NUR 2092 Health Assessment Exam 2 Study Guide

1

NUR 2092 Health Assessment Exam 2 Study Guide

Respiratory assessment: methods of lung assessment, Types of breath sounds

(normal and abnormal and what they might indicate; signs of long term hypoxia; vocal sound The thoracic cage is a bony structure with a conical shape, which is narrower at the top. It is defined by the sternum, 12 pairs of ribs, and 12 thoracic vertebrae. Its floor is the diaphragm.The costochondral junctions are the points at which the ribs join their cartilages; they are not palpable! Rib 1-7 attach to the costal cartilage, 8-10 attach to the costal cartilage above, and 11-12 are floating with free palpable tips.*Surface landmarks on the thorax are signposts for underlying respiratory structures.Anterior Thoracic Landmarks

• Suprasternal Notch – Feel this hollow U-shaped depression just above the sternum,

between the clavicles

• Sternum – The “breastbone” has 3 parts: the manubrium, the body, and the xiphoid

process. Walk your fingers down the manubrium a few cm until you feel a distinct bony ridge, the sternal angle.

• Sternal Angle – Often called the “angle of Louis,” this is the articulation of the

manubrium and body of the sternum, and is continuous with the second rib. It is useful place to start counting ribs, which helps to localize a respiratory finding horizontally.Also marks the site of tracheal bifurcation into the left/right main bronchi.

• Costal Angle – The right and left costal margins form an angle where they meet at the

xiphoid process. Usually 90 degrees or less, this angle increases when the rib cage is chronically overinflated, as in emphysema.Posterior Thoracic Landmarks

• Vertebra Prominens – Start here. Flex your head and feel for the most prominent bony

spur protruding at the base of the neck. This is the spinous process of C7.

• Spinous Processes – Count down these knobs on the vertebrae, which stack together to

form the spinal column. The spinous processes align with their numbered ribs only down to T4.

• Inferior Boarder of the Scapula – The scapulae are located symmetrically in each

hemithorax. The lower tip is usually at the 7 th or 8 th rib.

• Twelfth Rib – Palpate midway b/t the spine and the person’s side to identify its free tip.

Reference Lines Use reference lines to pinpoint a finding vertically on the chest, such as the midsternal line and the midclavicular line on anterior chest. The posterior side has the vertebral (or midspinal) line and the scapular line, which extends through the inferior angle of the scapula when the arms at the sides of the body. Lift up the patient’s arm 90 degree and divide lateral chest by three lines: Anterior axillary line, posterior axillary line, and maxillary line.

2

*The mediastinum is the middle section of the thoracic cavity containing the esophagus, trachea, heat, and great vessels. The left/right pleural cavities are on either side of the mediastinum and contain the lungs.Lobes of the Lungs The Lungs are paired but not precisely symmetric structures. The right side is shorter than the left because of the underlying liver, while the left lung is narrower than the right because the heart bulges to the left. The right lung has three lobes, and the left lung has two lobes.Mechanics of Respiration

The four major functions of the respiratory system:

(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) Methods of Lung Assessment

• Inspect the posterior chest
• Note the shape and configuration of the chest wall.
• Check Anteroposterior diameter as it should be less than

the transverse diameter

• Neck and Trapezius should be developed normally
• Note the position of the client
• Assess the skin color and condition of the patient
• Palpate the posterior chest
• Assess symmetric chest expansion

Tactile Fremitus – Assess the tactile, or vocal, fremitus. It is a palpable vibration. Sounds are generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall, where you feel them as vibrations. Use the palmar base of the fingers and touch person’s chest while they repeat the words “99” or “blue moon.” These phrases generate strong vibrations.Percuss the Posterior Chest – Lung Fields: Determine the predominant note over the lung fields.Start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders. Then, percussing in the interspaces, make side to side comparison all the way down the lung region. Percuss in 5-cm intervals!Diaphragmatic Excursion – Determine the diaphragmatic excursion. Percuss to map out the lower lung boarder in both expiration and inspiration. Ask the patient to exhale and hold it while you briefly percuss down the scapular line until the sound changes from resonant to dull.(Thoracic Expansion).Auscultate the posterior, anterior, and axillary parts of the body. There are 6-7 points on the anterior line, 6-8 on the posterior side, and 2 points per axillary side.

3

Palpate the Anterior chest – Palpate symmetric chest expansion by placing your hands on the anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process.Assess the tactile (vocal) fremitus of anterior line. Begin palpating over the lung apices in the supraclavicular areas. Compare vibrations from one side to the other as the person repeats “99.” Palpate the anterior chest wall to note any tenderness and detect any superficial lumps or masses.Note skin mobility and turgor and skin temperature and moisture.Percuss the Anterior Chest – Begin percussing the apices in supraclavicular areas. Then, percussing the interspaces and comparing one side with the other, moving down the anterior chest. Interspaces are easier to palpate on the anterior chest than back. Do not percuss directly over female breast tissue because it will produce a dull note!Types of Breath Sounds Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in the subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.Resonance is the low-pitched, clear, hollow sound that predominates in healthy lung tissue in the adult. However, it is a relative term and has not constant standard. The resonant note may be duller in the athlete with heavily muscular chest wall and in the heavily obese, subcutaneous fat produces scattered dullness.Hyperresonance is a lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax.A dull note (soft, muffled thud) signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.Decreased/Absent breath sounds occur when the bronchial tree is obstructed by secretions, mucus plug, or a foreign body. In emphysema, it can be a result from the loss of elasticity in the lung fibers and decreased force of inspired air. Anything that obstructs the transmission of sound between the lung and stethoscope, such as pleurisy, fluid, air in the pleural space can cause a decrease in breath sounds. A silent chest means there is no air moving in or out!Increased breath sounds mean that sounds are louder than they should be (bronchial sounds are abnormal when they are heard over an abnormal location, the peripheral lung fields). They have a high-pitched, tubular quality, with a prolonged expiratory phase and a distinct pause between inspiration and expiration. Occur when consolidation (pneumonia) or compression (fluid in the intrapleural space) yields a dense lung area that enhances the transmission of sound from the bronchi.Adventitious Sounds are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused by moving air colliding with secretions in the tracheobronchial passageways or by the popping open of previously

4

deflated airways. If you hear these sounds, describe them as inspiratory vs. expiratory, loudness, pitch, and location on the chest wall.Crackles are discontinuous popping sounds heard over inspiration; wheezes are continuous musical sounds heard mainly over expiration.Atelectatic crackles are a type of adventitious sound that is not pathologic. They are short, popping, crackling sounds that last only a few breaths. When sections of alveoli are not fully aerated (as in sleepers or in older adults), they deflate slightly and accumulate secretions.Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.Tachypnea - Rapid, shallow breathing. Increased rate, >24 per minute. This is a normal response to fever, fear, or exercise. Rate also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons.Sign - Occasional sighs punctuate the normal breathing pattern and are purposeful to expand alveoli. Frequent sighs may indicate emotional dysfunction and also may lead to hyperventilation and dizziness.Hyperventilation - Increase in both rate and depth. Normally occurs with extreme exertion, fear, or anxiety. Also occurs with diabetic ketoacidosis (Kussmaul respirations), hepatic coma, salicylate overdose (producing a respiratory alkalosis to compensate for the metabolic acidosis), lesions of the midbrain, and alteration in blood gas concentration (either an increase in CO2 or a decrease in oxygen). Hyperventilation blows off CO2, causing a decreased level in the blood (alkalosis).Bradypnea - Slow breathing. A decreased but regular rate (<10 per minute), as in drug-induced depression of the respiratory center in the medulla, increased intracranial pressure, and diabetic coma.Hypoventilation - An irregular shallow pattern caused by an overdose of narcotics or anesthetics.May also occur with prolonged bed rest or conscious splinting of the chest to avoid respiratory pain.Cheyne-Stokes Respiration - A cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. The breathing periods last 30 to 45 seconds, with periods of apnea (20 seconds) alternating the cycle. The most common cause is severe heart failure; other causes are renal failure, meningitis, drug overdose, and increased intracranial pressure. Occurs normally in infants and aging persons during sleep.Biot Respiration - Similar to Cheyne-Stokes respiration, except that the pattern is irregular. A series of normal respirations (three to four) is followed by a period of apnea. The cycle length is variable, lasting anywhere from 10 seconds to 1 minute. Seen with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis.