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Saturday, May 17, 2008

Nursing Resource Slides: Thorax & Lungs

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Nursing Resource Slides: Thorax & Lungs Slide Transcript
Slide 1: Thorax and Lungs

Slide 2: Outline Structure and Function Subjective Data Objective Data Abnormal Findings

Slide 3: Structure and Function

Slide 4: Thoracic Cage /Cavity Shape- bony, conical shape, narrower at top borders – it is defined by:  Sternum – 3 parts: manubrium, body, xiphoid process  Ribs – 12 pairs, 1st seven attach to the sternum (costal cartilages) Ribs 8,9,&10 attach to the costal cartilage above, Ribs 11 & 12 are floating ribs  12 Thoracic vertebrae  Diaphragm – the floor, separates the thoracic cavity from the abdomen

Slide 5: Anterior Thoracic Landmarks Suprasternal Notch – U shaped depression Sternum – “breastbone” = 3 parts 1. Manubrium 2. Body 3. Xiphoid process  Angle of Louis – manubriosternal angle continuous with the 2nd Rib  Costal angle- usually 900 or <. (increases when rib cage is chronically overinflated)

Slide 7: Posterior Thoracic Landmarks Vertebra Prominens – Flex head, feel most prominent bony projection at base of neck = C7 next lower one is T1 Spinous Processes – spinal column- Scapula – symmetrical , lower tip at the 7 -8th Rib 12th Rib = midway b/t spine & side

Slide 9: Reference Lines Anterior Chest  Midsternal line  Midclavicular line Posterior Chest  Vertebral line – midspinal  Scapular line

Slide 10: Lateral Chest  Anterior Axillary line  Posterior Axillary line  Mid–axillary line

Slide 14: The Thoracic Cavity Mediastinum middle of the thoracic cavity & contains;  Esophagus  Trachea  Heart  Great Vessels Pleural Cavities on either side of the mediastinum contain the lungs

Slide 15: Lung Borders Anterior Chest –  Apex 3 -4 cm. ↑ inner 1/3 of the clavicles  Base – rests on the diaphragm, 6th rib, MCL Lateral Chest  Extends from Axilla apex to 7th –8th rib Posteriorly  Apex of lung is at C7 – Base T10 (on deep inspiration to T12)

Slide 16: Lobes of Lung Right Lung  3 lobes, upper, middle , lower  Shorter due to liver Left Lung  LUL = Left Upper and Lower ( 2 lobes)  Narrower due to heart

Slide 21: Lobes  Diagonal sloping segments  Oblique fissures

Slide 22: 3 Important Points • Left Lung – no middle lobe • Anterior chest contains upper & middle lobes with very little lower lobe • Posterior chest has almost all lower lobe. Rt middle lobe does not project into the posterior chest

Slide 23: Pleurae The Pleurae form an envelope b/t the lungs & chest wall Visceral pleura – lines outside of lungs Parietal pleura – lines inside of chest wall & diaphragm Pleural Cavity – the inside of the envelope- space b/t visceral & parietal pleura, lubrication. Normally has a vacuum or neg. pressure

Slide 25: Tracheal & Bronchial Tree Trachea – anterior to esophagus-  10-11 cm.long, begins at cricoid cartilage  Bifurcates just below the sternal angle ( AKA angle of Louis, manubriosternal angle) into the  Right Main Stem Bronchus – shorter, wider, more vertical ( Intubation – listen to breath sounds bilaterally)  Left Main Stem Bronchus

Slide 26: Tracheal & Bronchial Tree The trachea & bronchi provide the passage for air to get into the lungs from the environment = Dead Space (no air exchange takes place here)

Slide 27: Bronchi  Secrete mucus – captures particles  Cilia – moves the trapped particles up to be expelled or swallowed Acinus  Functional respiratory unit consisting of,  Bronchioles, alveolar ducts, alveolar sacs, & alveoli  Gaseous exchange in alveolar duct & alveoli

Slide 28: Mechanics of Respiration 4 Major Functions of the Respiratory System 1. Supply O2 for energy production 2. Remove CO2 , waste product of energy reactions 3. Homeostasis, acid-base balance of arterial blood 4. Heat exchange

Slide 29: Respiration maintains pH ( acid- base balance) of the blood by supplying O2 & eliminating CO2. Normal Range Values of Arterial Bld. Gases  pH= 7.35- 7.45  Pa CO2 = 35-45mmHg  PaO2 = 80-100mmHg  SaO2 = 94-98%

Slide 30: Lungs help to maintain the pH balance by adjusting the amt. of CO2 through:  Hypoventilation  Hyperventilation

Slide 31: Respiration = breathing Inspiration Expiration Control of Respiration  Involuntary control by respiratory center in the brain stem consisting of the pons & medulla  Hypercapnia is an ↑ in CO2 in the Bld. And provides the normal stimulus to breath  Hypoxemia

Slide 33: Subjective Data Cough SOB Chest Pain Respiratory Infections Smoking Environmental Exposure Self-care behaviors

Slide 34: Objective Data Inspect Palpate Percuss Auscultate After Posterior Thyroid Exam Posterior chest, Lateral chest, then Anterior chest

Slide 35: Remember to clean stethoscope end piece and warm prior to use on client. Quiet environment conducive to hearing lung sounds

Slide 36: Equipment for Exam Stethoscope Ruler – 15cm. Tape measure Washable marker Alcohol swabs

Slide 37: Posterior Chest Inspect Thoracic Cage  Shape and configuration  Anteroposterior Diameter should be < Transverse Diameter = Ratio 1:2 to 5:7  Note Position of Person to breathe.  ? orthopnea  Skin Color & Condition, nail color

Slide 39: Barrel Chest

Slide 40: Pectus Carinatum (Pigeon)

Slide 41: Pectus Excavatum (Funnel)

Slide 42: Posterior Chest Palpate  Symmetric Expansion- warmed hands – thumbs @ T9-T10- pinch sm. Fold of skin

Slide 44: Posterior chest  Tactile Fremitus – palpable vibration of sound from the larynx- use palmer base of fingers- “99” or Blue Moon  Symmetry important – vibration should feel the same bilaterally.  Avoid palpating over scapulae because bone dampens out sound

Slide 45: ↓ fremitus = obstructed bronchi, pleural effusion, pneumothorax or emphysema Note any barrier that is b/t the sound and your hand will↓ fremitus ↑ fremitus occurs only with gross changes (Lobar pneumonia).

Slide 47:  Entire Chest wall – gently palpate. Note  Tenderness, skin temp., moisture, lumps, lesions  Crepitus = coarse crackling sensation palpable over skin surface. (Subcutaneous emphysema when air escapes from lung into S/C tissue)

Slide 48: Posterior Chest Percuss start at the apices, across shoulders, then interspaces side to side (5cm. Intervals) Avoid scapulae & ribs  Resonance predominates in healthy lung  Hyperresonance – too much air, emphysema, pneumothorax  Dull = abnormal density, pneumonia, tumor, atelectasis

Slide 49: Expected Percussion notes

Slide 50: Diaphragmatic Expansion Lower lung borders in expiration & inspiration 1st Exhale & hold- percuss down the scapulae line until sound changes from resonant to dull. Mark with marker Estimates the level of the diaphragm separating the abd cavity. May be higher on Rt. Due to liver

Slide 51: Diaphragmatic Expansion Now take deep breath & hold. Percuss from mark to dull sound and mark. Measure the difference. Should be + bilaterally 3-5cm in adult may be 7-8 cm in well conditioned person Note hold your own breath when conducting this test!!!!!!!!!

Slide 52: Exhale Inhale

Slide 53: Posterior Chest Auscultate  Position client  Instruct to breath through mouth, little deeper than usual  Tell you if becomes light headed  Use flat diaphragm & hold firmly on chest  Must listen to at least 1 full respiration before moving stethoscope side to side  Compare both sides (lung fields)

Slide 54: Auscultation Sequence

Slide 55: Normal Breath Sounds Bronchial – Anterior Chest only = over trachea & larynx  Quality = harsh, hollow, tubular  Inspiration < Expiration  Amplitude = Loud

Slide 56: Breath Sounds Bronchovesicular both anterior & posterior  Over major bronchi, posterior b/t scapulae, anterior upper sternum, 1st & 2nd ICS  Pitch = high  Inspiration = Expiration  Moderate amplitude

Slide 57: Vesicular – Anterior & posterior  Quality = rustling, wind in trees  Inspiration > Expiration  Soft amplitude

Slide 58: Location of Breath Sounds

Slide 59: Decreased or Absent Breath Sounds  Causes =  obstruction of the bronchial tree by secretions, mucous plug, F.B  ↓ lung elasticity, emphysema = lungs hyperinflated  Pleurisy, pleural thickening, pneumothorax (air), pleural effusion (fld.) in the pleural space

Slide 60: Increased Breath Sounds = dense lung tissue enhances sound transmission as in consolidation ie. pneumonia Silent chest = ominous

Slide 61: Adventitious Sounds Not normally heard in the lungs. Caused by moving air colliding with secretions or by popping open of previously deflated airways Crackles (Rales)  Fine – high pitched popping- not cleared by coughing. Simulate sound by rolling strand of hair b/t fingers near ear or moisten thumb& index finger & separate them near your ear  Course crackles- (opening a velcro fastener) Pleural Friction Rub – coarse & low pitched, 2 pieces of leather rubbed together close to ear

Slide 62: Adventitious Sounds Wheeze (Rhonchi)  High pitched, musical squeaking = air squeezes - asthma  Low pitched musical snoring, moaning, =obstruction Stridor – high pitched, inspiratory, crowing, louder in neck = croup, acute epiglottitis

Slide 63: Coarse Crackles

Slide 64: Fine Crackles

Slide 65: Voice Sounds normal voice transmission is soft, muffled & indistinct. Pathology that ↑ lung density makes words clearer  Bronchophony – “99”  Egophony- ee-ee-ee if disease sounds like aa-aa- aa Record as “E → A changes”  Whisper pectoriloquy 1-2-3  These tests are only done if lung pathology is suspected

Slide 66: Anterior Chest Inspect  Shape & Configuration  Expression- relaxed  LOC – alert & cooperative  Skin color & condition  Quality of Respirations – reg. & even, no retraction or use of accessory muscles

Slide 67: Anterior Chest Palpate  Symmetric Chest Expansion  Tenderness, turgor, temp., moisture Tactile Fremitus  Compare both sides

Slide 68: Symmetric Expansion

Slide 69: Sequence for percussion & auscultation

Slide 70: Tactile fremitus

Slide 71: Percussion Apices in Supraclavicular Areas Interspaces = Resonance  Dullness  Female breast tissue  Liver – Rt. 5th intercostal space midclavicular  Heart – Lt. 3rd intercostal space midclavicular  Flat = muscle & bone  Tympany = stomach (Lt. Side)

Slide 72: Expected Percussion Notes

Slide 73: Auscultate Apices (supraclavicular) to 6th rib Bilateral moving down One full respiration Directly over chest wall – displace female breast tissue

Slide 74: Location Of Breath Sounds

Slide 75: Pulse Oximeter Noninvasive measurement of arterial oxygen saturation = SpO2 by measuring the relative amt. of light absorbed by oxyhemoglobin and unoxygenated hemoglobin. It compares light emitted to amt absorbed. Normally 97 -98%

Slide 76: Terms for Documentation Rate  Eupnea 12 – 20 bpm normal  Tachypnea > 24, rapid, shallow  Bradypnea < 10  Apnea = No respirations for 10 sec. or more

Slide 77: Pattern = breathing rhythm. Normal respirations are regular and even.  Cheyne – stokes = resp wax & wane in reg pattern with periods of apnea(20sec)  Biot’s or ataxisic Sim. To cheyne –stokes but pattern irreg.

Slide 78: Depth – on inspiration the normal depth is nonexaggerated and effortless.  Shallow  Sighing – purposeful to expand the alveoli

Slide 79: Symmetry – bilateral rise and fall of the chest with respiration Audibility – normally be heard by the unaided ear several centimeters from the patient’s nose/mouth

Slide 80: Patient position – healthy person breathes comfortably in supine, prone or upright position  Orthopnea Mode of Breathing – normally inhale/exhale through nose

Slide 81: Sputum  Sample  Color  Mucoid, yellow/green, rust/blood tinged, black, pink  Odor  Amount  Consistency

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