Randa M. Albusoul
Respiratory System
Anatomy
Chest assessment can be done in two dimensions:
vertical axis and circumference of the chest.
Thoracic cage is bony structure, conical shape, narrower at the top Defined by: sternum, 12 pairs of ribs, & 12 thoracic vertebrae
1-7 ribs: attach to sternum. 8,9 &10 ribs: attach to costal cartilage above. 11 & 12 ribs: are floating ribs.
The tip of 11th rib can
be felt laterally, and the
tip of 12th rib
posteriorly.
The intercostal space is
named after the rib
above it.
Posterior thoracic
landmarks:
•Vertebral prominens (C7): flex head & feel most prominent vertebrae at base of the neck; If 2 vertebraes seem prominent, upper is C-7 & lower is T-1. •Spinous process: count down these knobs on the vertebrae, which stack together to form the spinal column.
•Inferior border of scapula: lower tip is usually at 7th or 8th rib. •12th Rib: palpate midway between the spine & the person’s side to identify its free tip.
Anterior thoracic landmarks:
•The right and left costal margins form an angle
where they meet at the xiphoid process.
•Usually 90 degree or less.
•Sternal angle (angle of Louis): between the
manubrium and body of the sternum,
approximatly 5 cm under suprasternal notch, it is
continuous with the 2nd rib.
•The angle of Louis also marks the site of
tracheal bifurcation, it corresponds with the upper
border of the atria of the heart.
2nd intercostal
space for
Tension
pneumothorax
4th intercostal
space
For chest tube
T7-T8
intercostal
space for
Thoracentesis
Reference lines: for locating abnormalities on
the chest.
•The apex of lung extend above clavicle. •The base at the level of diaphragm. •At the midclavicular line anteriorly the lung extend to the 6th rib. •Midaxillary extend to the 8th rib. •Posteriorly the lung base lie at the 10th rib. •On inspiration the lung descends farther.
6 8
6 8 10
•Forms an thin envelope between the lungs and the chest wall. •Visceral pleura- lines the outside of the lungs, dipping down into the fissures; It is continuous with the parietal pleura lining the inside of the chest wall and diaphragm. •The inside of the envelope is a potential space filled with a few milliliters of lubricating fluid; It normally has a negative pressure, which holds the lungs tightly against the chest wall. •The lungs slide smoothly & noiselessly up & down during respiration. •The pleurae extend about 3 cm below the level of the lungs forming the costodiaphragmatic recess.
Lung fissures are a double fold of
visceral pleura that either completely or
incompletely invaginate lung parenchyma to
form the lung lobes. Each lung has
an oblique fissure separating the upper lobes
from the lower lobes and the right lung has
a horizontal fissure that separates the right
upper lobe from the right middle lobe.
•Trachea-Lies anterior to the esophagus; is 10-11 cm long in adult •Begins at cricoid cartilage & bifurcates just below the sternal angle into the R & L main bronchi; and T4 posteriorly; R bronchus shorter, wider, & more vertical. •Trachea & Bronchi transport gases between the environment and the lung parenchyma; They constitute the dead space that is filled with air but is not available for gaseous exchange-150 ml in adult.
• Breathing is controlled in
the brain stem and
mediated by muscles of
respiration.
•Diaphragm is the primary
muscle of inspiration;
when descends it enlarges
the thoracic cavity and
push the abdominal wall
outward.
•Muscles of the rib cage
and neck extend the thorax
during inspiration.
•Normal breathing is quiet and easy; barely audible.
• When a healthy person lies supine, the breathing
movements of the thorax are relatively slight. In
contrast, the abdominal movements are usually easy to
see.
• In the sitting position, movements of the thorax
become more prominent.
•During exercise and in certain diseases, extra work is
required to breathe, and accessory muscles join the
inspiratory effort. The sternomastoids are the most
important of these, and the scalenes may become
visible.
•Abdominal muscles assist in expiration.
Subjective Data
Concerning symptoms of the respiratory system are:
Shortness of breath (SOB) (Dyspnea)
Wheezing
Cough
Hemoptysis or purulent sputum
Chest pain
Dyspnea: may be sudden RT infection,
pulmonary embolism, anxiety,
pneumothorax….
Or may be gradual RT pulmonary fibrosis,
lung cancer….
Abnormality:
* Orthopnea: ( difficult breathing when supine R/T
heart failure.
* Paroxysmal nocturnal dyspnea ( sever dyspnea
that awaken the pt from sleep R/T heart failure.
Cough: is typically a reflex response to stimuli that
irritate receptors in the larynx, trachea, or large
bronchi. These stimuli include mucus, pus, blood,
dust, foreign bodies, and even extremely hot or cold
air.
An acute cough lasts ˂ 3 weeks,
Subacute 3 to 8 weeks,
and Chronic ˃ 8 weeks.
Wheezing is a high-pitched sound made while you
breathe. It is heard most clearly when you exhale, but
in severe cases, it can be heard when you inhale. It is
caused by narrowed airways (airway obstraction) from
secretions, tissue inflammation, or a foreign body.
-If the patient has cough; when and how often does it occur??
*Continuous cough RT acute infection. * Cough only in the morning RT chronic bronchitis, smoking.
*Cough in the evening RT exposure to irritant during
day.
*cough at night RT sinusitis.
-If there is any sputum. Color , amount with odor,
increase or decrease?
*Non productive cough RT URTI or early CHF .
* White sputum RT common cold , viral infection
*Yellow or green RT bacterial infection.
*Bloody sputum (hemoptysis).
*Pink frothy RT pulmonary edema.
Remember that
lung tissue itself has no pain fibers.
Pain in lung conditions such as
pneumonia or pulmonary infarction may
be RT inflammation of the parietal
pleura.
Chest pain: may be RT cardiac, respiratory,
gastrointestinal, or musculoskeletal causes.
Past History
•Have you had any prior respiratory problems,
such as respiratory infections, asthma, bronchitis,
emphysema, pneumonia, tuberculosis, collapsed
lung (pneumothorax), or cystic fibrosis?
●Have you had thoracic surgery, biopsy, or trauma
to your chest?
●Do you have any allergies that affect your
breathing or respiratory system?
Family History
●Does anyone in your family currently have a
respiratory infection disease?
●Has anyone had lung cancer, asthma, or
cystic fibrosis?
●Did anyone smoke in your home when you
were growing up? Who?
Lifestyle and Personal Habits
●Do you smoke or have you ever smoked? How
many? When start?
●Are you exposed to second-hand smoke? Where?
How many hours per day? For how many years?
●Are you exposed to any environmental conditions
at home or work that affect your breathing?
●Are you taking any prescription, herbal, or over-
the-counter (OTC) medications for breathing or
respiratory problems?
●Do you use oxygen or other treatments for
breathing problems (e.g., nebulizer treatments)?
Objective Data
•The chest can be examined in the supine, sitting,
and if necessary lateral positions.
•When examining posterior chest while patient is
sitting the patient’s arms should be folded across
the chest with hands resting, if possible, on the
opposite shoulders. This position moves the
scapulae partly out of the way and increases your
access to the lung fields.
Inspect for any signs of respiratory difficulty.
•Observe the patient’s facial expression; it should be
relaxed and calm.
●Observe level of consciousness.
●Assess the patient’s color for cyanosis, especially the
face, mucous membranes, and nail beds.
•Inspect the neck. During inspiration, is there
contraction of the accessory muscles, namely, the
sternomastoid and scalene muscles, or supraclavicular
retraction? Is the trachea midline?
Atelectasis
Pulmonary edema
Pleural effusion Clubbing nails
Inspect position of client :
*Normally sitting up relaxed, breath easily with arm
at side or in lap.
*Abnormal:
Tripod position RT COPD
•Observe the shape of the chest.
Normal Barrel
chest scoloisis
Kyphosis Pectus
Excavatum Pectus
Carinatum
•Impaired respiratory movement on one or both
sides, such as flail chest.
Flail chest or paradoxical
breathing is a life-threatening
medical condition that occurs
when a segment of the rib cage
breaks under extreme stress and
becomes detached from the rest
of the chest wall.
Inspect nasal flaring, pursed lip breathing.
** Normally not observed .
- Flaring nose seen in hypoxic child.
- Pursed lip RT asthma, CHF, or physiologic response
to slow down respiration
•Listen to the patient breathing; normally breathes
are quiet and regular “12-20” times per minute,
without any effort.
•Are there any audible sounds? Wheezing,
stridor…
Stridor: airway obstruction in the larynx, thorax.
Wheezing: severe asthma.
•Inspect posterior thorax;
-Let patient sit with arms at side.
-Stand behind the patient
-Observe the scapula and the shape and
configuration of chest wall
-Normally the scapula are symmetric and
non-protruding
*Shoulders and scapula are at equal
horizontal line
*The ratio of anteroposterior to the
transverse diameter is 1:2
Spinous process appear straight , thoracic appears
symmetric with rib sloping downward ar 45 degree
from spine.
•Identify tender or warm areas; palpate where
pain has been reported, or the area of lesions or
bruises.
•Assess any abnormalities such as masses.
•Test chest expansion: Place your hand on the posterior
chest wall with your thumb at the
level of T9 or T 10.
Press together to form small fold
Ask client take deep breath
Observe movement of the thumbs Normally the thumb should move 5-10
cm apart symmetrically.
•Feel for tactile fremitus:
Fremitus is vibration
of air in the bronchial
tubes transmitted to
the chest wall as the
patient is speaking.
use the ball or ulnar
edge of one hand.
•Ask patient to say ninety-nine, or one-one-one.
•Assess symmetry and intensity of vibration.
•Normally the fremitus is symmetric for bilateral
position, however, more prominent in the
intrascapular area and on the right side.
If not palpable ask pt to talk loudly.
RESONANCE- Predominates in healthy lung
tissue
HYPERRESONANCE- Too much air present as
in emphysema or pneumothorax.
DULLNESS- Abnormal density in lungs due to
possible pneumonia, pleural effusion, or tumor
Lung fields: the predominant note is resonance
in healthy lung tissue. percussion can detect
lesions in 5-6 cm deep.
•Percuss to map out the lower lung border in expiration and inspiration. •Ask pt to exhale & hold it. •Percuss down the scapular line until the sound changes from resonant to dull on each side. •Next, have pt take deep breath & hold it; continue percussing down scapular line & mark the level where the sound changes to dull. •Measure the difference; should be equal bilaterally & measure 3-5 cm in adults
•USE DIAPHRAGM
•HAVE PERSON BREATHE THRU
MOUTH
•WET CHEST HAIR IF NEEDED
•COMPARE ONE SIDE TO THE OTHER
•LISTEN TO FRONT & BACK
•LISTEN TO AT LEAST ONE FULL
RESPIRATION IN EACH LOCATION
Breath sounds:
•Vesicular are soft and low pitched. They are heard
through inspiration, continue without pause through
expiration, and then fade away about one third of the
way through expiration.
●Bronchovesicular, with inspiratory and expiratory
sounds about equal in length, at times separated by a
silent interval. Detecting differences in pitch and
intensity is often easier during expiration.
●Bronchial are louder and higher in pitch, with a short
silence between inspiratory and expiratory sounds.
Expiratory sounds last longer than inspiratory sounds.
•Listen to adventitious (extra sounds):
•Transmitted voice sounds:
•If you heard abnormal bronchov. Or bronchial
sounds, or adventitious sounds use this
technique.
•Ask the pt to say 99; normally muffled and
indistinct if clear bronchophony.
•Ask the pt to say ee; you should hear ee, if aa
lobal consolidation from pneumonia
•Ask the patient to whisper 99; heard faintly
and indistinctly.
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