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143 Cards in this Set
- Front
- Back
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Sternum |
3 parts: manubrium, body, xiphoid process |
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Suprasternal notch |
Ridged top of manubrium Most superior |
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Manubriosternal angle |
Also called sternal angle of Angle of Louis Bony ridge that is the articulation of manubrium and body of sternum Continuous with 2nd rib Site of tracheal bifurcation Corresponds with upper border of atria |
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ICS |
Intercostal spaces Numbered by rib above |
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Ribs |
12 pairs Costochondral junction: where rib attaches to cartilage |
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Costochondritis |
Inflammed costochondral junction |
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Floating ribs |
11 and 12 Attached to spinal column only |
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Costal angle |
Normally equal to or less than 90 degrees Abnormal: angle increases or flattens with hyperinflation of lungs, ie. emphysema |
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Verterbral Prominens |
C7 - palpated when head is flexed If there are 2 bumps, it is C7 and T1 |
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Thoracic vertebrae |
12 Spinous process - knobs on vertebrae, some palpable |
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Scapula |
Lower tip/inferior border at 7-8th rib May be difficult to palpate r/t muscle mass |
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Reference lines |
Verticle lines used to document findings |
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Anterior reference lines |
Midsternal Midclavicular (MCL) |
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Posterior reference lines |
Vertebral (midspinal) Scapular |
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Lateral reference lines |
Anterior axillary line (AAL): anterior axillary fold Midaxillary line (MAL): midway between AAL/PAL Posterior axillary line (PAL): at post axillary fold |
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Supraclavicular |
Above clavical |
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Intraclavicular |
Below clavicle |
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Infrascapular |
Below tip of scapula |
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Mediastinum |
Cavity that holds: Heart Great vessels Esophagus Trachea |
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Pleaural Cavities |
Contain lungs |
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Diaphragm |
Floor of thorax Major muscle of respiration |
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Lung Borders: Anterior |
Apex: 3-4 cm above 1st rib, listen on top of clavicle Base: Rest on diaphragm - Right: at 5th ICS, MCS (liver pushes it up) - Left: at 6th ICS, MCL |
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Lung borders: lateral |
From apex of axilla to 7-8th ribs |
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Lung borders: posterior |
C7 to T10 or T12 when inspiring Upper lobes: T1-T3 or T4 Lower lobes: T3-T10 (expiration) or T12 (inspiration) |
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Lobes: right |
3 lobes RUL, RML, RLL Shorter r/t liver RML extends into axilla |
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Lobes: left |
2 lobes LUL, LLL Narrower r/t heart border |
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Horizontal Fissure |
Right side only 4th rib right sternal border to 5th rib MAL Separates RUL and RML |
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Anterior oblique fissures |
Bilateral 5th rib MAL to 6th rib MCL Separates RML and RLL Separates LUL and LLL |
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Pleura |
Visceral: lines lung Parietal: lines chest wall and diaphragm Pleural cavity: negative pressure holds lung against chest wall with sucking pressure Costodiaphragmatic recess: pleura exends 3 cm below level of lung |
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Costodiaphragmatic recess |
Potential space for fluid/air collection that compresses lung Inflammatory fluid collected may be infected |
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Bleb |
Ruptured weakened alveoli Atmospheric pressure (+) is introduced and leaked into pleural cavity (-) Seen in young, male smokers |
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Anterior chest |
Mostly upper and middle lobes |
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Posterior chest |
Mostly lower lobes |
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Trachea |
Anterior to esophagus Starts at cricoid 10-11 cm long Bifurcates at manubriosternal angle/T4 |
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Bronchial tree |
Right main stem bronchus is shorter and straighter, greater risk of aspiration Lined with goblet cells and cilia |
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Dead space |
Trachea and bronchi Filled with air, but no gas exchange takes place |
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Goblet cells |
Secretes mucus that entraps particles Found in bronchial tree |
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Cilia |
Sweeps particles in airways upward Smoking paralyzes cilia and results in mucus pooling |
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Acinus |
Functional respiratory unit Bronchioles, alveolar ducts, alveolar sacs, and alveoli |
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Alveoli |
300 million Where gas exchange takes place |
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Mechanism of respiration |
Supplies O2 and eliminates CO2 Helps maintain acid/base balance |
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Respiratory acidosis |
Retained CO2 |
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Respiratory alkalosis |
Excessive excretion of CO2 through respirations |
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Respiratory center |
Brain stem - pons and medulla Increased CO2 is normal stiumuls to breath Chonic hypoxia desensitizes CO2 receptors and low O2 begomces the trigger to breath Delivery of high O2 concentrations = apnea |
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Ventilation |
Air in and out |
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Perfusion |
Diffusion of gases |
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Cough |
Note timing: may indication cause Continuous (resp infection) Night, when recumbent (post nasal drip, sinusitis, GERD) Morning, upon wakening (chronic bronchitis, smokers cough) Specific settings (allergies) |
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Cough character |
Hacking: mycoplasm pneumonia/walking pna Dry/nonproductive: early CHF, allergies, meds (ACEI) Barking: croup, whooping cough Congested: bronchitis, PNA |
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Sputum |
Amt, color, odor Clear/white: viral bronchitis, PNA Transluscent white/gray: noninfectious, chronic bronchitis, smoker Green/yellow: bacterial bronchitis, PNA Rust: pneumococcal PNA, blood and yellow sputum mixing Pink, frothy: pulmonary edema Hemoptysis: cancer, TB Foul odor: bacterial |
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SOB and Dyspnea |
Difficult, labored breathing |
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Orthopnea |
Difficulty breathing when supine Heart failure Measure pillows used for sleeping or degree of incline |
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Paroxysmal nocturnal dyspnea |
PND Starts and stops suddenly Awakens from sleep with SOB and resolves afer 10 min or so r/t heart failure |
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Dyspnea on Exertion |
DOE Walking up incline |
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Allergies |
dust, pollen, animals, mold |
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Mold allergies |
seen anywhere there is moisture: Water pipes, A/C, rain/dampness, plant mold Plant mold blows in with Santa Anna winds from desert exacerbating allergies/asthma |
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Diaphoresis/Night sweats |
TB, HIV, other infection |
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F/C/S |
Infection |
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Unintentional weight loss |
Cancer |
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Dependent edema, PND, orthopnea |
Heart failure |
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Confusion, restlessness |
Hypoxia |
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Pleurisy |
Chest pain with breathing Inflammation of pleura |
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Smoking history |
Cigarettes, cigars, pipes, marijuana Indicate never, past, current Pack yr history, 2nd hand smoke |
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Family history
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Allergies, asthma, TB (sick contacts), CF (genetic), lung cancer, emphysema (often r/t smoking or environmental exposure), antitripsin deficiency (genetic) |
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Environmental exposure |
How often, do they wear a mask Grain/pesticide inhalation (farmers) Histoplasmosis (midwest) Coccidioidomycosis (San Joaquin valley) Pneumoconiosis (coal miners) Silicosis (stone cutters, miners, potters) Asbestos (plumbers, navy ships) |
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Histoplasmosis |
Inhaled fungus Primarily in midwest r/t bird droppings or pigeon excrement |
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Coccidiodomycosis |
Valley fever Inhaled fungus San Joaquin Valley Causes cavitating lung lesions |
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Asbestos |
Exposure and smoking increases lung cancer more than 10x Old pipes were insulated with asbestos Plumbers and old navy ships |
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PPD |
Purified protein derivative TB screening |
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Influenza immunization |
Everyone > 50 yrs or at risk |
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Pneumococcal vaccine |
Over 65 yrs or at risk |
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Children |
Frequent URIs, 4-6/yr, lower immunities Asthma: may be grown out of as bronchial tubes enlarge Accidental aspiration: child-proof home |
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Aging Adult |
SOB and fatigue with ADLs Decreased vital capacity Lung disease Chest pain with breathing, rib fx r/t trauma, abuse, falls, severe coughing, osteoporosis |
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Vital capacity |
Exhaled air after maximum inspiration Measured by spirometry Will decrease with bronchoconstriction, assesses the degree of bronchoconstriction |
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Inspect |
Rate, rhythm, effort Normal shape and symmetry Spine: curvature may impair cardiopulmonary Body position: professorial or tripod |
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AP:TV ration |
1:2 to 5:7, increases with age May be closer to 1:1 in chronic lung conditions, ie. barrel chested COPD |
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Scoliosis |
Lateral curve Entire spine affected More common in adolescent girls Assess uneven shoulders, scapulas, hips Severe curvature (>45 degrees) may decrease lung volumes |
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Kyphosis |
Hump back T-Spine |
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Lordosis |
Sway back L-spine |
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Tripod position |
Abnormal Aids expiration COPD |
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Palpate |
Entire chest wall Note tenderness, lumps, masses |
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Symmetric chest expansion |
At level of T9 or T10 Uneven with atelectasis, pneumothorax, pleural effusion, phrenic nerve damage |
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Tactile fremitus |
Vocal fremitus Palpate vibrasions Most prominent between scapulae and sternum, progressively decreases down thorax Greater in thin people |
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Increased fremitus |
Consolidation extending to lung surface Lung tissue filled with fluid vs air PNA |
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Decreased fremitus |
Transmission of vibration blocked Bronchial obstruction, pneumothorax, pleural effusion, COPD |
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Crepitus |
Subcutaneous emphysema Course crackling sensation Air entering subcutaneous tissue via open thoracic injury, chest surgery, tracheostomy, CT placement |
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Percussed sounds |
Percuss ICS Resonant: normal Hyperresonant: emphysema, pneumothorax, more hollow Dull: increased density, atelectasis, PNA, pleural effusion |
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Diaphragmatic excursion |
Non-routine, assess movement of diaphragm Diaphragm should change 3-5 cm in inhalation vs exhalation If no change, may be r/t paralysis, phrenic nerve damage, pleural effusion, atelectasis of lower lobes |
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CVA tenderness |
Sign of kidney infection |
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Auscultation |
Use diaphragm of stethoscope Top to bottom and side to side |
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Bronchial sounds |
Loud, harsh Normally over neck, trachea, larynx Abnormal if heard over peripheral lung field, indicates consolidation |
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Bronchovesicular |
Moderately loud/harsh Normally over midsternum and between scapula Major bronchi |
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Vesicular |
Low, soft Normally over peripheral lung fields If absent, report immediately r/t mucus plug, collapsed lung |
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Adventitious sounds |
Added sounds, not normally present Crackles, rhonchi, wheezes |
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Crackles |
Rales, sound like velcro opening Produced when fluid inside bronchus causing a collapse of distal airways and alveoli. Occur when there is sudden equalization of pressure causing some airways to pop open Heard on inspiration doesn't clear with coughing May be caused by atelectasis, PNA, fibrosis, heart failure, pulmonary edema |
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Fine crackles |
High-pitched, short duration, cracking and popping sound |
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Coarse crackles |
Low-pitched, longer duration, bubbling and gurgling sounds |
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Rhonchi |
Deeper than crackles Clears with coughing Airflow through airway obstructed by thick secretions, spasm, or tumor - secretions pooling in bronchial tree Loud, low, coarse sounds, like a snore or rumble Heard continuously during expiration and inspiration Bronchitis, decreased cough reflex |
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Wheeze |
Airflow through constricted airway High-pitched squeaking, like a whistle Primarily heard on expiration, but may be on inspiration Assess breath sounds with forced expiration in an asthma pt to check for bronchoconstriction Bronchospasm r/t asthma, acute or chronic bronchitis |
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Stridor |
Sign of respiratory distress Partially obstructed airway Characterized by inspiratory wheeze Louder in neck than chest |
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Pleural friction rub |
Caused by inflammation of pleural spaces Coarse, rubbing or grating sound during inspiration or expiration that disappears when breath is held Pleurisy |
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Voice sounds |
Assess if breath sounds are abnormal |
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Bronchophony |
Listen to "99" on back Abnormal: clear "99" Increased lung density, PNA, atelectasis |
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Egophony |
Repeat "E" sound, listen on back Abnormal: "E" changes to "A" Consolidation |
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Whispered pectoriloquy |
Whisper 1, 2, 3 Abnormal: sounds clear and distinct Consolidation |
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Inspect anterior thorax |
Skin: pallor, cyanosis Nails: clubbing, r/t fibrotic lung changes Pursed lips: obstructive disease Spinting: shallow breaths to control pain Quality of respiration: quiet, easy, nonlabored Tracheal position: midline Chest Costal Angle: <90 degrees LOC: drowsiness r/t cerebral hypoxia Retraction or bulging ICS: unilateral vs bilateral Accessory muscle use |
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Pursed lips |
Seen in obstructive disease Prolongs expiration cycle to allow for exhalation of trapped air |
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Tension pneumothorax |
Trachea shifts, tracheal tug To opposite side of lung collapse |
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Pectus excavatum |
Sunken sternum, funnel chest Can impair respiration |
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Pectus Carinatum |
Forward protrusion Pigeon chest |
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Barrel chest |
Increased AP diameter Associated with aging, emphysema, asthma Costal angle > 90 degrees |
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Retraction of ICS |
Obstruction or increased respiratory effort |
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Bulging of ICS |
Trapped air, emphysema Leads to barrel chest |
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Accessory muscle use |
Neck muscles used to lift sternum and rib cage SCM, Scaleni (below SCM), and trapezius Neck muscles may be overdeveloped with chronic respiratory disease |
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Normal respiratory rate |
10-20 breaths/min with occasional sigh Sighs expand alveoli |
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Tachypnea |
Rapid, shallow breathing >20 breaths/min Fever, fear, anxiety, exercise, respiratory insufficiency, PNA, alkalosis, pleurisy, lesions in the pons |
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Hyperventilation |
Rapid, deep breathing Extreme exertion, fear, anxiety, DKA CO2 is excreted through respirations increasing the alkalinity of the blood |
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Bradypnea |
Regular, slow breathing < 10 breaths/min Depressant drugs, increased ICP, diabetic coma |
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Hypoventilation |
Irregular, shallow breaths Narcotic OD, anesthetics, prolonged bedrest, splinting with pain CO2 is retained, may cause acidosis |
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Cheyne-stokes |
Regular, cyclic Breathing 30-40 seconds followed by 20 sec apnea CHF and other causes |
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Biots |
Ataxic Irregular, deep breaths Slow rate with periods of apnea Precedes Cheyne-stokes |
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Stertorous |
Snoring |
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Stridor |
Croup, foreign body, growth on vocal cords, high-pitched on inspiration |
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PEFR |
Peak Expiratory flow rate Maximum flow of air during forced expiration Useful surrogate to measure vital capacity Compare results to pt's personal best (% of pt's personal best) or to norms (% of predicted) |
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Atelectasis |
Collapsed alveoli Predisposes to PNA |
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PNA |
Pneumonia: infection of alveoli, interstitial lung tissue, and/or bronchioles |
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Viral PNA |
More common in children |
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CAP |
Community acquired PNA usually strep or H. Flu |
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Atypical PNA |
Mycoplasm Walking PNA |
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Nosocomial PNA |
Hospital acquired Usually gram (-), ie. pseudomonos staph if gram (+) |
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Aspiration Pneumonia |
Aspiration of gastric contents Usualy r/t poor gag refluex |
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Lobar PNA |
Large area of lung parenchyma involved Very serious type of PNA |
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Bronchitis |
Inflammation of bronchi Acute or Chronic |
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Emphysema |
Destruction of alveoli Decreased gas exchange |
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Asthma |
Intermittent bronchospasm, constriction May lead to chonic lung disease |
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Pleural effusion |
Fluid in pleural space |
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Pneumothorax |
Air in pleura space Collapsed lung |
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Hemothorax |
Blood in pleural space |
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Empyema |
Purulent exudate in pleural space |
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Cystic Fibrosis |
Autosomal recessive disorder of exocrine glands affecting lungs, pancreas, sweat glands |
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Bronchiectasis |
Chronic dilation of bronchi and bronchioles Caused by repeated infections Very serious condition |
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Corpulmonale |
Lung disease that causes hypertrophy of right ventricle and progresses to heart failure |
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Pre-term infants |
Surfactant is produced at 32 weeks gestation Collapse of alveoli if pre-term labor before 32 weeks
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Assessing infants/children |
Count RR for 60 seconds, irregular rate Less than 3 mo: obligatory nose breathers, nasal obstruction can cause death because soft palate obstructs oral airway - suction out nares Less than 5-6 yrs: bronchovesicular breath sounds normal in lung fields |
