NANCY SANDERSON MSN, RNLECTURE 5

NRS 103 Thorax and Lungs Chapter 11

Concept Overview

Oxygenation: Processes that facilitate and impair

oxygenation. Adequate perfusion is necessary to deliver

oxygenated blood to tissues and remove metabolic waste.

Intracranial regulation supports oxygenation.

Adequate oxygenation needed to support intracranial function.

Interrelationship necessary.

The primary purpose of the respiratory system is to supply oxygen to cells and remove carbon dioxide .

• This purpose is accomplished using the process of ventilation and diffusion.

o Ventilation is the process of moving gases in and out of the lungs by inspiration and expiration.

o Diffusion is the process by which oxygen and carbon dioxide move from areas of high concentration to areas of lower concentration.

o After inspiration oxygen concentration is higher in the alveoli than in the pulmonary capillaries. This difference in concentration causes oxygen to move or diffuse from the alveoli across the alveoli-capillary membrane to the adjacent pulmonary capillaries. It is then carried by the erythrocytes (RBC’S) to the cells.

Anatomy and Physiology

Three main structures within thorax or chest: • Mediastinum and right and left pleural

cavities.

Mediastinum positioned in middle of chest. Within it are:• Heart• Arch of aorta• Superior vena cava• Lower esophagus• Lower part of trachea

Structures in the Thorax:Mediastinum

Structures within the thorax:

Right lung has three lobes and left has two. Each lobe has a major, oblique fissure dividing

upper and lower portions. However, right lung has a lesser horizontal fissure

dividing upper lung into upper and middle lobes.Each lung extends anteriorly about 1.5 inches

above first rib into base of neck in adults. Posteriorly, lungs’ apices rise to level of T1 (first

thoracic vertebrae); lower borders expand down to T12 and, on expiration, rise to T9.

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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Structures of the Thorax: The lungs

Structures in the Thorax:Pleural Cavities

Pleural cavities contain lungs. • These cavities lined with two types of serous

membranes: • Parietal pleura• Visceral pleura

Chest wall and diaphragm are protected by parietal pleura, and lungs are protected by visceral pleura.

Small amount of fluid lubricates space between pleurae to reduce friction as lungs move during inspiration and expiration.

Health History:

Tobacco use (amount, duration, Pack year index) ½ pack/day x 30 years = 15 year smoking history

http://www.coquitline.org/• 3rd hand smoke exposure• 2nd hand smoke exposure

Occupation/Exposure to pulmonary irritants• Chemicals, vapors, dust, allergens, animals, smoke,

asbestos, arsenic, coal dust, radiation) PMH/FH of respiratory illness/disease/cancer or allergies

• Pneumonia, TB, COPD, asthma, lung cancer• Pneumonia or influenza vaccine received?

Health History: TB

Risk factors for TB: • HIV, substance abuse, low income or homeless,

resident of nursing home, shelter or prison, immigrant from country with high TB rate

Health History cont. :

Do you have any shortness of breath? (Dyspnea)• Occurs @ rest, with exercise, lying flat?

Have you heard any wheezing? Do you have a cough?

• Dry, productive, barking, etc..• http://www.youtube.com/watch?v=mXAxnZ4JJ6A

• Amount, color,& consistency of sputum. Presence of odor.

• Hemoptysis- coughing up blood (varies from blood streaked phlegm to frank blood)

Do you have chest pain with breathing? Have you recently had any pain in calves or

been on any long car or plane rides?

Inspection:

Observe symmetry, rate, rhythm, depth and effort of breathing• Symmetry: Chest wall movement equal bilaterally• Rate: Adult 12-20 resp/min is normal

• Bradypnea: Slow (<12 per minute)• Tachypnea: Rapid (>20 per minute)

• Rhythm: Regular vs. irregular• Cheyne-Stokes, Kussmaul’s respirations, Biot’s

• Depth• Hypoventilation–rate slow, depth• Hyperventilation–rate rapid, depth deep

Respirations 16/min, symmetrical,relaxed and even

Inspection cont.:

Observe symmetry, rate, rhythm, depth and effort of breathing• Symmetry: Chest wall movement equal bilaterally• Rate: Adult 12-20 resp/min is normal

• Bradypnea: Slow (<12 per minute)• Tachypnea: Rapid (>20 per minute)

• Rhythm: Regular vs. irregular• Cheyne-Stokes, Kussmaul’s respirations, Biot’s

• Depth• Hypoventilation–rate slow, depth Hyperventilation–rate rapid, depth deep

Respirations 16/min, symmetrical,relaxed and even

Inspection cont.:

Body position• Relaxed vs. Upright/Tripod position

Color of skin, lips, nail beds• Even skin tone vs. cyanotic

Presence of clubbing

Patient relaxed. Skin and mucous membrane pink. Nail beds pink without clubbing in upper and lower extremities.

Pictures of finger clubbing pg. 108

Inspect/Palpate Trachea Position

Inspect Should be midline

Palpate For tracheal shift

Place finger in sternal notch and slip to each side.

Trachea midline.

Inspection Documentation:

Wounds, scars, drains, tubes, dressings• Documentation must include location, size, amount

of drainage and discharge if present, and signs of inflammation.

• Additional terms to describe location:o Supraclavicular- Above the clavicleso Infraclavicular- Below clavicleso Interscapular- Between scapulao Infrascapular- Below scapulao Midaxillary line- Along line of armpito Midclavicular- Along line in middle of clavicle

No wounds, scars, drains, tubes, or dressings. Or- No lesions.

Inspection: Shape of Thorax

Shape of Chest :• Deformities • Symmetrical vs. asymmetrical

o Pectus carniatum, Pectus excavatum, Spinal deformitiies• Normal AP diameter vs.. increased AP diameter

o Oval vs. barrel chesto Ribs slope downward vs. more horizontalo Barrel chest appears as if patient in continuous

inspiratory positionChest symmetrical without deformities. AP < transverse.

Refer to pictures on pg. 207 for examples of the above deformities and abnormals.

Palpation Assess for masses,

tenderness, or crepituso Subcutaneous emphysema-

air escapes form lungs into subcutaneous tissue

Assess chest expansion Posteriorly place thumbs at

level of 10th rib & place palms on posterolateral chest.

Approx 2 inches apart before inspiration. Feel thoracic expansion during quiet & deep inspiration. Look for symmetry.

Chest expansion symmetrical. No masses or tenderness.

http://www.youtube.com/watch?v=ygD93IKorEw

Palpation

Tactile Fremitus• Palpable vibrations

transmitted through bronchopulmonary tree to chest when patient speaks

• Have patient repeat 99 or 1, 1, 1 while palpate with ulnar surface or ball of hando Decreased or absent when

vibration impeded by obstructed bronchus, tumor, or separation of pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), or air (pneumothorax)

o Increased with gross compression or consolidation (lobular pneumonia) without bronchus obstruction

Tactile fremitus equal bilaterally.

Percussion

Tapping of an chest to set chest wall and underlying tissues into motion

Helps to establish if underlying tissue air-filled, fluid-filled, or solid

Normal sound is resonance

Resonant to percussion over all lung fields.Review pictures on pg. 204 for locations for

percussion and auscultation: Anterior, Posterior and Lateral views.

Percussion

Auscultation

Use diaphragm of stethoscope andhave patient breath out of their mouth.

• Peds- use smaller pediatric diaphragm

Place stethoscope firmly on skin. Avoid movement because it may produce confusing sounds (i.e. clothing)

Auscultate at least one complete respiration

Move from one side to the otherObserve for hyperventilation, allow to rest

if needed Peds- transmission of sounds enhanced,

harder to localize sounds

Auscultation (con’t)

Hairy chest men: Hold stethoscope firmly over chest hair Prevents moving over and giving false sounds

Put stethoscope on skin (seasoned nurses and MD’s may put over light shirt

because of expert status)

Auscultation: Anterior

AuscultationAdventitious Breath

Sounds Wheezes (Sibilant

wheeze) High pitched, musical

sound heard during inhalation or exhalation

Mild, moderate, severe

Rhonchi (Sonorous wheeze) Low pitch snoring

sound during inspiration or exhalation, but louder on exhalation

May clear with coughing

Asthma

Auscultation

Crackles/Rales Popping sounds heard

on inhalation

Fine High pitched fine, short,

interrupted crackling sounds heard during end of inspiration

Medium Lower, more moist sounds

heard during middle of inspiration

Course Loud, bubbly sounds heard

during inspiration

http://www.med.ucla.edu/wilkes/intro.html

Auscultation

Stridor High pitched, harsh sound heard on inspiration

when trachea or larynx is obstructed Croup, foreign body, large airway tumor

http://www.youtube.com/watch?v=QkaX83H31QY&feature=PlayList&p=0C59700763AFDD1E&playnext=1&index=8

http://www.youtube.com/watch?v=Z1_uKqmPyLA&feature=related

Auscultation Cont.:

Voice Sounds• Bronchophony

• “99” or “1-2-3”o Normal- Muffledo Abnormal- Clear

• Whispered Pectoriloquy• Whisper “1,2,3”

o Normal- faint and indistincto Abnormal- clear and distinct

• Egophony• “eeeeeeee”

o Normalo Abnormal “aaaaaa”

Auscultation Documentation:

Breath sounds vesicular without adventitious sounds.

Or- Lungs sounds CTA in all lung fields without wheezes, rales, rhonchi, or rubs

Auscultation: Abnormal

Pneumonia

Atelectasis

pneumothorax

Also known as collapsed lung• Spontaneous• Traumatic• Tension

Treatment is Chest tube:

Important to get good history• If smokes offer smoking cessation classes • History asthma

o What is current treatment? If has c/o chronic cough ask about history and

exposure so MD can rule out (r/o):• Birds including chickens r/o TB• Smoker r/o cancer• Chemicals/asbestos r/o cancer

Summary: Bringing it all together

Summary (continued)

Shortness of breath and recent travel:• Pulmonary embolism • Swelling of legs: DVT

Proper auscultationPercussionMultiple problems & concerns

Summary Continued

AsthmaAtelectasisBronchitisCancerCroupEmphysema

HemothoraxPleural EffusionPneumoniaPneumothoraxTuberculosis