NCM 101 RLE

• Sternum is divided into three parts: Manubrium, Body, Xiphoid process
• Manubrium


  • Carries the greatest physical load
  • Forms upper part of sternum
  • Articulates with body of sternum at manubriosternal joint
• Body


  • Articulates with manubrium (above) and xiphoid process (below)
  • Articulates with 2nd (lower half) to the 7th ribs

  
• Xiphoid Process


  • Thin plate of cartilage
  • Becomes ossified at its proximal end during adult life
  • No ribs or costal cartilages are attached
• Ribs


  • Twelve pairs
  • Attached posteriorly to the thoracic vertebrae

  
• Categories of ribs


  • True ribs
  • False ribs
  • Floating ribs

  
• True Ribs


  • Upper seven pairs
  • Attached to the sternum by their costal cartilages

  
• False Ribs


  • Ribs 8th to 10th
  • Attached anteriorly to each other
  • Also attached to the 7th rib by their costal cartilages and small synovial joints

  
• Floating Ribs


  • Ribs 11th and 12th
  • No anterior attachment

  
• Costal Cartilages


  • Bars of cartilage
  • Connects upper 7 ribs to lateral edge of sternum
  • Connects 8-10th ribs to cartilage immediately above them
  • 11th – 12th ribs end in abdominal musculature

  
• Mechanics of Respiration


  1. Inspiration: Increase in thoracic cavity capacity

  2. Expiration: Decrease in thoracic cavity capacity

  3. Physiologic rate: 16-20 breaths per minute
• Quiet Inspiration


  1. Increased vertical diameter of thoracic cavity due to contraction and descent of diaphragm

  2. Increased transverse and anteroposterior due to rising of ribs and thrusting of sternum forward
• Forced Inspiration


  1. Scalenus anterior and medius

  2. Sternocleidomastoid

  3. Serratus anterior and pectoralis minor
• Quiet Expiration


  Passive process: Elastic recoil of lungs, Relaxation of intercostal muscles and diaphragm
• Forced Expiration


  Active process: Contraction of muscles of abdominal wall, Contraction of quadratus lumborum, Contraction of latissimus dorsi
• Eupnea


  Mode of breathing that occurs at rest and does not require cognitive thought
• Hyperpnea


  Mode of breathing that can occur during exercise or actions that require the active manipulation of breathing
• Explain the procedures to the client, Wash your hands, Provide privacy, History taking: family history (illnesses) medications, Current health problems
• Assemble equipment: Stethoscope, Skin marker/pencil, Centimeter ruler
• Inspect shape and symmetry of the thorax from posterior and lateral views


  Normal: Adult thorax is oval, overall shape is elliptical, Wider than it is deep

  
• Inspect spinal alignment for deformities

  Normal: 2 forward curves (cervical and lumbar spine), 2 backward curves (thoracic and sacral area), Vertically aligned

  
• Palpate posterior thorax


  1. Normal: Chest wall intact, no masses, no tenderness

  2. Abnormal: Lumps, bulges, depressions, CREPITUS, chest tenderness, fractures

  
• Palpate posterior chest for respiratory excursion


  1. Normal: Full and symmetric chest expansion; thumbs separate: 3-5 cm (1.5-2 in)

  2. Abnormal: Asymmetric and/or decreased chest expansion

  
• Palpate chest for vocal (tactile) fremitus

  1. Normal: Bilateral symmetry of vocal fremitus

  2. Abnormal: Decreased/absent fremitus, Increased fremitus
• Percuss the thorax

  1. Normal: Resonance except over scapula

  2. Abnormal: Asymmetry in percussion, Areas of dullness or flatness over lung tissue, Unilateral Hyper-resonant, Generalized hyperresonance, Dull
• Percuss for diaphragmatic excursion


  1. Normal: Bilateral excursion, Male: 5 – 6 cm, Female: 3 – 5 cm, Diaphragm is slightly elevated on the right side

  2. Abnormal: Abnormally high level of dullness and absence on excursion
• Auscultate the chest


  1. Normal: Vesicular, Bronchial, Bronchovesicular

  2. Abnormal: Adventitious breath sounds, Absence of breath sounds

  
• Inspect breathing patterns


  1. Normal: Eupnea (unlabored breathing)

  2. Abnormal: Tachypnea, Bradypnea, Hyperpnea, Biot's, Kaussmaul's, Cheyne–stokes, Apnea, Apneustic

  
• Inspect costal angle at which ribs enter the spine


  1. Normal: Angle is less than 90 degrees

  2. Abnormal: Costal angle is widened

  
• Palpate anterior chest for respiratory excursion


  Abnormal: Decrease chest excursion - COPD, severe atelectasis, pneumonia, chest trauma, pleural effusion, pneumothorax

  
• Palpate tactile fremitus in the anterior chest


  If the breasts are large and cannot be retracted adequately for palpation, this part of the examination is usually omitted.
• Percuss the anterior chest


  1. Normal: Resonate until 6th rib at level of diaphragm but are flat over areas of heavy muscle and bone, heart, liver, an tympany over stomach

  2. Abnormal: Asymmetry in percussion, areas of dullness or flatness over lung tissue
• Auscultate the trachea


  1. Normal: Bronchial and tubular breath sounds

  2. Abnormal: Adventitious breath sounds

  
• Auscultate the anterior chest


  1. Normal: Bronchovesicular and vesicular

  2. Abnormal: Adventitious breath sounds

  
• Document findings in the client's record
• Normal breath sounds

  • Vesicular
  • Bronchial
  • Bronchovesicular
• Coverage


  • Thorax (Chest and Lungs)
  • Heart
  • Abdomen
  • Rectum & Anus
• Thorax


  • Sternum
  • Ribs
  • Costal cartilages
• Sternum


  Flat bone divided into three parts: Manubrium, Body, Xiphoid process

  
• Manubrium


  • Carries the greatest physical load
  • Forms upper part of sternum
  • Articulates with body of sternum at manubriosternal joint