Chapter 19: Thorax and Lungs Nursing Exam 2022

Chapter 19: Thorax and Lungs Nursing Exam 2022 What is the thoracic cage? - Answer- -bony structure with a conical shape, narrower at top -defined 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.......