Health Assessment - Lecture 5

Front 1

What are two functions of the respiratory system? How are these functions efficient for the body?

Back 1

-Exchange of gases in the body –Intake of O2(supply energy production) and release of CO2(remove waste product of energy) –maintains pH/acid base balance of blood

Front 2

What are three functions of the Central Nervous System?

Back 2

-Maintain acid base balance of arterial blood, maintain body fluids, Assists with speech

Front 3

Explain hypoventilation vs hyperventilation.

Back 3

Hypo-slow, shallow breaths>>CO2 buildup in blood. Hyper-fast deep breaths>>CO2 blown off

Front 4

What is the normal stimulus to breathe? Another less effective method?

Back 4

-hypercapnia, increase in CO2 in blood –hypoxemia-decreased O2 in blood increases respirations

Front 5

What do people often mistake about anatomy of the lungs? Why is it harder for pregnant women to breathe?

Back 5

-they don’t go to down to the abdomen, only end of rib cage –diaphragm is elevated 4cm from enlarged uterus

Front 6

The mediastinum contains which body structures? (5)

Back 6

-esophagus, trachea, major blood vessels, heart, pleural cavities

Front 7

The thoracic cage contains which body structures?(4)

Back 7

-bony structure with 12 ribs, 12 vertebrae, costal cartilage, and supportive muscles

Front 8

The Upper respiratory tract consists of ? (6)

Back 8

-Nose,mouth, sinuses, Pharynx, Larynx, trachea(part)

Front 9

The Lower respiratory tract consists of?(6)

Back 9

-Distal trachea, bronchi, lungs, pleural membranes, respiration muscles, mediastinum

Front 10

Describe each of the following Bony landmarks: Suprasternal notch, Sternum, Angle of Louis(why important?),

Back 10

-Ushape above sternum –manubrium(top), body(mid), and xiphoid process(bottom) –manubriosternal angle b/w manubrium & sternal body and site of bifurcation of lungs(bronchi) important for heart sounds

Front 11

Describe each of the following Bony landmarks: Costal Angle(explain angles), Clavicles, Vertebra prominens, Scapula

Back 11

– Right & left costal margin form angle & meet at xiphoid, ≤ 90 normal; >90= emphysema, chronically overinflated –apex of lungs, 3-4cm inner third –bony prominence at base of neck(C7, T1) –inferior border at 7th-8th rib

Front 12

What is the major difference between the right and left lobes of the lungs?

Back 12

-2 on left, 3 on right

Front 13

When looking at the anterior chest, what are three lines of reference? Posterior chest? Lateral ? Left oblique fissure? Right oblique fissure? Horizontal fissure? Midsternal, midclavicular, anterior axillary

Back 13

–vertebral line, scapular line(midclav), posterior axillary –anterior axillary, midaxillary line, Posterior axillary line –T3 to 6th rib –T3 to 6th rib -5th rib R MAL to 3rd ICS

Front 14

For posterior view of lung lobes, what is the range of the upper lobe? Lower lobe?

Back 14

-T1 to T3/T4 – T10(expiration) T12(inhalation)

Front 15

Looking laterally of the left lung lobes, explain Upper vs lower lobe location. Where is Left oblique fissure?

Back 15

-Upper –mostly on anterior ; Lower –mostly on posterior –T3 to 6th rib at midclavicular line

Front 16

Looking lateral at the right lung lobes, explain the following fissures: Right oblique, Horizontal fissure. Where is RML?

Back 16

-T3 to 6th rib at MCL, -4th rib to 5th Rib on MAL –under breasts

Front 17

Why is it important to ausculatate laterally? Why is right lung shorter than the left lung?

Back 17

-Lung sounds present there too. –because of liver location.

Front 18

When asking about cough, what might the following characteristics indicate: continuous throughout day, afternoon/evening, night, early morning

Back 18

-acute illness(respiratory infxn) –exposure to irritants –post nasal drip(sinusitis) –chronic bronchial inflammation of smokers

Front 19

What is hemoptysis? Orthopnea? Paroxysmal nocturnal dyspnea? Four symptoms of respiratory assessment?

Back 19

-coughing up blood –difficulty breathing when supine-awaking from sleep with SOB(need to sit up) –cough, sputum, SOB, pain with breathing

Front 20

It’s important to check the health history of which respiratory infections? What other type of history is important to assess? Why is it important to ask about allergies and meds?

Back 20

-Asthma, bronchitis, emphysema, pneumonia – smoking history and habits –they can have a major impact on respiratory system

Front 21

If lower neck was swollen, how would you proceed with assessment?

Back 21

-listen for bruits(wooshing, pulsatile sounds with bell of diaphragm)

Front 22

When inspecting anterior/posterior thorax, what are we observing for the: Shape & configuration(5), AP:TD, 1:1?

Back 22

-symmetric, shape of chest cavity, posture, scoliosis, kyphosis –should be 1:2 – indication of barrel chest(chronic emphysema, hyperinflation of lungs)

Front 23

How would a patient with COPD be positioned? Regular? How would COPD change neck muscles? Chest appearance?

Back 23

-tripod, leaning forward -Erect –hypertrophy from aiding respiration –barrel chested

Front 24

What skin conditions should you watch out for those with respiratory distress?

Back 24

-Pallor, cyanosis

Front 25

If respirations are retracted, what does it usually mean? Bulging indicates? Respiratory rate?

Back 25

-obstruction of respiratory tract –forced expiration D/T emphysema or asthma –fast, slow, irregular

Front 26

Describe the following Respiration patterns and give examples of each: Tachypnea, Bradypnea, hyperventilation, hypoventilation, Eupnea

Back 26

-rapid, short breaths >24/min(fear, fever, exercise – slow breaths <10/min(diabetic coma)– increase rate & depth(fear, anxiety). –irregular shallow depth (overdose, prolonged bedrest) –normal pattern

Front 27

Describe the following Respiration patterns and give examples of each: Cheyne-Stokes, Biot’s, Chronic obstructive, Sighing

Back 27

-periods of deep breathing with periods of apnea; regular pattern (heart , liver failure, drug overdose)–shallow deep respirations with periods of apnea; irregular pattern(head trauma, brain abscess, heat stroke) –prolonged expiration (air trapping) – frequent sighs may mean emotional dysfunction (hyperventilation and dizziness)

Front 28

When you palpate trachea, what should be the expected result? What are you palpating on the chest?

Back 28

-midline on sternal notch –sternum, ribs, intercostals spaces

Front 29

How are you palpating tactile fremitus (Post and anterior)? What can you expect as you percuss? Which part of the stethoscope do you use(sound types)?

Back 29

-looking for vibrations with ulnar surface of ball of hands –sounds should get lighter as you go down chest “say 99” –Diaphragm, high frequency

Front 30

What respiratory problems can occur if patient is lying in bed for a long time? What can you do?

Back 30

-Infections can build up, hospital acquired pneumonia -Raise Head of bed 30-40 degrees or sit them up

Front 31

For palpating the posterior thorax, how can we assess air in the lungs? How do you know if something is wrong? What are other conditions?

Back 31

-Thoracic expansion (place hands at T9 to t10, have them take deep breath – one side will expand, other will not move (poss. Collapsed lung) –atelectasis, pneumonias or thoracic trauma

Front 32

What are some abnormalities that exist with tactile fremitus?

Back 32

-Decreased fremitis (obstruction): pneumothorax, emphysema, pleural effusion -Increased fremitis(compression of lung tissue): lobar pneumonia

Front 33

In percussion of the chest, what would you expect to hear for a normal sound? Hyperresonance? (give examples) Typanic? Muscles/obesity? Flat bone/muscle? Children?

Back 33

-Resonant, hollow –booming, indicates hyperinflation of lungs (Asthma, COPD, emphysema, pneumothorax) –drumlike (liver) –dull, thud –flat –hyperresonance normal

Front 34

When percussing the chest, how many sites should we be assessing? Similarities b/w palpation, percussion, and auscultation?

Back 34

6 side-to –side by midspinal line (5cm), 1 midscapular, 2 lateral –checking same site all three times

Front 35

What is the purpose of the diaphragmatic excursion? How do you test this? What should you expect to see? Hyperresonance indicates what?(2) Dullness signals what? (4)

Back 35

How far the diaphragm goes down after you breath –deep breath and hold, percuss down scapula line and note sounds resonance to dullness, mark line, percuss back up and make mark. Repeat on other side and measure. Should be 3-5cm -right is slightly higher than left d/t liver. –too much air as in emphysema and pneumothorax –abnormal density in lungs as in pneumonia, pleural effusion, and atelectasis(collapse of lung), tumor

Front 36

Describe the following breath sounds,and give location, pitch, duration, and I vs E: Bronchial(tracheal), Bronchovesicular, Vasicular (overweight/muscular? Thin/child?)

Back 36

-trachea, high pitch, loud and long, I<E –bronchus and upper right posterior lung, medium pitch, I=E –most of lung fields, low pitch, soft and short, I>E; diminished ; accentuated

Front 37

**For breath sounds, if sound is amplified (increased), why could that be? Decreased or absent breath sounds may indicate?

Back 37

-consolidation(Pneumonia) or compression (fluid in intrapleural space) –obstruction or foreign body (pneumothorax, pleural effusion), emphysema you will hear quieter sounds

Front 38

Adventitious sounds? What are the four types of adventitious sounds and describe what they sound like?

Back 38

-sounds not normally heard in lungs –Crackle(course-velcro fastener, fine-roll strand of hair), wheeze(sibilant,-musical squeaking sonorous-deep musical snore), pleural rub-leather rubbing, and stridor-crowing sound

Front 39

For fine crackles, what types of inspirations, and give example disorders?

Back 39

-Early inspiratory: obstructive (bronchitis, asthma, emphysems) –Late inspiratory: restrictive (pneumonia, CHF, interstitial fibrosis

Front 40

Describe continuous vs discontinuous sounds, give examples

Back 40

-c-connected musical sounds (wheeze, stridor) d-discrete crackle sounds (fine, course, friction rub)

Front 41

Give example conditions of each of the following: Course crackles, pleural friction rub, sibilant wheeze, sonorous wheeze, stridor

Back 41

-pulmonary edema & fibrosis –pleuritis(painful breathing) –acute asthma, chronic emphysema – bronchitis, obstruction – croup and acute epiglottis in children, foreign objects

Front 42

What is the purpose of vocal resonance/sounds? For the following tests, explain test/abnormal findings: Brochophony, Egophony, Whispered Pectoriloquy

Back 42

-to detect consolidation or compression of lungs, which enhances voice sounds –“99 loud and clear as in pneumonia –ee-ee-ee normal, ee-to-aa(goat) –“one two three loud & clear”

Front 43

Explain the following abnormalities in chest configuration: Barrel chest, Pectus excavatum(funnel chest), Pectus carnivatum(pigeon chest)

Back 43

-AP=TD & ribs are horizontal –depression of sternum and adjacent costal cartilage –forward displacement of sternum with depression of adjacent costal cartilage

Front 44

Kyposis vs Scoliosis? -exagerated posterior curvature of thoracic spine(humpback)

Back 44

–lateral curvature and rotation of thoracic and lumbar spine (S shaped)

Front 45

For inspection of Pneumonia, what do you expect to observe? (2)(children?) Palpation? Percussion? Auscultation? Adventitous sounds present?

Back 45

-Increased respiratory rate, guarding & lag on expansion on affected side(nasal flaring, sternal retraction) –chest expansion decreased on affected side, increased tactile fremitius if bronchus patent, decreased tactile fremitius if bronchus obstructed –dull over lobar pneumonia –Breath sounds louder, voice sounds increase in clarity –crackles, fine to medium

Front 46

For Inspection of Atelectasis, what would you expect to observe?(4) Palpation? (3) Percussion? Auscultation?(2) Adventitious sounds present?

Back 46

-cough; lag expansion on affected side, increased respiratory rate & pulse, possible cyanosis –chest expansion decreased on affected side, tactile fremitus decrease/absent on affected area, tracheal shift toward affected side –dull over area, others may be hyperresonant –breath sounds decreased or absent, voice sounds decreased/absent –none if bronchus obstructed, fine crackles if patent bronchus

Front 47

For inspection of Pleural effusion, what would you expect to observe?(6) Palpate?(3) Percussion? (2) Auscultation? Adventitious sounds?

Back 47

-increased RR, dyspnea, dry cough, tachycardia, cyanosis, abd distension –tactile fremitus decreased/absent, tracheal shift to unaffected side, chest expansion decrease on affected side –dull to flat; no diaphragmatic excursion on affected side –BS decreased/absent, voice sounds decreased/absent, remainder of lung compressed near effusion, bronchial BS sounds over compression -none

Front 48

For inspection of pneumothorax, what would you expect to observe?(5) Palpate?(5) Percussion? Auscultation? Adventitous?

Back 48

-unequal chest expansion, if large: tachypnea, cyanosis, apprehension, bulging interspaces –tactile fremitus decrease/absent; tracheal shift to unaffected side, chest expansion to affected side, tachycardia, low bp –hyperresonant, decreased diaphragmatic excursion –BS decreased/absent, voice sounds decrease/absent -none

Front 49

For inspection of CHF, what would you expect to observe?(7) Palpation? Percussion? Auscultation? Adventitious?

Back 49

-increased RR, SOB on exertion, orthopnea, PND, nocturia, ankle edema, pallor –skin moist, clammy, tactile fremitus normal –resonant sounds –normal vesicular, heart sounds include s3 gallop –crackles at base

Front 50

Healthy people 2010 focus areas? (4)

Back 50

-asthma, COPD, chronic sleep apnea, tobacco use

Front 51

Healthy people 2010 key objectives for asthma?(4) COPD? (2) Obstructive sleep apnea? (2)Tobacco use? (3)

Back 51

-reduce deaths, hospitalizations, limitations, increase care –reduce deaths and number of adults with limited activity – increase management of symptoms for population, reduce accidents related to excess sleep –reduce tobacco use by adults and adolescents, second hand smoke exposure, increase smoking cessation programs

Front 52

Tactile fremitus findings would be ↑ when:
A. The patient has a blocked bronchus
B. The patient has a mild case of pneumonia
C. The patient has an advanced case of pneumonia
D. The patient has a pleural effusion

Back 52

C. The patient has an advanced case of pneumonia
Consolidation must reach to the lung border/chest wall in order to carry the vibration to the examiner’s hands. A blocked bronchus or a pleural effusion will decrease tactile fremitus, while early pneumonia that has created a small area of consolidation is not likely to change the finding at all.

Front 53

Your older clinic patient is being seen today as a follow-up for a 2-day history of pneumonia. The patient continues to have a productive cough, shortness of breath, and lethargy and has been spending most of the day lying in bed. You should begin the chest examination by:
A. percussing all lung fields.
B. auscultating the lung bases.
C. determining tactile fremitus.
D. estimating diaphragmatic excursion

Back 53

B. auscultating the lung bases.
Because the patient has consolidation and has been recumbent and fatigued, the most appropriate first step is to listen to the lung bases before the patient gets exhausted. The lung bases would be the most likely sites for adventitious sounds and would more likely result in a wheeze.