Thoracic AssessmentUnit 6Thoracic Assessment Overview Anatomy & Physiology History IPPA Developmental Considerations Nursing Diagnoses Teaching Opportunities Oro/naso pharynx and respiratory treerespiratory system extends from nares to diaphragmAnatomy & PhysiologyThoracic 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 fluidLungs 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 inBreathingExhalation nearly opposite passive event diaphragm relaxes chest wall and lungs recoil (elastic) air is expelledPulmonary pressuresIntrapulmonic (within lungs)Intrapleural (around lungs) Boyles law - volume of gas varies inversely with P intrapleural pressure ALWAYS NEGATIVE(unless chest cavity open) essential - creates suctionholds 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 AssessmentInspection Skin color and nutritional state lips - color nail beds - color and shape posture Thoracic contour shape, symmetry developmental: Pigeon chestFunnel chest Spinal DeformitiesKyphosis 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= E low pitch soft intensity sigh Bronchovesicular-over bronchi I=E moderate pitch and intensity, breezy Bronchial/Tracheal I