Chapter 18: Thorax, Lungs, and Respiratory Assessment

Chapter 18: Thorax, Lungs, and Respiratory Assessment Anatomy Review · inspiration is triggered by the rise of blood CO2 · inspiratory muscles contract · lung fields descend by 2 rib spaces · 500-800 mL of air intake · Expiration is 2x longer and passive Inspiration: · active · intercostal muscles · diaphragm ↳ phrenic nerve & CN X Expiration · passive · Trachea bifurcates at the sternal angle (anterior) or T4 (posterior) · Right bronchus is shorter, wider, and more vertical so there is higher risk of choking for the right bronchus · alveoli = gas exchange Landmarking C7 T2 TT T10 Anterior · RUL 2.5cm higher than LUL apex · RML 4-6 rib at sternum · Size: RUL + RML = LUL · RLL size & position = LLL size & position Posterior · Lung fields: C7-T10 · LUL & RUL: C7-T3 · LLL & RLL: T3-T10 · inspiration descend by 2 rib spaces Side lungs Physical Assessment Focused Health History · All 4 techniques · sleep apnea ↳ inspection · pleuritic pain ↳ palpation · cough (sputum? ) ↳ percussion · dyspnea or shortness of breath ↳ auscultation · wheezing or stridor · tachyphea Homeostasis & Regulation · infections · Gas exchange · asthma ↳ ventilation · bronchitis ↳ oxygenation · COPD, TB? ↳ transport ↳ perfusion Peripheral cyanosis ① Inspection · posture ↳ tripod position ↳ Facial expression · LOC · skin colour ↳ central vs. peripheral cyanosis · Respirations ↳ muscles ↳ rate, depth, rhythm, quality, retractions · Nail clubbing · Thorax shape ↳ barrel chest in COPD (1:1) Anterior chest expansion > posterior chest expansion ② Palpation · Palpate the chest for tender areas · symmetrical chest expansion ↳ Posterior (hands at T9-T10), anterior (hands at costal margin) ↳ tested when there are concerns about reduced lung volumes · tactile fremitus ↳ use ulnar surface of hand on chest/back and have patient repeat "99" ↳ used when there are concerns about lung disease Chest expansion Palpation points ③ Percussion · percuss from apex (above clavicle) to lung base but avoid the clavicle and ribs · expected findings: resonant throughout · abnormal findings: hyper resonance or dullness Have them tell you if dizzy! · diaphragmatic excursion * ↳ instruct patient to exhale and hold, then percuss downwards until you reach dullness around T10. Mark this spot ↳ then instruct patient to inhale and hold, and percuss until dull again. The difference between these two points is the amount of movement of the diaphragm (should be around 3-5 cm or 2 ribs) ④ Auscultation · assess for intensity, pitch, quality, duration, and adventitious sounds · always listen over direct skin · diaphragm of stethoscope · listen to one breath per location · in larger airways sounds are louder and coarser, and in smaller airways sounds are softer and finer · Note: lower lobes can only be heard laterally and posteriorly b/c of anatomy * · Adventitious sounds include: ↳ Wheeze ↳ Rhonchi ↳ Crackles ↳ Stridor Expected Findings: · inspection: respiratory rate regular and nonlaboured 12-20 breaths/min Thorax symmetrical; no retractions or use of accessory muscles. AP diameter < transverse diameter · palpation: chest expansion symmetrical. No tenderness upon palpation. Tactile fremitus equal over all lung fields · Percussion: resonant percussion note over all lung fields bilaterally. Diaphragm descends 3-5cm bilaterally · auscultation: Vesicular breath sounds heard over periphery, anteriorly and posteriorly bilaterally. No crackles or wheezes bilaterally.