Nrsg238 Ch. 18 - More Respiratory

Front 1

Name the landmark lines for the anterior chest

Back 1

RSB or LSB
MSL
RMCL or LMCL
RAAL or LAAL

Front 2

Name the landmark lines for the lateral chest

Back 2

PAL
MAL
AAL

Front 3

Name the landmark lines for the posterior chest

Back 3

No abbreviations

Front 4

What are the borders of the thoracic cage?

Back 4

 The thoracic cage is defined by the sternum, 12 pairs of ribs, and 12 thoracic vertebrae. The diaphragm forms the floor of the thoracic cavity. The intercostal space is named for the rib above it.

Front 5

What are the Anterior Thoracic landmarks?

Back 5

• Suprasternal Notch – U-shaped depression just above the sternum.
• Sternum – Three parts – manubrium, body, xiphoid process
• Angle of Louis – Manubriosternal angle/sternal angle - the articulation of the manubrium and the body of the sternum; continuous with the 2nd rib; level of the tracheal bifurcation, upper border of the atria of the heart; lies above the fourth thoracic vertebra.
• Costal Angle – The angle of the lower costal margins; meet at the xiphoid process; should be 90° or less.

Front 6

What are the Posterior Thoracic Landmarks?

Back 6

• Vertebra Prominens – Most prominent bony spur protruding at the base of the neck; spinous process of C7; one right below it will be T1
• Spinous Processes – Count down these to locate the level of thoracic vertebrae and the ribs branching off of them
• Inferior Border of the Scapula – The lower tip is usually at the 8th or 9th rib
• Twelfth Rib – Palpate midway between the spine and the person’s side to identify its free tip

Front 7

What is the Pleurae and Costodiaphragmatic Recess?

Back 7

• The thin, slippery Pleurae form an envelope between the lungs and the chest wall. The Visceral pleura lines the outside of the lungs, and the Parietal pleura lines the inside of the chest wall and diaphragm.
• The Costodiaphragmatic Recess is a space of the pleurae that extends about 3cm below the level of the lungs. It can abnormally fill with fluid or air and compromise lung expansion.

Front 8

Explain details about the Trachea

Back 8

• The Trachea lies anterior to the esophagus and is 10-11 cm long in an adult. The tracheal bifurcation is at the level of T4 or T5 posteriorly, at the level of the Angle of Louis or 2nd ICS anteriorly, and high in the axilla laterally. The right main bronchus is shorter, wider, and more vertical than the left. This makes it easier for a foreign body to lodge in the right bronchus.

Front 9

What is the Bronchial Tree?

Back 9

• The Tree and the Bronchi transport gases between the environment and the lung parenchyma. They constitute dead space and do not allow for gas exchange, however they are lined with goblet cells and cilia to trap particles from the air and transport them out of the respiratory system.

Front 10

What is an Acinus?

Back 10

• An Acinus is the functional respiratory unit; consists of the bronchioles, alveolar ducts, alveolar sacs, and the alveoli.

Front 11

4 Main Mechanics of Respiration:

Back 11

• Supply oxygen to the body for energy production
• Remove CO2 as the waste product of energy reactions
• Maintain homeostasis of the acid-base balance system of arterial blood
• Maintain heat exchange

Front 12

What is Hypercapnia, Hypoxemia, and Surfactant?

Back 12

• Hypercapnia is the increase of CO2 that stimulates us to breathe
• Hypoxemia is a decrease in O2 in the blood that can stimulate us to breathe, but is less effective than hypercapnia
• Surfactant is the complex lipid substance neeed to sustained inflation of the alveoli

Front 13

What are the anterior surface landmarks of the thorax?

Back 13

• Anterior Chest: Suprasternal notch, sternum, manubriosternal angle (Angle of Louis)(2nd Rib), costal angle (should be <90°), tracheal bifurcation (2nd rib or intercostal space), clavicle (top of lung is 3-4 cm above the clavicle)

Front 14

What are the posterior surface landmarks of the thorax?

Back 14

• Posterior Chest: Vertebra prominens, superior border of scapula (around 2nd rib), inferior border of scapula (7th or 8th rib), 10th rib (lower level of lung with normal respiration), 12th rib (lower level of lung during deep inspiration), tracheal bifurcation (2nd rib or intercostal space); to locate T10, palpate floating rib in and move up to 11th rib, make a ‘v’ with your hands and you will be right around T10

Front 15

What are the borders of the lungs?

Back 15

• Lung Border Summary: Anterior – Above clavicle and down to the 6th rib; Lateral – High in axilla and down to the 8th rib; Posterior – T1 to T10 or T12; Lower borders are easy to remember as 6, 8, 10, and 12.

Front 16

What are three normal breath sounds in their expected region?

Back 16

• Bronchial – Normal over the trachea; loud with harsh sounds, tubular; I<E (inspiration is shorter than expiration)
• Bronchovesicular – Normal over major airways; quieter sound heard over sternum and scapulae; I=E
• Vesicular – Normal in peripheral lung fields; I>E

Front 17

What are the three normal voiced sounds of the lungs?

Back 17

• Bronchophony – Client voicing ‘99’ at each point of ascultation; should sound soft, muffled, and indistinct; fluid in the lungs would carry the sound and make it clearer
• Egophony - Client voicing ‘eeee’ at each point of ascultation; should hear an ‘aaaa’ (ay) sound; hearing an ‘eeee’ sound indicates consolodation (fluid, bacteria, RBC’s, WBC’s)
• Whispered Pectoriloquy – Client whispering ‘1, 2, 3’ at each point of ascultation; normal sound will be faint and muffled; hearing the whispers clearly transmitted indicates consolodation
• Documentation for ‘normal’ evaluation – “No bronchophony or egophony”

Front 18

What are four adventitious sounds that are always abnormal?

Back 18

 Crackles (rales): Discontinuous sounds due to fluid in alveoli or alveoli popping open after being compressed; always allow a person to move around/cough, etc. after waking up first thing – some alveoli may have closed while client was sleeping, but will clear up after some deeper breathing – could lead to a false diagnosis
 Wheezes: Continuous, high pitched sounds d/t obstructed air flow; typically heard with asthma
 Rhonchi: Continuous, low pitch type of wheeze; snoring sound; from mucous or fluid in the airway
 Stridor: From an upper airway obstruction; indicates a medical emergency will soon be happening; ex. Choking on foreign body

Front 19

What are five questions to ask while performing auscultation?

Back 19

• Where did I hear it?
• What did I hear?
• How did it compare to the opposite lung?
• Did it go away with coughing? (Especially with crackes and wheezes)
• Where in the respiratory cycle did I hear it? Inspiration/Expiration or Both?

Front 20

What are the expected normal findings of a thorax exam?

Back 20

 General inspection should show a normal LOC, VS, SpO2; no obvious signs of illness; moderate, rhythmic, symmetrical, unlabored respirations (Eupnea with 12-20 respirations per minute, around 1 breath for every 4 heartbeats); no pallor or cyanosis; anterior angle of costal margins at or <90 °; no retractions in the ICS (intercostal spaces); spine is straight with no scoliosis, kyphosis, “spine straight with no deviation”; AP to transverse shape/configuration is roughly 1:2 (not including infants)

Front 21

What are the general signs of respiratory distress?

Back 21

 General signs of respiratory distress include: Hypertrophy of the neck muscles, nasal flaring (esp. in babies), ICS retractions, pursed lips on expiration, tripod position, barrel chest with 1:1 configuration and costal margins >90° (from long-standing COPD)

Front 22

What are the 12 subjective areas we ask our patients for a respiratory assessment?

Back 22

• Any hx of chronic cough?
• Any shortness of breath?
• Any chest pain with breathing?
• Any past hx of illness associated with the lungs? Any hx of lung CA?
• Any hx of smoking?
• Any hx of environmental exposure to things such as farming chemicals, working in heavy outdoor traffic, etc.?
• Have you ever had a TB test or chest x-rays? What were the results?
• Are you current on childhood immunizations?
• Do you take any medications?
• Any personal or family hx of heart disease or heart problems?
• Do you have any allergies?
• Don’t forget COLDSPA!!

Front 23

What six things do we check upon inspection of the thorax?

Back 23

• Perform identification of landmarks, structures, and reference lines
• Include a description of skin including the lips and nails
• Include the thoracic configuration and ratio (ex. AP=1:2)
• Look at the angle of rib insertion anteriorly an posteriorly (ex. Anterior – horizontal, Posterior – sloped)
• Assess the ICS – note any bulging or retractions)
• Give a description of the spine

Front 24

What are the four areas of palpation assessment that we do for the thorax?

Back 24

• Perform a tracheal assessment (midline?)
• Check for symmetrical chest expansion using bilateral hand placement technique
• Assess skin turgor, lesions, moisture, and texture
• Assess tactile (vocal) fremitus on the anterior, posterior, and lateral chest (“99” palpation techniques)

Front 25

What are three general guidelines when percussing the thorax?

Back 25

• Be specific as to sound elicited and location heard. Describe lung borders, techniques, and findings
• Use percussed resonance starting at the apicies and comparing side to side as you work down
• Abnormal findings must be at least 2-3 cm wide

Front 26

What four sound qualities are possible when percussing a thorax?

Back 26

• Resonance – The sound heard over “healthy adult lungs,” sounds hollow, low-pitched, and clear
• Hyperresonance – Lower-pitched booming sound found when too much air is present, as in emphysema or pneumothorax; can be normal in small children as they do not have as much adipose tissue overlaying their chest cavity
• Dullness – A soft, muffled thud heard with abnormal density that would be present with pneumonia, pleural effusion, atelectasis, or tumor. Also heard over bone
• Diaphragmatic Excursion – Use percussion to determine equal movement of the diaphragm upon expiration and inspiration

Front 27

What are the sounds heard upon auscultation in 'normal' lungs and how do you document it?

Back 27

Vesicular, Bronchovesicular, Bronchial, Broncophony, Whispered Pectoriloquy, Egophony
• Documentation for ‘normal’ evaluation – “No bronchophony or egophony”

Front 28

What is the pattern to assess areas of tactile fremitus?

Back 28

Front 29

What is the lateral pattern for tactile fremitus?

Back 29

Front 30

What is the pattern for assessing percussion on the anterior and lateral aspects of the thorax?

Back 30

Front 31

What is the pattern for assessing percussion in the posterior position?

Back 31

Front 32

Where are the areas to auscultate lung sounds on the anterior chest?

Back 32

Front 33

Where are the areas to auscultate breath sounds on the posterior chest?

Back 33

Front 34

What is the pattern for auscultating breath sounds on the anterior and lateral chest?

Back 34

Front 35

What is the pattern for auscultation of breath sounds on the posterior chest?

Back 35

Front 36

What are some reasons for diminished breath sounds?

Back 36

-obesity
-foreign body
-hyperinflated lung (emphysemia)
-air or fluid in the pleural space
-not moving enough air
-

Front 37

What are the normal findings for auscultation?

Back 37

Front 38

What are the normal findings for inspection?

Back 38

Front 39

What are the normal findings for palpation?

Back 39

Front 40

What are the normal findings with percussion?

Back 40

Front 41

Components of a respiratory assessment in the clinical setting

Back 41

Front 42

Components of charting by exception in the clinical setting

Back 42

Front 43

What would be the typical documentation for this disease process?

Back 43

Pneumonia (consolodation) - Increased RR; guarding and lag on expansion on affected side; increased tactile fremitus, increased breath sounds on affected side (patent airway for both); increased clarity, bronchophony, egophony, whispered pectoriloquy present; crackles

Front 44

What is the expected findings of this disease process? (Enlarged alveoli and alveoli wall deterioration)

Back 44

Emphysema (COPD) - Increased anteroposterior diameter; barrel chest; use of accessory muscles; SOB; tachypnea; decreased tactile fremitus and chest expansion; hyperresonant; decreased diaphragmatic expansion; decreased breath sounds; muffled heart sounds; possible wheeze

Front 45

What are the expected findings of this disease process?

Back 45

Pneumothorax - Mediastinum shifted from midline; unequal chest expansion; poss tachypnea, cyanosis, bulging in interspaces; tactile fremitus decreased or absent; decreased BP; tachycardia; hyperresonant; decreased diaphragmatic excursion; breath sounds decreased or absent; no adventitious sounds

Front 46

What is atelectasis?

Back 46

Collapse of part of lung, or the entire lung

Front 47

Which of the following is true regarding the vertebra prominens? The vertebra prominens is:
1. the spinous process of C7.
2. usually not palpable in most individuals.
3. opposite the interior border of the scapula.
4. located next to the manubrium of the sternum.

Back 47

#1

Front 48

When performing a respiratory assessment on a patient, the nurse notes a costal angle of approximately 90 degrees. This characteristic is:
1. seen in patients with kyphosis.
2. indicative of lung disease.
3. a normal finding in a healthy adult.
4. an expected finding in a patient with a barrel chest.

Back 48

#3 - #1 would have no effect, #4 is >90°

Front 49

Which statement about the apices of the lungs is true? The apices of the lungs:
1. are at the level of the second rib anteriorly.
2. extend 3 to 4 cm above the inner third of the clavicles.
3. are located at the sixth rib anteriorly and the eighth rib laterally.
4. rest on the diaphragm at the fifth intercostal space in the midclavicular line.

Back 49

#2 - #3 and 4 are at the base

Front 50

During an examination of the anterior thorax, the nurse recalls that the trachea bifurcates anteriorly at the:
1. costal angle.
2. sternal angle.
3. xiphoid process.
4. suprasternal notch.

Back 50

#2 - Angle of Louis

Front 51

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
1. adventitious sounds and limited chest expansion.
2. increased tactile fremitus and dull percussion tones.
3. muffled voice sounds and symmetrical tactile fremitus.
4. absent voice sounds and hyperresonant percussion tones.

Back 51

#3 - Consolodation, like pneumonia

Front 52

The primary muscles of respiration include the:
1. diaphragm and intercostals.
2. sternomastoids and scaleni.
3. trapezius and rectus abdominis.
4. external obliques and pectoralis major.

Back 52

#1 - The others are used in labored respiration

Front 53

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
1. Between the scapulae
2. Third intercostal space, MCL
3. Fifth intercostal space, MAL
4. Over the lower lobes, posterior side

Back 53

#1 - At the level of the trachial bifurcation

Front 54

The nurse is aware that tactile fremitus is produced by:
1. moisture in the alveoli.
2. air in the subcutaneous tissues.
3. sounds generated from the larynx.
4. blood flow through the pulmonary arteries.

Back 54

#3

Front 55

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
1. shallow breathing.
2. normal lung tissue.
3. decreased adipose tissue.
4. increased density of lung tissue.

Back 55

#4

Front 56

The most important technique when progressing from one auscultatory site on the thorax to another is:
1. side-to-side comparison.
2. top-to-bottom comparison.
3. posterior-to-anterior comparison.
4. interspace-by-interspace comparison.

Back 56

#1

Front 57

When auscultating the chest in an adult, the nurse would:
1. instruct the patient to take deep, rapid breaths.
2. instruct the patient to breathe in and out through his or her nose.
3. use the diaphragm of the stethoscope held firmly against the chest.
4. use the bell of the stethoscope held lightly against the chest to avoid friction.

Back 57

#3

Front 58

The nurse is assessing voice sounds during a respiratory assessment. Match the assessment with the correct technique:
1. The normal response is faint, muffled, and almost inaudible when the patient says “one, two, three” in a very soft voice.
2. Ask the person to say “ninety-nine” repeatedly while auscultating the chest wall. Normally, a sound will be heard but the examiner will not be able to distinguish exactly what is being said.
3. Listen to the chest while the patient says a long “ee-ee-ee” sound; hearing a long “aaaaaa” sound may be noted over areas of consolidation.

B = Bronchophony
E = Egophony
W = Whispered pectoriloquy

Back 58

1. W
2. B
3. E