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What are the three parts of the sternum?
- 1) manubrium
- 2) body
- 3) xiphoid process
What is the ridged top of manubrium called of the sternum?
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
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]
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
Where is the Vertebral Prominens and how would you palpate the site?
- - palpate with head flexed
- - if 2 bumps (then C7 & T1)
Where is the thoracic vertebrae?
- - spinous process (knobs on vertebrae)- some palpable
Where is the scapula?
lower tip (inferior border) at 7th-8th rib
What are the reference lines are what lines do they consist of?
: verticle lines used to document physical findings
- - midsternal
- - midclavicular (MCL)
- - vertebral (midspinal)
- - scapular
- Lateral: - Anterior axillary line (AAL)- at anterior axillary fold
- - Midaxillary line (MAL)- midway between AAL and PAL
- - Posterior axillary line (PAL)
What are three other landmarks?
- 1. suprclavicular (above clavicle)
- 2. infraclavicular (below clavicle)
- 3. infrascapular (below tip of scapula)
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)
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
- - (C7 to T10 [or T12 with inspiration])
- - upper lobes T1 to T3/T4
- - lower lobes T3 to T10 (expiration) or T12 (inspiration)
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
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)
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
Where is the trachea?
- - trachea anterior to esophagus
- - starts at cricoid (10-11 cm long)
- - bifurcates at manubriosternal angle (anteriorly)
- - bifurcates at T4 (posteriorly)
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)
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)
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)
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)
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)
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)
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)
What is the past history to include when assessing respiration?
- - lung disease, COPD, asthma, cystic fibrosis, etc.
- - allergies (dust, pollen, animals, mold)
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
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)
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
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)
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
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)
How should you percuss?
- - percuss ICS
- - start at aspices (above clavicle) and percuss side-to-side down back
- - avoid scapula and ribs
What are the sounds to be aware of when percussing?
- Resonant: normal
- Hyperresonant: emphysema, pneumothorax
- Dull: increased density- atelectasis, pneumonia, pleural effusion
CVA tenderness is a sign of?
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)
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!
What are adventitious sounds and give some examples.
- - added sounds not normally present
- - rhonchi, crackles
Differntiate between rhonchi and crackles.
- rhonchi: clear with coughing and crackles do not
- - rhonchi are deeper, more prolonged, more rumbling, more pronounced during expiration
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)
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
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.
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
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)
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
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
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
Why would retraction or bulging occur?
Retraction: (obstruction or increased respiratory effort)
Bulging: (trapped air-emphysema)-causes barrel chest
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
- 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
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)
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)
how do you ascultate the anterior thorax?
- - start at supraclavicular space and progress down to 6th rib
- - follow same pattern as with percussion
What is atelectasis?
collapsed alveoli; predisposes to pneumonia
What is bronchitis?
inflammation of bronchi-acute or chronic
what is emphysema?
destruction of alveoli; decreased gas exchange
what is asthma?
intermittent bronchospasm/constriction- may lead to chronic lung disease
What is pleural effusion?
fluid in pleural space
What is pneumothorax?
air in pleural space; collapsed lung
what is hemothorax?
blood in pleural space
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)