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Thorax and Lungs

Thorax and Lungs. Health History. Tobacco use (amount, duration, Pack year index) http://www.coquitline.org/ 2 nd hand smoke exposure Occupation/Exposure to pulmonary irritants Chemicals, vapors, dust, allergens, animals, smoke, asbestos, arsenic, coal dust, radiation)

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Thorax and Lungs

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  1. Thorax and Lungs

  2. Health History • Tobacco use (amount, duration, Pack year index) http://www.coquitline.org/ • 2nd hand smoke exposure • Occupation/Exposure to pulmonary irritants • Chemicals, vapors, dust, allergens, animals, smoke, asbestos, arsenic, coal dust, radiation) • PMH/FH of respiratory illness/disease/cancer or allergies • Pneumonia, TB, COPD, asthma, lung cancer • Pneumonia or influenza vaccine received? • Risk factors for TB: • HIV, substance abuse, low income or homeless, resident of nursing home, shelter or prison, immigrant from country with high TB rate

  3. Health History • Do you have any shortness of breath? (Dyspnea) • Occurs @ rest, with exercise, lying flat? • Have you heard any wheezing? • Do you have a cough? • Dry, productive, barking, etc.. • http://www.youtube.com/watch?v=mXAxnZ4JJ6A • Amount, color,& consistency of sputum. Presence of odor. • Hemoptysis- coughing up blood (varies from blood streaked phlegm to frank blood) • Do you have chest pain with breathing? • Have you recently had any pain in calves or been on any long car or plane rides?

  4. Sample Charting

  5. Respiratory Symptoms Difficulty breathing Dyspnea with exertion Dyspnea at rest Unable to lie flat Difficulty coughing Difficulty clearing secretions Sample Electronic Charting

  6. Inspection • Observe symmetry, rate, rhythm, depth and effort of breathing • Symmetry: Chest wall movement equal bilaterally • Rate: Adult 12-20 resp/min is normal • Bradypnea: Slow (<12 per minute) • Tachypnea: Rapid (>20 per minute) • Rhythm: Regular vs. irregular • Cheyne-Stokes, Kussmaul’s respirations, Biot’s • Depth • Hypoventilation–rate slow, depth • Hyperventilation–rate rapid, depth deep Respirations 16/min, symmetrical,relaxed and even

  7. Inspection • Effort • Unlabored vs. labored • Presence of retractions • Suprasternal: above clavicle & sternum • Intercostal: between ribs • Subcostal: below lower costal margin • Substernal: Below Xiphoid process • Presence of nasal flaring (inhalation) or grunting (exhalation) • Infants/children • Use of accessory muscles • Neck/shoulders (ie Sternocleidomastoid & trapezius) • Abdominal (exhalation) Respirations nonlabored. http://www.youtube.com/watch?v=Hv68EQ3tCBI http://www.youtube.com/watch?v=J2R8MOoQtd8

  8. Inspection • Body position • Relaxed vs. Upright/Tripod position • Color of skin, lips, nail beds • Even skin tone vs. cyanotic • Presence of clubbing Patient relaxed. Skin and mucous membrane pink. Nail beds pink without clubbing in upper and lower extremities.

  9. Inspect/Palpate Trachea Position Inspect Should be midline Palpate For tracheal shift Place finger in sternal notch and slip to each side. Trachea midline.

  10. Inspection • Wounds, scars, drains, tubes, dressings • Documentation must include location, size, amount of drainage and discharge if present, and signs of inflammation. • Additional terms to describe location: • Supraclavicular- Above the clavicles • Infraclavicular- Below clavicles • Interscapular- Between scapula • Infrascapular- Below scapula • Midaxillary line- Along line of armpit • Midclavicular- Along line in middle of clavicle No wounds, scars, drains, tubes, or dressings. Or- No lesions.

  11. Inspection • Shape of Chest : • Symmetrical vs. asymmetrical • Deformities • Pectus carniatum, Pectus excavatum, Spinal deformitiies • Normal AP diameter vs.. increased AP diameter • Oval vs. barrel chest • Ribs slope downward vs. more horizontal • Barrel chest appears as if patient in continuous inspiratory position Chest symmetrical without deformities. AP < transverse diameter

  12. Kyphosis Scoliosis

  13. Palpation • Assess for masses, tenderness, or crepitus • Subcutaneous emphysema- air escapes form lungs into subcutaneous tissue • Assess chest expansion • Posteriorly place thumbs at level of 10th rib & place palms on posterolateral chest. • Approx 2 inches apart before inspiration. Feel thoracic expansion during quiet & deep inspiration. Look for symmetry. Chest expansion symmetrical. No masses or tenderness. http://www.youtube.com/watch?v=ygD93IKorEw

  14. Palpation • Tactile Fremitus • Palpable vibrations transmitted through bronchopulmonary tree to chest when patient speaks • Have patient repeat 99 or 1, 1, 1 while palpate with ulnar surface or ball of hand • Decreased or absent when vibration impeded by obstructed bronchus, tumor, or separation of pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), or air (pneumothorax) • Increased with gross compression or consolidation (lobular pneumonia) without bronchus obstruction Tactile fremitus equal bilaterally.

  15. Palpation

  16. Percussion • Tapping of an chest to set chest wall and underlying tissues into motion • Helps to establish if underlying tissue air-filled, fluid-filled, or solid • Normal sound is resonance Resonant to percussion over all lung fields.

  17. Percussion http://www.youtube.com/watch?v=PlUejZE6c_w

  18. Auscultation • Use diaphragm of stethoscope and have patient breath out of their mouth. • Peds- use smaller pediatric diaphragm or adult bell • Place stethoscope firmly on skin. Avoid movement because it may produce confusing sounds (i.e. clothing) • Auscultate at least one complete respiration • Move from one side to the other • Observe for hyperventilation, allow to rest if needed • Peds- transmission of sounds enhanced, harder to localize sounds

  19. Auscultation- Anterior Chest

  20. Auscultation- Lateral Chest

  21. Auscultation- Posterior Chest

  22. Anatomy Review • Air: Mouth/Nose respiratory portion of larynx  trachea  right & left bronchus  smaller bronchi  smaller bronchioles  alveolar duct  individual alveoli

  23. Auscultation • Breath Sounds • Bronchial (Tracheal) • Heard over trachea • Exp > insp • Loud, High pitch • Hollow quality • Bronchovesicular • Heard over major bronchi • Insp = exp • Medium, Medium pitch • Blowing sound • Peds in periphery • Vesicular • Heard over lung parenchyma/periphery • Insp > exp • Soft, Low pitch • Breezy quality • Diminished

  24. Auscultation • Adventitious Breath Sounds • Wheezes (Sibilant wheeze) • High pitched, musical sound heard during inhalation or exhalation • Mild, moderate, severe • Rhonchi (Sonorous wheeze) • Low pitch snoring sound during inspiration or exhalation, but louder on exhalation • May clear with coughing Asthma

  25. Auscultation Bronchitis Emphysema

  26. Auscultation • Crackles/Rales • Popping sounds heard on inhalation • Fine • High pitched fine, short, interrupted crackling sounds heard during end of inspiration • Medium • Lower, more moist sounds heard during middle of inspiration • Course • Loud, bubbly sounds heard during inspiration • http://www.med.ucla.edu/wilkes/intro.html

  27. Auscultation Pneumonia Atelectasis

  28. Auscultation • Pleural friction rub • Dry, low pitched rubbing or grating sound on inhalation and exhalation • Heard loudest over lower lateral anterior surface • Occurs with pleurisy or pleuritis • http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html

  29. Auscultation • Stridor • High pitched, harsh sound heard on inspiration when trachea or larynx is obstructed • Croup, foreign body, large airway tumor • http://www.youtube.com/watch?v=QkaX83H31QY&feature=PlayList&p=0C59700763AFDD1E&playnext=1&index=8 • http://www.youtube.com/watch?v=Z1_uKqmPyLA&feature=related

  30. Auscultation • Breath sounds vesicular without adventitious sounds. • Or- Lungs sounds CTA in all lung fields without wheezes, rales, rhonchi, or rubs

  31. Auscultation • Voice Sounds • Bronchophony • “99” or “1-2-3” • Normal- Muffled • Abnormal- Clear • Whispered Pectoriloquy • Whisper “1,2,3” • Normal- faint and indistinct • Abnormal- clear and distinct • Egophony • “eeeeeeee” • Normal • Abnormal “aaaaaa”

  32. Bringing it all together http://www.youtube.com/watch?v=ygD93IKorEw http://www.youtube.com/watch?v=nUJQvFXmTxQ&feature=related

  33. Case Study Juan Pablo comes to the Urgent Care Clinic for complaint of a cough that started about a week ago. He is accompanied by his friends who work at the local chicken processing plant with him. He is from Mexico and has lived in the United States now for 2 years. He speaks English hesitantly. His family still lives in Mexico. He is 38 years old and states that he has been in good health. He smokes one pack of cigarettes daily and occasionally drinks alcohol. Polly Curtis is a student nurse assigned to do a health assessment and physical exam with the registered nurse. Polly is 25 years old and is in her second year of nursing school.

  34. Sample Charting

  35. Sample Electronic Charting • Normal Parameters Met • Breath sounds clear through all lung fields. • Respirations unlabored, symmetrical, regular rhythm and depth. • No shortness of breath • Cough effective • Skin color within pt’s norm • Sputum clear or white

  36. Sputum Amount Scant Small Moderate Large Copious Swallowed Sputum Color Yellow Tan Green Pink Brown Bloody Sample Electronic Charting

  37. Sputum Consistency Thin Mucoid Thick Mucus plug Frothy Small Tenacious Clots Sample Electronic Charting

  38. Effort Labored Shallow Stridor Agonal Accessory muscle use Gasping labored Grunting Mechanical ventilated Moderate labored Slightly labored Nasal flaring Pursed lip Splinting Sample Electronic Charting

  39. Retraction Type Substernal Intercostal Supraclavicular Subclavicular Abdominal Depth Deep Shallow Mediastinal Shift? Yes No Sample Electronic Charting

  40. Pattern Irregular Bradypnea Tachypnea Gasping Grunting Kussmaul Cheyne-stokes Irregular or periodic Paradoxical Agona Apnea Respiratory Pattern Comment: _______ Sample Electronic Charting

  41. Auscultation Clear throughout Absent Diminished Inspiratory wheeze Expiratory wheeze Rales Rhonchi Rub Lung Characteristics Audible Decreased Diffuse Increased Slightly decreased Tight Difference between anterior and posterior breath sounds: _______ Lung sound comments:___________ Sample Electronic Charting

  42. Additional Website

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