Lecture 3

• Review: Heart sounds

  S1: when AV values close (mitral and tricuspid valves splitting the atrium and ventricles)

  S2: when the semilunar valves close (aortic and pulmonary splitting ventricles and body/great arteries)
• Reference lines

  Anterior = midclavicular; anterior axillary line; midsternal line

  Posterior = scapular line; vertebral line
• Reference lines (lateral)

  Anterior axillary line; posterior axillary line; midaxillary line
• Acinus


  where gas exchange happens (new oxygen enters blood cell, CO2 leaves cell into lungs)
• Lobes of the lungs

  Right lung = RUL; RML; RLL

  Left lung = LUP; LLL
• Why does the left lung only have two lobes

  due to the location of the heart
• posterior location of lungs

  most of the back are the lower lobes
• So why do we breath?

  to get a supply of oxygen, release carbon dioxide, keep homeostasis, filter and warm up air
• forced inspiration

  heavy exercise; respiratory distress

  **neck muscles bring up sternum and rib cage (accessory muscles of respiration)
• forced expiration

  abdominal muscles contract to push abdominal viscera in and up against diaphragm making it move upwards as a dome and squeeze against lungs
• Ventilation

  how are we breathing? mechanics, airway, effective breathing?, hyper vs. hypoventilation, OSA, COPD, asthma, pneumothorax, trauma
• perfusion

  gas exchange at alveolar level, blood flow, hypercapnea vs. hypoxia, pulmonary emboli, shock
• Subjective data: health history


  cough, dyspnea/shortness of breath, chest pain, history of respiratory infections, smoking history, environmental exposure, self-care behaviours, Opqrstu (onset)
• OPQRSTU

  onset, provoking, quality, radiating, severity, timing, understanding
• history Q's for infants and kids

  how many colds/yeat (4-6?), smokers at home, childproof/choking hazards?, new foods introduced, emergency care interventions, do parents know CPR
• Developmental considerations for infants and kids

  vulnerability related to small size and immaturity of pulmonary system, Neonates: OBLIGATE mouth breathers (no nose)
• Developmental considerations of pregnant peeps

  enlarging uterus elevates diaphragm; decreases vertical diameter of thoracic cage, compensated by increase in horizontam diameter
• Developmental considerations of older adults

  lungs are harder to inflate, less vital capacity and # of alveoli, more residual volume, more shortness of breath on exertion
• More health history Q's for infants and kids

  often colds, allergy, chronic respiratory illness, safety (childproofing, toxin substances), environmental smoke
• additional health history Q's for older adults

  activity intolerance, level of activity, lung disease, pain
• PMHx

  past medical history
• Fam/Soc Hx

  family/society history
• Med

  medications
• ROS

  review of system
• Objective data: physical examination

  Preparation: position, draping, timing during complete exam, cleaning stethoscope endpiece
• Objective data: equipment needed

  stethoscope
• IPPA

  Inspect, palpation, percussion, ascultation
• Inspect thoracic cage (posterior)

  shape and configuration or chest wall, anteroposterior/transverse diameter, position patient takes to breathe, skin colour and condition
• Inspect thoracic cage (anterior)

  shape and configuration of chest wall, facial expression, level of consciousness, skin colour and condition, quality of respirations, rib interspaces, accessory muscles
• Level of consciousness (LOC)

  AVPU scale:

  Alert: answers questions

  Voice: responds to commands

  Pain: responds to painful stimuli

  Unresponsive: no response to voice or pain
• no oxygen

  no oxygen = hypoxia (brain starts to shut down)
• Facial expression

  calm and relaxed: easy breathing, focused on other things

  Fearful, panicked: troubled breathing, experiencing anxiety
• skin colour and condition

  face, toes, fingers, posterior and anterior chest, Cyanotic = blue, pallor = pale
• clubbing

  too little oxygen to the nails
• Anteroposterior to transverse diameter

  1:2 ratio (two whole widths to make up one front)
• abnormal findings (thorax kyphosis)

  barrel chest, scoliosis, kyphosis
• patient positions

  supine = on back

  Prone = on front

  Fowler's position = upright
• diaphragm positions

  inhalation = contracts (moves down)

  exhalation = relaxes (moves up)
• tripod position

  easier to breath, lowers work needed of accessory muscles in inspiration, engages pectoralis minor muscle in lifting ribcage
• Palpation

  chest wall, symmetrical chest expansion (two hands watch breathe), tactile fremitus, superficial lumps, skin (temp, colour, moist), no pain tenderness, along reference lines