thorax and lungs

• Republic of the Philippines
• Bulacan State University
• City of Malolos, Bulacan
• COLLEGE OF NURSING
• Nursing Assessment of Physical Systems: THORAX and LUNGS
• Thoracic Cage/Cavity


  Bony, conical shape, narrower at top borders

  
• Structures defining the thoracic cage

  • Sternum (manubrium, body, xiphoid process)
  • Ribs (12 pairs, 1st seven attach to sternum, 8-10 attach to cartilage above, 11-12 floating ribs)
  • 12 Thoracic vertebrae
  • Diaphragm

  
• Anterior Thoracic Landmarks


  • Suprasternal Notch
  • Sternum (manubrium, body, xiphoid process)
  • Angle of Louis
  • Costal angle
• Posterior Thoracic Landmarks


  • Vertebra Prominens
  • Spinous Processes
  • Scapula
  • 12th Rib
• Thoracic Cavity


  Middle of the thoracic cavity, contains esophagus, trachea, heart, great vessels
• Pleural Cavities


  On either side of the mediastinum, contain the lungs

  
• Lung Borders


  • Apex 3-4 cm above inner 1/3 of clavicles
  • Base rests on diaphragm, 6th rib, MCL
  • Extends from axilla apex to 7th-8th rib posteriorly
  • Apex at C7, base at T10 (on deep inspiration to T12)

  
• Lobes of Right Lung


  • Upper
  • Middle
  • Lower

  
• Lobes of Left Lung


  • Upper and Lower
• Lung Lobes


  • Left lung has no middle lobe
  • Anterior chest contains upper & middle lobes with little lower lobe
  • Posterior chest has almost all lower lobes, right middle lobe does not project into posterior chest

  
• Pleurae


  • Visceral pleura lines outside of lungs
  • Parietal pleura lines inside of chest wall & diaphragm
  • Pleural Cavity is the space between visceral & parietal pleura, normally has a vacuum or negative pressure

  
• Trachea


  10-11 cm long, begins at cricoid cartilage, bifurcates below sternal angle into right and left main stem bronchi
• Bronchi


  Secrete mucus to capture particles, cilia move trapped particles up to be expelled or swallowed
• Acinus


  Functional respiratory unit consisting of bronchioles, alveolar ducts, alveolar sacs, & alveoli where gaseous exchange takes place

  
• Major Functions of Respiratory System

  • Supply O2 for energy production
  • Remove CO2, waste product of energy reactions
  • Homeostasis, acid-base balance of arterial blood
  • Heat exchange
• Respiration maintains pH (acid-base balance)


  By supplying O2 and eliminating CO2
• Normal Range Values of Arterial Blood Gases

  • pH 7.35-7.45
  • PaCO2 35-45 mmHg
  • PaO2 80-100 mmHg
  • SaO2 94-98%

  
• Acidosis


  pH <7.35, PaCO2 >45, HCO3 <22
• Alkalosis


  pH >7.45, PaCO2 <35, HCO3 >26
• Lungs maintain pH


  By adjusting CO2 through hypoventilation or hyperventilation
• Respiratory Center


  Involuntarily controls respiration, located in brain stem (pons and medulla)
• Hypercapnia


  Increase in CO2 in the blood, provides the normal stimulus to breathe
• Hypoxemia


  Decrease in oxygen in the blood
• Subjective Data from Interview

  • Cough
  • Shortness of Breath
  • Chest Pain
  • Respiratory Infections
  • Smoking
  • Environmental Exposure
  • Self-care behaviors
• Equipment for Exam


  • Stethoscope
  • Ruler
  • Tape measure
  • Washable marker
  • Alcohol swabs
• Inspection of Thoracic Cage


  • Shape and configuration
  • Anteroposterior Diameter should be < Transverse Diameter = Ratio 1:2
  • Note position of person to breathe (orthopnea)
  • Skin color & condition, nail color

  
• Palpation of Posterior Chest


  • Symmetric Expansion
  • Tactile Fremitus (palpable vibration of sound from larynx)
  • Entire chest wall (tenderness, skin temp., moisture, lumps, lesions, crepitus)
• Tactile Fremitus


  • Decreased fremitus = obstructed bronchi, pleural effusion, pneumothorax or emphysema
  • Increased fremitus occurs only with gross changes (Lobar pneumonia)
• Percussion of Posterior Chest

  • Resonance predominates in healthy lung
  • Hyperresonance = too much air, emphysema, pneumothorax
  • Dull = abnormal density, pneumonia, tumor, atelectasis
• Diaphragmatic Expansion


  Measure difference in lower lung borders on expiration and inspiration, should be 3-5 cm in adults

  
• Inspection of Anterior Chest


  • Shape & Configuration
  • Expression
  • Level of Consciousness
  • Skin color & condition
  • Quality of Respirations
• Palpation of Anterior Chest


  • Symmetric Chest Expansion
  • Tenderness, turgor, temp., moisture
  • Tactile Fremitus
• Percussion of Anterior Chest

  • Resonance in interspaces
  • Dullness over female breast tissue, liver, heart
  • Flat = muscle & bone
  • Tympany = stomach
• Auscultation of Lungs


  • Bronchial breath sounds over trachea & larynx
  • Bronchovesicular breath sounds over major bronchi, posterior between scapulae, anterior upper sternum, 1st & 2nd ICS
  • Vesicular breath sounds over anterior & posterior lung fields
• Decreased or Absent Breath Sounds

  Caused by obstruction of bronchial tree, decreased lung elasticity, pleurisy, pneumothorax, pleural effusion