Thorax

• ANATOMY OF THE THORAX Thorax • Sternum • Ribs • Costal cartilages
• Sternum - flat bone
• The Sternum is divided into three parts:

  1.Manubrium 2. Body 3. 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
• Twelve pairs of ribs attached posteriorly to the thoracic vertebrae
• The ribs are divided into three categories: True ribs, False ribs, and 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
• Floating Ribs - ribs 11th and 12th; no anterior attachment
• Costal Cartilages - bars of cartilage that connects the upper 7 ribs to lateral edge of sternum and 8th-10th ribs to cartilage immediately above them. Note: 11th – 12th ribs end in abdominal musculature
• MECHANICS OF RESPIRATION: Inspiration and expiration are accomplished by: - Increase and decrease of thoracic cavity capacity - Physiologic rate (16-20 breaths per minute)
• QUIET INSPIRATION - Increased vertical diameter of thoracic cavity due to contraction and descent of diaphragm - Increased transverse and anteroposterior due to rising of ribs and thrusting of sternum forward - Through contraction of intercostal muscles
• FORCED INSPIRATION - In addition: Scalenus anterior and medius, Sternocleidomastoid, Serratus anterior and pectoralis minor
• QUIET EXPIRATION - Passive process (accomplished by): Elastic recoil of lungs, Relaxation of intercostal muscles and diaphragm
• FORCED EXPIRATION - Active process (accomplished by): Contraction of muscles of abdominal wall, Contraction of quadratus lumborum o Contraction of latissimus dorsi
• QUIET INSPIRATION AND EXPIRATION: EUPNEA – mode of breathing that occurs at rest and does not require cognitive thought
• FORCED INSPIRATION AND EXPIRATION: HYPERPNEA – mode of breathing that can occur during exercise or actions that require the active manipulation of breathing
• Have client bend forward at the waist and observe from behind. (ADAMS’S FORWARD BEND TEST)
• Inspect SPINAL ALIGNMENT for deformities Normal: 2 forward curves (cervical and lumbar spine), 2 backward curves (thoracic and sacral area), and Vertically aligned
• Palpate POSTERIOR THORAX • For clients who have no respiratory complaints, rapidly assess the temperature and integrity of the chest skin
• For clients with respiratory complaints, palpate all chest areas for bulges, tenderness, or abnormal movements
• CREPITUS – a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone
• CAUSE: subcutaneous emphysema; results from air leaking into the subcutaneous tissue; check around wound sites, chest tubes, central lines or tracheostomy tubes
• Resonance - long, low pitched percussion sounds; Normal Lung
• Flat - Short, soft, high-pitched sounds; Atelectasis
• Dull - Medium intensity; Lobar Pneumonia
• Hyperresonant - very loud percussion sound; Pneumothorax
• Tympanic - musical percussion sound; Large Pneumothorax (air collection)
• UNILATERAL HYPER-RESONANT – when too much air is present
• GENERALIZED HYPERRESONANCE – in COPD, asthma, and emphysema
• DULL – when abnormal density in the lungs as with lobar pneumonia, pleural effusion, atelectasis, tumor, empyema, or fibrous tissue
• DIAPHRAGMATIC EXCURSION • Normal: Bilateral excursion ▪ Male: 5 – 6 cm ▪ Female: 3 – 5 cm
• Auscultate the CHEST using the flat disc diaphragm of the stethoscope
• Use the Systematic Zigzag Procedure in percussion. Ask client to take slow, deep breaths through the mouth. Listen at each point to the breath sounds during a complete inspiration and expiration. • Compare findings at each point with the corresponding point on the opposite side of the chest.
• VESICULAR – soft and low pitched; usually heard over most of both lungs
• BRONCHIAL – louder and higher in pitch; usually heard over the manubrium
• BRONCHOVESICULAR – intermediate intensity and pitch; usually heard over 1st and 2nd intercostal spaces
• ADVENTITIOUS BREATH SOUNDS - are abnormal sounds that are heard over a patient's lungs and airways. These sounds include abnormal sounds such as fine and coarse crackles, wheezes, pleural rubs, and stridor.