Chapter 19: Thorax and Lungs Nursing
Exam 2022
What is the thoracic cage? - Answer- -bony structure with a conical shape, narrower
at top
-defined
... [Show More] by sternum, ribs and thoracic vertebrae
What is the sternum? - Answer- -"breast bone"
-has 3 parts:
>manubrium
>body
>xiphoid process
How many ribs do we have? - Answer- -12 pairs
>first 7 are attached directly to sternum via costal cartilage
>8, 9, and 10 attach to the costal cartilage above
>11 and 12 are "floating" ribs with free palpable tips
What are the costochondral junctions? - Answer- -the points at which the ribs join
their cartilages
What is the suprasternal notch? - Answer- -U shaped hollow depression just above
sternum, between the clavicles
What is the sternal angle? - Answer- -AKA angle of Louis
-it is the articulation of the manubrium and body of sternum, it is continuous with the
2nd rib
-this is a useful place to start counting the ribs
-this angle also marks the site of tracheal bifurcation into the right and left main
bronchi
How are the intercostal spaces numbered? - Answer- -they are numbered by the rib
above it
How far can you easily palpate down? - Answer- -easily palpate to the 10th rib
What is the costal angle? - Answer- -right and left costal margins form an angle
where they meet at the xiphoid process
-usually 90 degrees or less
-this angle will increase when the rib case is chronically overinflated (ex:
emphysema)
What is the vertebra prominens? - Answer- -flex head and feel for most prominent
bony spur protruding at the base of the neck.. this is the C7
-note: if two bumps seem equally prominent, the top one is C7 and the bottom is T1
How to palpate the 12th rib? - Answer- -palpate midway between the spine and the
person's side to identify its free tip
What are the reference lines? - Answer- -on the anterior chest, note the midsternal
line and the midclavicular line
-on the posterior chest, note the vertebral line and scapular line
-life up person's arm 90 degrees, note the anterior axillary line, posterior axillary line,
and midaxillary line
What is the mediastinum? - Answer- -middle section of thoracic cavity containing
esophagus, trachea, heart, and great vessels
Lung Borders - Answer- -in anterior chest, apex (highest point), of lung tissue is 3-4
cm above inner third of the clavicles
-the base (lower border) rests on diaphragm at about the 6th rib in midclavicular line
-laterally lung tissue extends from the apex of the axilla down to the 7th or 8th rib
-posteriorly the location of C7 marks apex of lung and T10 marks base
Lobes of the Lungs - Answer- -right lung is shorter and wider
-left lung is narrower bc heart bulges into left
-right lung has 3 lobes
-left lung has 2 lobes
Anterior Chest - Answer- -oblique fissure crosses 5th rib in the midaxillary line and
terminates at the 6th rib in the midclavicular line
Posterior Chest - Answer- -almost all lower lobe
-inferior border reaches down to the level of T10 on expiration and T12 on inspiration
Lobes of the LEFT Lung - Answer- -upper and lower
-upper lobe extends from apex of axilla down the 5th rib at midaxillary line
-lower lobe continues down from 8th rib in midaxillary line
Lobes of the RIGHT Lung - Answer- -upper, middle, lower
-upper lob extends from apex of the axilla down to horizontal fissure at 5th rib
-middle lobe extends from horizontal fissure down and forwards to 6th rib at the
midclavicular line
-lower lobe continues from 5th rib to the 8th rib in the midaxillary line
What are the three points that commonly confuse beginning examiners? - Answer- -
the left lung DOES NOT have a middle lobe
-the anterior chest contains MOSTLY upper and middle lobe with very little lower
lobe
-the posterior chest contains ALMOST ALL lower lobe
What are pleurae? - Answer- -thin, slippery serous membranes that form an
envelope between the lungs and the chest wall
-inside the envelope, the pleural cavity, is a potential space filled only with a few
milliliters of lubricating fluid
Where is the trachea located? - Answer- -lies anterior to the esophagus (in front of)
-10-11cm long in an adult
What are the four major functions of the respiratory system? - Answer- (1) supplying
oxygen to the body for energy production
(2) removing carbon dioxide as a waste product of energy reactions
(3) maintaining homeostasis (acid-base balance) of arterial blood
(4) maintaining heat exchange (less important in humans)
What is hypoventilation? - Answer- -slow shallow breathing
-causes carbon dioxide to build up in the blood
What is hyperventilation? - Answer- -rapid, deep breathing
-causes carbon dioxide to be blown off
How are respirations controlled? - Answer- -involuntarily
-mediated by respiratory center in brainstem (pons and medulla)
What is hypercapnia? - Answer- -increase of carbon dioxide in blood
What is hypoxia? - Answer- -decease of oxygen in the blood
-note: this also increases respirations by is less effective than hypercapnia
Respiration - Answer- -inspiration: air rushes into lungs as chest size increases
-expiration: air is expelled from lungs as chest recoils
How does the mechanical expansion and contraction of the chest cavity alter the
size of the thoracic cavity? - Answer- (1) vertical diameter lengthens or shortens,
which is accomplished by downward or upward movement of the diaphragm
(2) the anteroposterior (AP) diameter increases or decreases, which is accomplished
by elevation or depression of the ribs
The fukkin aging adult - Answer- -costal cartilages become calcified —> thorax is
less mobile
-respiratory muscle strength declines after age 50 yo and continues to decrease into
70s
-decrease in elastic properties within the lungs making them less distending less and
lessening their tendency to collapse and recoil
-aging lung is a more rigid structure and harder to inflate
-changes result in an increase in small airway closure, which yields a decreased vital
capacity and increases residual volume
Histologic changes in the motha fukkin aging adult - Answer- -gradual loss of intraalveolar septs and decreased number of alveoli
-less surface area is available for gas exchange
-lung bases become less ventilated as a result of closing off a number of airways —>
increased risk for dyspnea with exertion beyond his or her usual workload
-increased risk for postoperative pulmonary complications
-increased risk of postoperative atelectasis and infection from a decreased ability to
cough and a loss of protective airway reflexes and increased secretions
What is vital capacity? - Answer- -maximum amount of air that a person can expel
from the lungs after first filling the lungs to maximum
What is residual volume? - Answer- -amount of air remaining in the lungs after the
most forceful expiration
What is atelectasis? - Answer- -complete or partial collapse of a lung or a lobe of a
lung
Lung cancer - Answer- -is the 2nd most commonly diagnosed cancer in both men
and women, but it is the leading cause of cancer death in the US
Tuberculosis - Answer- -an airborne lung disease that has infected one-third of the
worlds population
-due to increased globalization and air travel
-"social and migratory" disease
-ppl at risk for TB: HIV, homeless, ppl in group settings (shelters, prisons, and longterm care)
Subjective Data: What do you ask patient? - Answer- (1) cough
(2) shortness of breath
(3) chest pain with breathing
(4) history of respiratory infections
(5) smoking history
(6) environmental exposure
(7) patient centered care
Subjective Data: Coughing - Answer- -do you have a cough? when did it start?
gradual or sudden onset?
-how long have you had it?
-how often do you cough? any special time of day or just on rising? does your cough
wake you up at night?
-phlegm?
-do you cough up blood? foul odor?
-hacking, dry, barking, hoarse, congested, bubbling?
-does it come with activity?
Subjective Data: SOB - Answer- -are you having SOB?
-within last day?
-any hard-breathing spells? When did it start? How severe? How long does it last?
-affected by position?
-any specific time of day or night?
-sob associated with night sweats?
Subjective Data: Chest Pain - Answer- -chest pain with breathing? Point to location
-when did it start? Constant, or does it come and go?
-describe pain: brushing or stabbing?
-brought on by respiratory infection, coughing, trauma? Associated with fever, deep
breathing, unequal chest inflation?
Subjective Data: History of Respiratory Infections - Answer- -any past history of
breathing trouble or lung disease (Bronchitis, emphysema, asthma, pneumonia)
-any unusually frequent or unusually severe colds?
Subjective Data: Smoking History - Answer- -do you smoke cigarettes or cigars? At
what age did you start? How many packs per day? For how long?
-have you ever tried to quit? What helped?
-live with someone who smokes?
Subjective Data: Environmental Exposure - Answer- -are there 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?
-do you do anything to protect your lungs, such as wear a mask or have ventilatory
system checked at work?
-do you do anything to monitor your exposure?
-do you have periodic examinations, pulmonary function tests, or x-ray
examinations?
-do you know what specific symptoms to note that may signal breathing problems?
Subjective Data: Patient Centered Care - Answer- -last TB skin test, chest X-ray
study, pneumonia vaccine, or influenza immunization?
Additional History: Old Fukks - Answer- (1) have you noticed any SOB or fatigue with
your daily activities?
>old fukks have a less efficient respiratory system—> less tolerance for activity
(2) tell me about your usual amount of physical activity
>may have reduced exercise capacity because of pulmonary function deficits
>sedentary or bedridden ppl at risk for respiratory infection
Lung Function Questionnaire - Answer- -if score 18 or less= at risk for COPD
-use this test especially for smokers
-determines who should be further assessed for lung function
Acute Cough - Answer- -lasts less than 2 or 3 weeks
Chronic Cough - Answer- -lasts over 2 months
Conditions with characteristic timing of cough - Answer- (1) continuous throughout
day—acute illness (e.g., respiratory infection)
(2) afternoon/evening—may be exposure to irritants at work
(3) night—postnasal drip, sinusitis
(4) early morning—chronic bronchial inflammation of smokers.
Hemoptysis - Answer- -coughing up blood
Conditions that have characteristic sputum production - Answer- (1) white or clear
mucous- colds, bronchitis, viral infections
(2) yellow or green- bacterial infections
(3) rust colored- TB, pneumococcal pneumonia
(4) pink, frothy- pulmonary edema, some sympathomimetic medications have side
effect of pink-tinged mucus
Conditions with characteristic cough - Answer- -mycoplasma pneumonia- hacking
-early heart failure- dry
-croup- barking
-colds, bronchitis, pneumonia- congested
Dyspnea - Answer- -difficulty breathing
Determining how much activity precipitates SOB - Answer- -state specific number of
blocks walked
-number of stairs
Chronic Dyspnea - Answer- -SOB lasting >1 month and may have neurogenic,
respiratory, or cardiac origin
-also occurs with anemia, anxiety, deconditioning
What is orthopnea? - Answer- -difficulty breathing when supine (laying down on
back)
-state number of pillows needed to achieve comfort
What is paroxysmal nocturnal Dyspnea? - Answer- -awakening from sleep with SOB
and needing to be upright to achieve comfort
-jumps out of bed in middle of night gasping for air
Costochondritis - Answer- -an inflammation of the cartilage that connects a rib to the
sternum
-chest pain of thoracic origin occurs with muscle soreness from coughing or from
inflammation of pleura overlying pneumonia
-coughing a lot can lead to a cracked rib
What are farmers at risk of? - Answer- -grain or pesticide inhalation
What are people in Midwest at risk of? - Answer- -histoplasmosis exposure (fungus)
What are people in southwest and Mexico at risk for? - Answer- -cidiodomycosis
(causes infection when inhaled)
What are coal miners at risk for? - Answer- -pneumoconiosis (occupational lung
disease)
How to obtain objective data - Answer- -begin respiratory examination just after
palpating thyroid gland when you are standing behind the person
-perform inspection, palpating, percussion, and auscultation on posterior and anterior
thorax
-after, move to front and perform maneuvers on anterior chest
Inspecting: posterior chest - Answer- -note the AP diameter (should be less than
transverse diameter) [1:2 ratio]
Abnormal findings for inspecting posterior chest - Answer- -AP = transverse
diameter: barrel chest- ribs are horizontal, chest appears as if held continuous
inspiration
-occurs from COPD from hyperinflation of lungs
-ppl with COPD often sit in tripod position, leaning forward with arms braced against
their knees, chair, or bed, it gives them leverage so the abdominal, intercostal, and
neck muscles all can aid in expiration
Palpating: posterior chest - Answer- -confirm symmetric chest expansion by placing
hands sideways on posterolateral chest wall with thumbs pointing together at the
level of T9 or T10
-ask person to take deep breath, your thumbs should move apart symmetrically
-tactile fremitus
Tactile Fremitus - Answer- -palpable vibration
-sounds generated from larynx are transmitted through patent bronchi and the lung
-palmar base (the ball) of the fingers or the ulnar edge of one hand and touch the
person's chest while he or she repeats the words "ninety-nine" or "blue moon"
-these are resonant phrases that generate strong vibrations
-start over the lung apices and palpate from one side to the other
-symmetry is most important; the vibrations should feel the same in the
corresponding area on each side
-fremitus is most prominent between the scapulae and around the sternum, sites
where the major bronchi are closest to the chest wall
-normally decreases as you progress down because more and more tissue impedes
sound transmission
-fremitus feels greater over a thin chest wall than over an obese or heavily muscular
one where thick tissue damps the vibration
-a loud, low pitched voice generates more fremitus than a soft, high pitched
Abnormal findings for palpating the posterior chest - Answer- -unequal chest
expansion occurs with marked atelectasis, lobar pneumonia, pleural effusion,
thoracic trauma (fractured ribs or pneumothorax)
-decreased fremitus: occurs with obstructed bronchus, pleural effusion or thickening,
pneumothorax, or emphysema
-increased fremitus: occurs with compression or consolidation of lung tissue
-rhoncal fremitus: palpable with thick bronchial secretions
-pleural friction fremitus: palpable with inflammation of the pleura
Crepitus - Answer- -a coarse, crackling sensation palpable over the skin surface
-occurs in subq emphysema when air escapes from the lung and enters subq tissue,
as after open thoracic injury or surgery
Percussing: Posterior Chest - Answer- -determine predominant note over the lung
fields
-start at apices and percuss the band of normally resonant tissue across the tops of
both shoulders
-make side to side comparison
-percuss at 5 cm intervals
-avoid damping effect of scapulae and ribs
-resonance is always heard over lungs
Resonance - Answer- -always heard over normal lungs
-low pitched, clear, hollow sound
-resonant not may be duller in athlete with heavy muscular chest
-in heavily obese -> scattered dullness
Abnormal findings for percussing posterior chest - Answer- -hyperresonance: lower
pitched booming sound when too much air is present such as in emphysema or
pneumothorax
-a dull note (soft, muffles, thud) signals abnormal density in the lungs, as with
pneumonia, pleural effusion, atelectasis, or tumor
Auscultating: Posterior Chest - Answer- -evaluate presence and quality of normal
breath sounds
-instruct pt to breathe through mouth a little deeper than usual but stop if he or she
begins to feel dizzy
-do not confuse extraneous noises
-while standing behind person, listen to the following areas: posterior from the apices
at C7 to the bases (around T10) and laterally from axils down to 7th or 8th rib
-should expect to hear three types of sounds
What are the 3 types of normal breath sounds? - Answer- -bronchial
-bronchovesicular
-vesicular
Bronchial Breath Sound - Answer- -pitch: high
-amplitude: loud
-duration: inspiration less than expiration
-quality: harsh, hollow, tubular
-normal location: trachea and larynx
Bronchovedicular Breath Sound - Answer- -pitch: moderate
-amplitude: moderate
-duration: inspiration = expiration
-quality: mixed
-normal location: over major bronchi where fewer alveoli are located: posterior,
between scapulae especially on right; anterior, around upper sternum in 1st and 2nd
intercostal spaces
Vesicular Breath Sound - Answer- -pitch: low
-amplitude: soft
-duration: inspiration greater than expiration
-quality: rustling, like the sound of wind in the trees
-normal location: over peripheral lung fields where air flows through smaller
bronchioles and alveoli
Abnormal findings for auscultating posterior chest - Answer- -breath sounds are
changed by obstruction in passageways or by disease in lung parenchyma, the
pleura, or chest wall
-decreased or absent breath sounds: occur when
>bronchial trees are obstructed at some by point by secretions, mucus plug, or
foreign body
>in emphysema as a result of loss of elasticity in lung fibers and decreased force of
inspired air; the lungs also are already hyper inflated, so the inhaled air does not
make as much noise
>when anything obstructs transmission of sound between lung and stethoscope
such as pleurisy or pleural thickening (pneumothorax) or fluid (pleural effusion) in
pleural space
-silent chest means no air is moving in or out
-increased breath sounds mean that sounds are louder than they should be
(bronchial sounds are abnormal when they are heard over an abdomen location, the
peripheral lungs)
Adventitious Sounds - Answer- -added sounds that are not normally heard in lungs
-if present, they are heard as being superimposed on the breath sounds
-they are caused by moving air colliding and it's secretions in the tracheobronchial
passageways or by the popping open of previous deflated airways
Atelectic Cackles - Answer- -short, popping, crackling sounds that only last s few
breaths
-heard only over periphery
Crackles (breath sound) - Answer- -discontinuous popping sounds heard over
inspiration
Wheezes (breath sound) - Answer- -continuous musical sounds heard mainly over
expiration
Voice sounds - Answer- -normal voice transmission is soft, muffles, and indistinct;
you can hear sound through the stethoscope, but cannot distinguish exactly what is
being said
-pathology that increases lung density enhances transmission of voice sounds
-not elicited routinely
-testing for possible presence of bronchophony, egophony, and whispered
pectoriloquy
Inspecting: anterior chest - Answer- -shape and configuration of chest wall
-ribs are sloping downward with symmetric interspaces
-costal angle is within 90 degrees
-not facial expression
-note skin color and condition
-quality of respirations
Abnormal findings for inspecting anterior chest - Answer- -barrel chest has horizontal
ribs and costal angle >90 degrees
-unequal chest expansion occurs when part of lung is obstructed
-retraction in interspaces suggests obstruction of respiratory tract or than increased
inspiratory effort is needed
Palpating: anterior chest - Answer- -symmetric chest expansion
-asses tactile fremitus ("99" "blue moon")
-avoid palpating over female breast tissue
Percussing: anterior chest - Answer- -begin Percussing the apices in the
supraclavicular areas, comparing one side with the other
Auscultating: anterior chest - Answer- -listen to one full respiration in each location
(inspiration and expiration)
Measurement of pulmonary function status - Answer- -forced expiratory time:
number of seconds it takes for the person to exhale from total lung capacity to
residual volume (air left behind)
-handheld spirometer measures lung health in chronic conditions such as asthma
-pulse oximeter: noninvasive method to asses arterial oxygen saturation
-6 minute walk test: used as an outcome measure for people in pulmonary rehab
What is forced vital capacity (FVC)? - Answer- -total volume of air exhaled
What is forced expiration volume in 1 seconds (FEV1)? - Answer- -volume exhaled
in the first measured second
What is kyphosis? - Answer- -outward curvature of the thoracic spine
-seen in aging adult
Normal Adult (for comparison) - Answer- -thorax has an elliptical shape with an
anteroposterior-to-transverse diameter documented
Barrel Chest - Answer- -note equal AP-transverse diameter and that ribs are
horizontal instead of the normal downward slope
-associated with normal aging and also with chronic emphysema and asthma as a
result of hyperinflation of lungs
Socliosis - Answer- -a lateral S-shaped curvature of the thoracic and lumbar spine,
usually with involved vertebrae rotation
-note unequal shoulder and scapular height and unequal hip levels, rib interspaces
flared on convex side
-more prevalent in adolescent age-groups, especially girls
-mild deformities are asymptomatic
if severe (>45 degrees) deviation is present, scoliosis may reduce lung volume, and
person is at risk for impaired cardiopulmonary function
-primary impairment is cosmetic deformity, negatively affecting self-image
Kyphosis - Answer- -an exaggerated posterior curvature of the thoracic spine
(humback) that causes significant back pain and limited mobility
-severe deformities impair cardiopulmonary function
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