIerent areas:%pg. 0(
1. Pulmonary,. 3usculoskeletal. Kastrointestinal
ii. Uni#ersal sign of chest pain: -lenched +st to thechest1. 3en: classic,. *omen: diIer %!aw pain$ "ack pain$ etc.(
". +spnea: shortness of "reathi. +spnea on exert#on%D@B( 6 Nuantify e)actly
%i.e. &after walking two "locks'( 6 Paro)ymal$-onstant or intermittent$ /ecum"ent
ii. "arox+mal nocturnal d+spnea%P9D(: occurswith Heart failure$ supine increases #olume ofintrathoracic "lood$ weakened heart cannot
accommodate1. Typically$ After , hours of sleep$ person
awakens with the need for fresh airc. Cough: Any sputum
i. Producti#e cough$ mucoid or purulent.ii. Hemoptysis: coughing up "lood
1. @ften pulmonary disorder,. Does occur with m#tral stenos#s
d. @at#gue: tiring easilyi. Unusual fati8ue is a topprodromal 37 symptom
for women
ii. Decrease cardiac output is worse in the e#eningiii. An)iety or depression occurs all day$ or worse in
morninge. dema: Swelling
i. Bdema: Dependent when caused "y heart failureii. Card#a edema: worse in e#ening
1. ?etter in morning %ele#ated legs all night(,. ?ilateralF unilateral swelling has local #ein
causef. C+anos#s or "allor: ?oth occurs with 37 or low cardiac
output decreased tissue perfussion
g. Noctur#a: waking up at night to urinatei. /ecum"ency at night promotes 2uid resorption
and e)cretionF this occurs with heart %a#lureinthe person who is am"ulatory during the day
h. "ast ealth #stor+#. @am#l+ Card#a #stor+/. L#%est+le ealth a!#ts
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i. 9utrition$ Smoking$ B)ercise$ S$ stress$weight$ cholesterol$ checkupO
C. Preparation for ascultating the heart: Should "e re#iew1. *ash hands,. -lean Steth
. *arm and 8uiet room. Pri#acyC. Access to chest 6 gown>. *atch with second hand5. Stethoscope;. Patient sitting upright
>. @"!ecti#e Data 7nspection anteriora. PT in upright sitting position". 9ot skin colorc. Base of /espirationsd. 9ot #isi#le pulsations in neck or chst
e. 9eck Messel Destintion %XMD(5. -arotid Artery: %pg. >>(
a. Kroo#e "etween Trachea andsternocleidomastoid muscle
". Palpation and Ausculation:i. Palpate gently and locate
1. Light$ apply "ell %light: #agalstimulation could decrease heartrate(
,. Listen for ?ruit %9ormal: none(a. &ru#t: ?lowing$ swishing
sound: tur"ulence. ?reathe: B)hale 6 Hold ?reath 6
?reathe
. ?ilateral ?ut *A/979K: @9B S7DBat a time
C. 9o percussion of arteries %DUH(
1
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;. Xugular Meins
a. -lues a"out riht side of hearti. 7nternal 6 deepii. B)ternal 6 more super+cial
". 7nspection %tells us heart e4ciency as a pump and #olumestatus(
i. Pt in supine position %face up(ii. Stand on the right side of the pation$ ask them to
turn their head slightly to the left1. 9ormal: 2attened %no XMD( with H@? ele#ated
%C degrees(,. 9ormal: no palpa"le #enous pulsation
. 7f Destension: Unilateral or "ilateralO. XMD can "e measured in cm
iii. 9ote: Misi"le neck #ein distension while patient islying 2at is 9@/3AL
1. /aise the head of the "ed$ it should disappearB. The "record#um
a. $nspect#on:Anterior -hest Precordium
,
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i. Pulsation: 3ay "e a"le to see apical impulse %left#entricle rotating against the chest wall duringsystole(.
1. thor Cthintercostal space at or insidemidcla#icular line
,. Basier to see in children. A"normal:ea*eor l#%t: sustained forcefulthrusting of #entricle during systole
a. Mentricle hypertrophy %increasedworkload(
". /ight Mentricular Hea#e: seen at sternal"order
c. Left Mentricular Hea#e: seen at ape)". "alpat#on: Precordium
i. Apical 7mpulse %can "e palpated in ,C adults 6C5 in left lateral position( 6 palpate with one
+nger.1. Ask Patint to e)hale and hold
ii. Palpation across the Precordium: using palmaraspects
1. plapate the ape)$ left sternal "orde$ and the"ase %searching for any other pulsations(
A?9@/3AL 79D79KS:1) Card#ac enlargement,( Le%t *entr#cular d#lat#on%#olume o#erload( displaces impulse
down and to left and increases siJe more than one space
%Diameter cm or greater G dilated(a. @ccurs in Heart failure". @ccurs in -ardiomyopathy
( Susta#ned $mpulse: increased force and duration "ut nochange in location occurs in left #entricular hypertrophy and nodilation %pressure o#erload(
( Palpa"le #i"rations %Thr#ll(
c. Percussion: 9ot on the heartd. Ausculatation
i. Auscultor+ Areas
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1. eart @a#lure:%pg 0C( &i!ns and &ymptomsa. Shortness of ?reath". Ad#entitious Soundsc. Dissiness
d. Tiredness %fatigue( = weaknesse. /apid or irregular H/$ Sf. Swelling in ankles$ legs and a"domen and weight gaing. @ther: 9ausea$ palpitations$ -hest pain$ waking suddenly
at night una"le to "reath %P9D($ changes in sleep patternsh. YY Suggest aspirin
11. De#elopmental -onsiderations:a. 7nfants and -hildren %pg. >5(
i. Listen whene#er you can %sleeping$ 8uiet(ii. unctional %innocent( murmurs common
1. Usually change or disappear with position
change,. /BB/ ALL 3U/3U/Siii. -heck heart and femoral pulse simultaneously in
infant for delay %coarctation(i#. Signi+cant History indings in 7nfants and -hildren:
1. 3other. re8uent respiratory infection
5. amily history". Blderly: -onsider
i. Slow position changes in elderly: /isk orthostat#ch+potens#on%sudden drop in ?P(
ii. ?P gradual systolic rise with ageiii. -arefully listen for S and Si#. @ccasional irregular "eats common#. Enown cardiac/espiratory historyO
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#i. 3edications#ii. Bn#ironment
1,. Accurately document +ndings to determine your patientZscardio#ascular status. % see e)amples at the end of thechapter(
Chapter : "er#pheral ascular S+stem andL+mphat#c S+stem ("g. 5B)
-ool act: if laid in line an adult
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". Takes e)tra 2uid to "lood stream%drainage system(
c. Lymph nodes 6 clumps of tissuesurrounded "y the #essels
d. Super+cial and deep
e. Super+cial 6 cer#ical$ a)illary$epitrochlear$ and inguinalf. HBB9T = K7 class
( Peripheral Mascular Assessment:a. Su!/ect#*e: History
#. Leg "a#n or cramps1. Peripheral #ascular
disease %PMD(: "lood2ow cannot matchdemand during
e)ercise %musclefatigue or pain whenwalking 6 claudation(
,. -laudation Distance:num"er of "lockswalked or stair climedto produce pain.
##. S6#n Changes on arms orlegs
1. -olor change,. Hair loss
. Temp %symm(. Soresulcers %leg ulcers with chronic arterial
and #enous disease(###. S'ell#ng #n arms or legs
1. Bdema: "ilateral when the cause is generaliJed%heart failure(
a. Unilateral when it is the result of localo"structionin2ammation
i#. L+mph node enlargement: occur with infection$malignancies$ and immunologic disease
#. ed#cat#onsO
1. 3ay cause hypercoagula"le state,. Lowdose aspirin or clopidogrel are used to
pre#ent "lood clots in selected people#i. Smo6#ngO
1. To"acco -auses all of the followinga. constricts arteries". increases coagula"ilityc. in!ures endothelium
>
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d. promotes in2ammation,. Strongest risk for PAD. Starting 1> yrs and under$ ,) risk
!. -!/ect#*ei. $nspect and palpate the Arms:
1. 9ote color skin and nail "edsF temperature$te)ture$ and turgor of skinF present of anylesions$ edema or clu""ing
a. Lift "oth patient. -ollateral -irculation:
a. Allen Test %e)plained later(##. $nspect and palpate the Legs
1. Symmetry:a. 7nspect "oth legs together: note color$
hair distri"ution$ #enous pattern$ siJe%swellingatrophy($ any lesionsulcers
i. A"normal:1. Pallor: #asoconstriction,. Brythema: #asodilation
. -yanosis: decrease tissueperfusion
. 3alnutrition: thin$ shiny$atrophic skinF thick ridgednails$ loss of hairF ulcersFgangrene
a. Pallor$ coolness%arterial insu4ciency(
5
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". 3easure circumference %note location ofany a"normality(
i. Asymmetry:1. 1cm: mild lymphedema,. Ccm: moderate
lymphedema. VCcm: se#ere lymphedemac. Temperatured. Pulses:
i. emoral %groin(1. A"normal:"ruit occurs with
tur"ulen "lood 2ow %indicatespartial occlusion(
ii. Popliteal %"ehind knee(\patientsupine or prone
iii. Posterior ti"ial %posterior to ankle(
i#. Dorsal pedis pulse %on the tarsals(e. Preti"ial edema: A"normal
i. Krading1. 1[$ 3ild pitting$ slight
indentation$ no percepti"leswelling of the leg
,. ,[$ 3oderate pitting$indentation su"sides rapidly
. [. Deep pitting$ indentationramins for a short time$ leglooks swollen
. [$ Mery deep pitting$indentation lasts a long time$leg is grossly swollen anddistorted
ii. 7f !#lateral: e)amine neck #eins1. Distention of neck #eins:
peripheral edema may "erelated to heart disease
,. 9ormal neck #eins: othercomplications %i.e. li#erdisease$ nephrosis$ chronic
#enous insu4ciency$antihypertensi#e or hormonalmedication(
###. Color changes1. 7f you suspect arterial de+cit$ raise legs a"out
cm %1, inches( 6 drains oI #enous "lood soyou can inspect coloration due to arterial"lood.
;
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a. 9ormal:i. Light skinned: little pale "ut still
should "e pinkii. Dark skinned: soles should re#eal
e)treme color change
i#. The oppler ultrason#c "ro!e%pg. C,C(1. @nly way to "e sure of Maricosities.a. Palpation is unrelia"le "c #aricosities
occure "elow or "etween e#encompetent #al#es
#. The Ankle and ?rachial 7nde) %don
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neuromuscular#asculartissue damage(
Y9europathic: pain and sensation decrease
( Assessing Pulses
a. -arotid". ?rachialc. /adiald. emorale. Poplitealf. Posterior Ti"ial %medial(g. Dorsalis pedis %lateral to tendon
of "ig toe(C( Assessing e)tremities:
a. 7nspection:i. -olor
ii. SiJeiii. Symmetryi#. 9ails#. Hair
#i. Maricosities#ii. ?ulges#iii. Mascular patternsi). Lesions or ulcers
". Palpation:i. -ompare ?ilaterallyii. Symmetry in siJe$ shape$ color
iii. Temperature %"ack of hand(i#. -ondition %skin$ nail "ed$ hair distri"ution(#. Pulses
#i. Bdema %see skin assessment(#ii. 3easurements#iii. -apillary /e+ll %Q, seconds(
>( PMS Assessment 3neumonic:a. &Please 3ake Sure To -hart'
i. Pulsesii. 3o#ementiii. Temperature
i#. -olor and or -apillary /e+ll". Always look for symmetry
5( Bdema:a. -heck for preti"ial edema$ Press +rm for C seconds$ release
i. 9ormal: no indentation". Pitting Bdema %pg C,(
i. ?ilateral %generaliJedF 2uid o#erload(ii. Unilateral %o"struction or in2ammation(
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;( Allen Test:Used to e#aluate the ade8uacy of collateralcirculation
a. Prior to arterial stick %check for ade8uacy of collateralcirculation(
". A?9@/3AL: Pallor persistes$ or sluggish reutn to colorsuggests occlus#on%reduced "lood 2ow due toatherosclerosis( of the collateral arterial 2ow. A#oid radialartery annulation until ade8uate circulation is shown.
13. lcers: enous *s. Arter#alenous Stas#slcer
Arter#al ($schem#c) lcer
Su!/ect#*e ata
Aching Pain
"elow knee
*orse standing$
may itch
Deep muscle pain$
lower calf or foot
Pain with walking
%claudication(-!/ect#*e ata
irm$ ?rawny
edema
9ormal Pulses
Ulcer une#en
edges
-ool$ pallor$ diminished
pulses
Thin$ shiny skin$ hairless
toe
Thick nails
Ulcer: well de+ned
edges$ punched outlook
1
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a.enouse Stas#s lcer: After Acute or chronic incompetent#la#es in deep #eins. Menous ulcers account for ; oflower leg ulcers
#. @ccur at medial malleolus and are
##. Character#2ed !+: "leeding$ une#en edges.%"ecause "lood is getting there$ "ut not o)ygen(!.Arter#al ($schem#c) lcer: ?uildup of fatty pla8ues on
intima %atheroscleros#s6 chronic gradual "uild up of%att+ strea6s$0!ro#d plaue, calc#0cat#on o% *essel'all$ and throm!us %ormat#on6 in that order( plusharden$ calci+cation of arterial wall %arteriosclerosis(
###. @ccur at toes$ metatarsal heads$ heels$ and lateralankle.
i. Character#2ed !+: Pale ischemic "ase$ well de+nededges and no "leeding %"c decreased tissueperfusion(
1. T%Deep Mein Throm"ophle"itis(a. Mein occlusion "y throm!us %clot(". #s6: ?edrest %V days($ trauma$ #aricositiesc. Su!/ect#*e: sudden onset$ sharp$ deep muscle paind. -!/ect#*e: *armth$ swelling$ redness$ tender to palpation
i. #s6: em"olism
1C. Aneur+sm%pg. CC(i. A sac formed "y dilation in the artery wall
,
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ii. Atheroclerosis %most common cause( weaken middlelayer %media( of #essel wall
iii. Stretches inner and outerlayers %intima andad#entitia(
i#. BIect of "lood pressurecreates !alloonenlargement
". 3ost -@33@3 sites: Aorta or-ere"ral
c. Highest at risk:i. 3en o#er CCii. *omen o#er 5
d. Symptoms #aryi. Serious: can "e deadly
1>. -ommon A?9@/3AL7TW: "hle!#t#s Throm!ophle!#t#s
a. Throm!ophle!#t#s:in2ammation of the wall of a #ein withassociated throm"osis$ often occurring in the legs duringpregnancy.
". "hle!#t#s:7n2ammation o f #eini. 7M in+ltration or irritationii. @ften with throm"osis %clot( (hrombophlebitis
1G.Throm!ophle!#t#s *s T:
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a. Throm"ophle"itis: more super+cial". DMT: Deep
1;. De#elopmental -onsiderations %children and aging adult( 6PMS and Lymphatic system:
a. $n%ants and Ch#ldren: Pulse force should "e normal andsymmetric %same in upper and lower e)tremeties(
i. Palpa"le lymph nodes: often in healthy infants andchildren
1. Small$ +rm$ mo"ile$ nontender
,. 3ay "e se8uelae froma. past infection". #accines
. Still not location and characterics %local orgeneraliJed(
A?9@/3AL 79D79KS:
9ea6pulses: #asoconstriction of diminished cardiac output
@ull, !ound#ngpulses occur with patent ductus arteriosus from
the large lefttoright shunt
#m#n#shed or A!sent%femoral Pulse(: while upper e)tremity
pulses are normal %coarctation of aorta( nlarged Tender Nodes: current infection
b. Aging adult: DP and PT pulses may "ecome more di4cul to+nd.
i. Trophic changed associated with arterial insu4ciency
1.Thin
2. Shiny skin
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3.Thickridged nails
4. Loss of hair on lower legs
ii. All occur normally with Aging.
A?9@/3AL 79D79KS: ;eneral#2ed dema: suggests heart disease
+pertens#on: suggests preeclampsia %dangerous o"stetric
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