Nursing 202

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stephanie831
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41193
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Nursing 202
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2010-10-10 20:48:27
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Nursing Lungs Thorax
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Lungs and Thorax
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  1. What are the three parts of the sternum?
    • 1) manubrium
    • 2) body
    • 3) xiphoid process
  2. What is the ridged top of manubrium called of the sternum?
    suprasternal notch
  3. Where and What is the the manubriosternal angle?
    • - bony ridge (articulation of manubrium and body of sternum)
    • - Continuous with 2nd rib (count rib and ICS from this point)- ICS numbered by rib above
    • - site of tracheal bifurcation into right and left main bronchi
    • - corresponds with upper border of atria
  4. How many ribs are there and what are some of the sites called?
    1. 12 ribs

    • 2. Costochondral junction: where rib attaches to cartilage
    • intercostal spaces: below each rib
    • floating ribs (11-12)- attached to spinal column only; 12th rib tip palpable midway between spine and side [11 is on side and 12 is more posterior]
  5. What is the normal angle of costal angle? What would an abnormal angle mean?
    • normal: < or equal to 90 degrees
    • abnormal: (angle increases [flattens] with hyperinflation)- e.g. emphysema
  6. Where is the Vertebral Prominens and how would you palpate the site?
    • C7
    • - palpate with head flexed
    • - if 2 bumps (then C7 & T1)
  7. Where is the thoracic vertebrae?
    • 12
    • - spinous process (knobs on vertebrae)- some palpable
  8. Where is the scapula?
    lower tip (inferior border) at 7th-8th rib
  9. What are the reference lines are what lines do they consist of?
    reference lines: verticle lines used to document physical findings

    • Anterior:
    • - midsternal
    • - midclavicular (MCL)
    • Posterior:
    • - vertebral (midspinal)
    • - scapular
    • Lateral:
    • - Anterior axillary line (AAL)- at anterior axillary fold
    • - Midaxillary line (MAL)- midway between AAL and PAL
    • - Posterior axillary line (PAL)
  10. What are three other landmarks?
    • 1. suprclavicular (above clavicle)
    • 2. infraclavicular (below clavicle)
    • 3. infrascapular (below tip of scapula)
  11. What consists of the thoracic cavity?
    • 1. Mediastinum (heart and great vessels, esophagus, trachea)
    • 2. Pleural Cavities (contains lungs)
    • 3. Diaphragm (floor of thorax; major muscle of respiration)
  12. Locate the anterior, lateral and posterior lung borders.
    • Anterior
    • - Apex (3-4 cm above 1st rib)-top
    • - base (rests on diaphragm)- bottom
    • - right side (at 5th ICS, MCL)
    • - Lt side (at 6th ICS, MCL)

    • Lateral
    • - from apex to axilla to 7th-8th ribs

    • Posterior
    • - (C7 to T10 [or T12 with inspiration])
    • - upper lobes T1 to T3/T4
    • - lower lobes T3 to T10 (expiration) or T12 (inspiration)
  13. How many lobes in the right lung and left lung?
    Right (3 lobes: upper/middle/lower)- shorter due to liver

    Left (2 lobes: upper/lower)- narrower due to heart border
  14. What the type types of fissures that the left and right lungs consists of?
    • 1. Horizontal Fissure (right side only)- 4th rib right sternal border to 5th rib MAL
    • - separates upper and middle lobe

    • 2. Anterior Oblique Fissures (bilateral)- 5th rib MAL to 6th rib MCL
    • - right (separates middle and lower lobes)
    • - left (separates upper and lower lobes)
  15. Describe the pleura and what it does?
    • Visceral (lines lung surface)
    • Parietal (lines chest wall and diaphragm)

    • Pleural Cavity (negative pressure holds lungs against chest wall)
    • Costodiaphragmatic recess (pleura extend 3 cm below level of lung)- potential space for fluid/air which may compress lung
  16. Where is the trachea?
    • - trachea anterior to esophagus
    • - starts at cricoid (10-11 cm long)
    • - bifurcates at manubriosternal angle (anteriorly)
    • - bifurcates at T4 (posteriorly)
  17. What consists of the bronchial tree?
    • - right main stem bronchus (shorter and straighter)- increased risk of aspiration
    • - dead space (trachea and bronchi)- filled with air, but no gas exchange
    • - bronchial tree lines with goblet cells (secret mucus that entrap particles) and cilia (sweep particles upward); smoking paralyzes the cilia and results in mucus pooling
    • - acinus (functional respiratory unit)- bronchioles, alveolar ducts, alveolar sacs and alveoli
    • - alveoli (300 million)
  18. What are the mechanisms of respiration and what are the abnormalities?
    • 1. supplies O2 and eliminates CO2
    • - respiratory acidosis: retained CO2
    • - respiratory alkalosis: excessive excretion of C)2 through respirations
    • 2. helps maintain acid-base balance
    • - Respiratory center (brain stem)-pons and medulla
    • - increased CO2 is normal stimulus to breathe
    • - chronic hypoxia desensitizes CO2 receptors in the brain; thus
    • low O2 levels become the stimulus to breathe (delivery of high
    • O2 concentrations may result in apnea)
  19. What is the subjective data to look for (10)?
    • 1. Cough (timing)
    • 2. Cough (character)
    • 3. Sputum (amount, color, odor)
    • 4. Shortness of Breath and Dyspnea (difficult, labored breathing)
    • 5. Past history
    • 6. Miscellaneous symptoms
    • 7. Smoking history (cigarettes, cigars, pipes, marijuana)
    • 8. Family History (allergies, asthma, TB, cystic fibrosis, lung cancer, emphysema, etc.)
    • 9. Environmental Exposure (use of protective masks?)
    • 10. Health Promotion (PPD, influenza immunization, pneumococcal vaccine)
  20. What do you factor in with the timing of the cough?
    • - Continuous- respiratory infection
    • - Nighttime, when recumbent (post nasal drip; sinusitis, GERD)
    • - morning, upon awakening (chronic bronchitis, "smokers cough")
    • - specific setting (allergies)
  21. What do you factor in with the character of the cough?
    • - hacking (mycoplasm pneumonia)
    • - dry, non productive (early CHF, allergies, meds [acei])
    • - barking (croup)
    • - congested (bronchitis, pneumonia)
  22. What are the different types of sputum? (7)
    • 1. Clear/white (viral bronchitis/pneumonia)
    • 2. Translucent white/gray (noninfectious, chronic bronchitis, smoker)
    • 3. Rust (pneumococcal pneumonia)- blood mixed with yellow sputum
    • 4. Green/yellow (bacterial bronchitis/pneumonia)
    • 5. Pink: frothy (pulmonary edema)
    • 6. Blood (hemoptysis)- cancer, TB
    • 7. Foul odor (bacterial)
  23. What are some of the complications that result from SOB and Dyspnea (difficult, labored breathing)?
    • - Orthopnea: (difficult breathing supine- 2 pillow, etc.)- heart failure
    • - paroxysmal nocturnal dyspnea (PND)- awakens from sleep with SOB (heart failure)
    • - DOE (dyspnea on exertion)
  24. What is the past history to include when assessing respiration?
    • - lung disease, COPD, asthma, cystic fibrosis, etc.
    • - allergies (dust, pollen, animals, mold)
  25. What are some miscellaneous symptoms to factor in?
    • 1. Diaphoresis (night sweats) TB, HIV, other infection
    • 2. Fever, chills, sweats (f/c/s)- infection
    • 3. Unintentional weight loss- cancer
    • 4. Dependent edema, PND, orthopnea- heart failure
    • 5. Confusion, restlessness- hypoxia
    • 6. Pleurisy (chest pain with breathing)- inflammation of pleura
  26. What are types of Environmental exposure to factor in?
    • 1. Grain/pesticide inhalation (farmers)
    • 2. Histoplasmosis (inhaled fungus)- midwest
    • 3. Coccidioidomycosis or "Valley fever" (inhaled fungus)- San Joaquin Valley [Bakersfield area]
    • 4. Pneumoconiosis (coal miners)
    • 5. Silicosis (stone cutters, miners, potters)
    • 6. Asbestos (plumbers)- abestos exposure + smoking increases lung CA risk (more than 10x)
  27. What are some complications of child respiration?
    • - URIs (4-6/year = normal) compared to adults (2-4/yr)
    • - Asthma- may outgrow as bronchial tubes enlarge
    • - accidental aspiration- child proof the home
  28. What are some complications for the aging adult?
    • - SOB/ fatigue with daily activities (decreased vital capacity [exhaled air after maximum inspiration] as measured by spirometry)
    • - lung disease
    • - chest pain with breathing (rib factures-spontaneous or r/t trauma/abuse/falls)
  29. What are you Inspecting for?
    • 1. Respiratory rate, rhythm, effort
    • 2. Normal shape and symmetry of chest wall (AP diameter< transverse; 1:2 to 5:7 [increases with age])
    • 3. Spine (assess for abnormal curvatures; may impair cardiopulmonary function)
    • - Scoliosis (lateral curve)- entire spine affected
    • - more common in girls, adolescents
    • - assess uneven shoulder, scapular, hip heights
    • - observe gait
    • - severe curvature (>45)- may decrease lung volumes
    • - Kyphosis (hump back)- T-spine
    • - Lordosis (sway back)- L-spine
    • - body position
    • - Relaxed
    • - Professional or tripod position (abnormal)- aids in expiration
  30. What are some normalities and abnormailities when palpating?
    • - Palpate entire chest wall (tenderness lumps, masses)
    • - Symmetric chest expansion (at level T9 or T10) may be uneven with atelectasis, pneumothorax, pleural effusion, phrenic nerve damage, etc.
    • - tactile fremitus (vocal fremitus)- repeat "99"
    • - palpable vibrations (use base of fingers at MCP joint or ulnar surface) - should be felt
    • - start at lung apices (symmetry is most important)
    • - most prominent between scapulae and sternum; progressively decreases down thorax
    • - greater in thin persons (due to decreased thickness of chest wall)
    • - Increased fremitus
    • - consolidation extending to lung surface (pneumonia)
    • - decreased Fremitus (transmission of vibration blocked)
    • - bronchial obstruction
    • - pneumothorax
    • - Pleural effusion
    • - COPD (emphysema)
    • - Crepitus (sub-q emphysema)
    • - course cracking sensation
    • - R/T air entering sub-q tissue (open thoracic injury, chest surgery, tracheostomy)
  31. How should you percuss?
    • - percuss ICS
    • - start at aspices (above clavicle) and percuss side-to-side down back
    • - avoid scapula and ribs
  32. What are the sounds to be aware of when percussing?
    • Resonant: normal
    • Hyperresonant: emphysema, pneumothorax
    • Dull: increased density- atelectasis, pneumonia, pleural effusion
  33. CVA tenderness is a sign of?
    kidney infection
  34. What is the auscultation technique.
    • - from C7 to T10
    • 1) Lean forward; breathe deeply through mouth (hug chest to open interspaces)
    • 2) Use diaphragm of stethoscope (assess symmetry and don't forget lateral lung fields)
    • 3) Progress from top to bottom and side to side; listen at each location; listen at each location for a full respiratory cycle (inspiration and expiration)
  35. What are three types of respiratory sounds and describe each?
    • 1. Bronchial
    • - loud, harsh
    • - norm over neck (trachea and larynx)
    • - ABN if heard over peripheral lung fields (indicates consolidation)
    • 2. Bronchovesicular
    • - moderately loud/harsh
    • - norm over midsternum and between scapula in back (major bronchi)
    • 3. Vesicular
    • - low, soft
    • - norm over peripheral lung fields
    • - absent (mucus plug, collapsed lung)- report immediately!

  36. What are adventitious sounds and give some examples.
    • - added sounds not normally present
    • - rhonchi, crackles
  37. Differntiate between rhonchi and crackles.
    • rhonchi: clear with coughing and crackles do not
    • - rhonchi are deeper, more prolonged, more rumbling, more pronounced during expiration
  38. What are crackles, fine and coarse crackles?
    • - sounds like a velcro opening
    • - produced when there is fluid inside a bronchus causing a collapse of distal (smaller) airways and aveoli. Crackles occur when there is sudden equalization of pressure causing some of the airways to pop open.
    • - Heard on inspiration; doesn't clear with coughing
    • - causes (atelectasis, pneumonia, fibrosis, heart failure, pulmonary edema)
    • fine crackles: (high pitched, short duration, cracking and popping sounds)
    • coarse crackles (low-pitched, longer duration, bubbling and gurgling sounds)
  39. What is rhonchi?
    • - airflow through airway obstructed by thick secretions, spasm, or tumor (bronchitis, decreased cough reflex, etc.)
    • - loud, low, coarse sounds (like a snore or rumble) most often heard continuously during inspiration or expiration
    • - often clears with coughing or suctioning
  40. What is wheezing and how is it caused?
    • - airflow through a constricted airway (bronchospasm associated with asthma; acute or chronic bronchitis)
    • - high-pitched sqeaking sound (like a whistle)
    • - primarily heard on expiration, but, may also be heard on inspiration
    • - assess breath sounds with forced expiration in an asthma patient to check for bronchoconstriction.
  41. What is stridor and how is it caused?
    • - a sign of respiratory distress
    • - r/t partial airway obstruction (foreign body)
    • - louder in the neck than chest
  42. What is pleural friction rub?
    • - caused by inflammation of pleural surfaces (pleurisy)
    • - coarse, rubbing or grating sound during inspiration or expiration (disappears with breath holding)
  43. Name the voice sounds and how you assess them.
    • Bronchophony (repeat "99" or "blue moon")
    • - Norm ("99" muffled and indistinct)
    • - ABN (clear "99)- increased lung density
    • Egophony (repeat "E")
    • - Norm ("eee" sound)
    • - ABN ("E" to "A" changes)- consolidation
    • Whispered pectoriloquy (whisper 1-2-3)
    • - Norm (sounds faint, muffled, almost inaudible)
    • - ABN (sounds clear and distinct)- consolidation
  44. What are 10 objective data factors of the anterior thorax?
    • 1. Skin (pallor, cyanosis)
    • 2. Nails (clubbing)- r/t chronic fibrotic lung changes
    • 3. Pursed lips (seen in obstructive disease)- prolongs expiration to allow for exhalation of trapped air
    • 4. Splinting- shallow breaths to control pain
    • 5. quality of respirations (quiet, easy and non labored)
    • 6. Tracheal Position
    • - tension pneumothorax-trachea shifts (called tracheal tug) to the opposite
    • side of lung collapse
    • 7. Chest
    • 8. Costal angle < 90 degrees (barrel chest >90)
    • 9. LOC (drowsiness r/t cerebral hypoxia)
    • 10. Retraction or bulging of ICS- unilateral vs bilateral
    • - retraction (obstruction or increased respiratory effort)
    • - bulging (trapped air-emphysema)- causes barrel chest
    • 11. Use of accessory neck muscles to lift sternum and rib cage (SCM, scaleni [below SCM] and trapezius; neck muscles may be overdeveloped with chronic respiratory disease)
    • 12. Respiratory Rate and Patterns
  45. What are three abnormalities of the chest?
    • 1. pectus excavatum: sunken sternum, funnel chest
    • 2. pectus carinatum: forward protrusion, pigeon chest
    • 3. barrel chest (increased AP diameter)- associated with aging, emphysema, asthma
  46. Why would retraction or bulging occur?
    Retraction: (obstruction or increased respiratory effort)

    Bulging: (trapped air-emphysema)-causes barrel chest
  47. What are 8 abnormal respiratory rates and patterns?
    • 1. tachypnea (rapid, shallow breathing; >20/min)- fear, fever, anxiety, exercise, respiratory insufficiency, pneumonia, alkalosis, pleurisy, lesions in the pons.
    • 2. hyperventilation (rapid, deep breathing)- extreme exertion, fear, anxiety, diabetic ketoacidosis (DKA)
    • - CO2 is excreted thru respirations (thus increasing the alkalinity of the
    • blood)
    • 3. bradypnea: (regular, slow breathing; <10/min) -depressant drugs, increased intracranial pressure (ICP), diabetic coma
    • 4. hypoventilation: (irregular, shallow)- narcotic OD, anesthetics, prolonged bedrest, splinting with pain.
    • - CO2 is retained (may cause acidosis)
    • 5. Cheyne-stokes (regular, cyclic; breathe 30-40 sec, then apnea x 20 sec)- CHF and other causes
    • 6. biots (ataxic)- irregular, deep, slow with periods of apnea (precedes Cheyne Stokes)
    • 7. Stertorous: snoring
    • 8. Stridor: croup, foreign body, growth on vocal cords, high pitched on inspiration
  48. How would you palpate the anterior thorax?
    • - symmetric chest expansion (thumbs on xyphoid process)
    • - tactile fremitus (chest wall vibrations while repeating "99")- start at apices and work down; avoid breast tissue
    • - palpate anterior chest wall (tenderness, lumps, masses)
  49. How would you percuss the anterior thorax?
    • - start at apices
    • - percuss interspaces for resonance
    • - compare sides
    • - avoid breasts
    • - note cardiac dullness
    • - border of liver (dullness at 5th ICS MCL)
    • - gastric bubble on left (tympanic)
  50. how do you ascultate the anterior thorax?
    • - start at supraclavicular space and progress down to 6th rib
    • - follow same pattern as with percussion
  51. What is atelectasis?
    collapsed alveoli; predisposes to pneumonia
  52. What is bronchitis?
    inflammation of bronchi-acute or chronic
  53. what is emphysema?
    destruction of alveoli; decreased gas exchange
  54. what is asthma?
    intermittent bronchospasm/constriction- may lead to chronic lung disease
  55. What is pleural effusion?
    fluid in pleural space
  56. What is pneumothorax?
    air in pleural space; collapsed lung
  57. what is hemothorax?
    blood in pleural space
  58. What are some developmental considerations for respiration for infants/children?
    • - count RR for 60 seconds
    • - less than or equal to three months old (obligatory nose breathers)- nasal obstruction can cause death
    • - less than or equal to 5-6 yo (bronchovesicular breath sounds normal in peripheral lung fields)

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