Finals Exam

• Thorax identifies the portion of the body extending from the base of the neck superiorly to the level of the diaphragm inferiorly
• Lower respiratory system includes lungs, distal portion of the trachea, and the bronchi located in the thorax
• Thoracic cage is the outer structure of the thorax
• Thoracic cavity contains respiratory components
• Thorough assessment of the lower respiratory system focuses on the external chest as well as the respiratory components in the thoracic cavity
• Major structure of the respiratory system includes mechanics of normal inspiration and expiration
• Assessment of the posterior thorax:

  • Inspect the configuration: client sits with arms at the sides, stand behind the client and observe the position of scapulae and the shape and configuration of the chest wall
  • Observe use of accessory muscles: watch as the client breathes and note use of muscles
  • Inspect the client's positioning: note the client's posture and ability to support weight while breathing comfortably
  • Palpate for tenderness and sensation: palpation may be performed with one or both hands, use your fingers to palpate for tenderness, warmth, pain, or other sensations
• Sequence of palpating the posterior thorax:

  • Palpate for crepitus: crackling sensation that occurs when air passes through fluid or exudate
  • Palpate the surface characteristics: feel for any unusual masses
  • Palpate for fremitus: vibrations of air in the bronchial tubes transmitted to the chest wall
  • Assess the chest expansion (diaphragmatic excursion)
  • Percuss the tone
  • Percuss for diaphragmatic excursion
  • Auscultate for breath sounds
  • Auscultate for adventitious sound
• Normal deviations from normal:

  • Scapulae should be symmetric and non-protruding
  • Shoulders and scapulae should be in equal horizontal positions
  • Ratio of anteroposterior to transverse diameter is 1:2
  • Spinous processes should appear straight
  • Thorax should appear symmetric, with ribs sloping downward at approximately a 45-degree angle in relation to the spine
  • Spinal configurations may have respiratory implications
• • Ribs appearing horizontal at an angle greater than 45 degrees with the spinal column are frequently the result of an increased ratio between the anteroposterior-transverse diameter (barrel chest), commonly seen in emphysema due to hyperinflation of the lungs
• Normal deviations from normal:

  • The client does not use accessory muscles to assist breathing
  • The diaphragm is the major muscle at work, evidenced by expansion of the lower chest during inspiration
  • Client leans forward and uses arms to support weight and lift chest to increase breathing capacity, referred to as the tripod position, often seen in COPD
  • Client should be sitting up and relaxed, breathing easily with arms at sides or in lap
  • Tender or painful areas may indicate inflamed fibrous connective tissue
  • Pain over the intercostal spaces may be from inflamed pleurae
• • Pain over the ribs, especially at the costal chondral junctions, is a symptom of fractured ribs
• Normal deviations from normal:

  • No crepitus should be present
  • Skin and subcutaneous tissue should be free of lesions and masses
  • Fremitus should be symmetric and easily identified in the upper regions of the lungs
  • Unequal fremitus is usually the result of consolidation or bronchial obstruction, air trapping in emphysema, pleural effusion, or pneumothorax
  • When the client takes a deep breath, the examiner's thumbs should move 5 to 10 cm apart symmetrically
  • Resonance is the percussion tone elicited over normal lung tissue
• • Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax
• Normal deviations from normal:

  • Resonance should change to dullness during diaphragmatic excursion
  • Auscultate for breath sounds at the apex of the lung at C7
  • Be alert to the client's comfort and offer times for rest and normal breathing if fatigue is becoming a problem
  • Auscultate for adventitious sounds added or superimposed over normal breath sounds and heard during auscultation
• Normal excursion should be equal bilaterally and measure 3-5 cm in adults
• The level of the diaphragm may be higher on the right due to the position of the liver
• In well-conditioned clients, excursion can measure up to 7 or 8 cm
• Dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space, such as in lobar pneumonia, pleural effusion, or tumor
• Diaphragmatic descent may be limited by atelectasis of the lower lobes or by emphysema
• The diaphragm remains in a low position on inspiration and expiration
• Three types of normal breath sounds may be auscultated: bronchial, bronchovesicular, and vesicular
• Diminished or absent breath sounds often indicate that little or no air is moving in or out of the lung area being auscultated
• Increased (louder) breath sounds often occur when consolidation or compression results in a denser lung area
• Bronchial breath sounds:

  • Pitch: high
  • Quality: harsh or hollow
  • Amplitude: loud
  • Duration: short during inspiration; long during expiration
  • Location: trachea and thorax
• Broncho vesicular breath sounds:

  • Pitch: moderate
  • Quality: mixed
  • Amplitude: moderate
  • Duration: same during inspiration and expiration
  • Location: over the major bronchi - posterior: between the scapulae; anterior: around the upper sternum in the first and second intercostal spaces
• Vesicular breath sounds:

  • Pitch: low
  • Quality: breezy
  • Amplitude: soft
  • Duration: long in inspiration; short in expiration
  • Location: peripheral lung field
• Discontinuous sound:

  • Characteristics: high-pitched, short, popping sounds heard during inspiration and not cleared with coughing; sounds are discontinuous and can be simulated by rolling a strand of hair between your fingers near your ear
  • Source: inhaled air suddenly opens the small, deflated air passages that are coated and sticky with exudate
  • Associated condition: crackles occurring in inspiration are associated with restrictive diseases such as pneumonia and congestive heart failure
• Crackles (coarse):

  • Characteristics: low-pitched, bubbling, moist sounds that may persist from early inspiration to early expiration; also described as softly separating Velcro
  • Source: inhaled air comes into contact with secretions in the large bronchi and trachea
  • Associated condition: may indicate pneumonia, pulmonary edema, and pulmonary fibrosis
• Pleural friction rub:

  • Characteristics: low-pitched, dry, grating sound much like crackles, only more superficial and occurring during both inspiration and expiration
  • Source: sound is the result of rubbing of two inflamed pleural surfaces
  • Associated condition: pleuritis
• Wheeze (sibilant):

  • Characteristics: high-pitched, musical sounds heard primarily during expiration but may also be heard on inspiration
  • Source: air passes through constricted passages (caused by swelling, secretions, or tumor)
  • Associated condition: sibilant wheezes are often heard in cases of acute asthma or chronic emphysema
• Wheeze (sonorous):

  • Characteristics: low-pitched snoring or moaning sounds heard primarily during expiration but may be heard throughout the respiratory cycle; these wheezes may clear with coughing
  • Source: same as sibilant wheeze
  • Associated condition: sonorous wheezes are heard in cases of bronchitis or single obstructional snoring before an episode of sleep apnea
• No adventitious sounds, such as crackles or wheezes, are auscultated
• Bronchophony: ask the client to repeat the phrase "ninety-nine" while you auscultate the chest wall
• Egophony: ask the client to repeat the letter "e" while you listen over the chest wall
• Whisper pectoriloquy: ask the client to whisper the phrase "one-two-three" while you auscultate the chest wall
• Respirations are relaxed, effortless, and quiet. They are of a regular rhythm and normal depth at a rate of 10-20 per minute in adults
• Abnormal breathing patterns include tachypnea, bradypnea, hyperventilation, hypoventilation, Cheyne-Stokes respiration
• Voice transmission is soft, muffled, and indistinct. The sound of the voice may be heard but the actual phrase cannot be distinguished
• Voice transmission will be soft and muffled but the letter "e" should be distinguishable