The chest, or thorax, is a cage of bone, cartilage, and muscle capable of movement as the lungs expand. It consists anteriorly of the sternum, manubrium, xiphoid process, and costal thyroid/cricoid; laterally, of the 12 pairs of ribs; and posteriorly, of the 12 thoracic vertebrae. The ribs are connected to the thoracic vertebrae

The diaphragm contracts and moves downward during inspiration. Also during inspiration, the anteroposterior chest increases and the internal intercostals decrease the transverse diameter.

The chest interior is divided into the right and left pleural cavities and the mediastinum. The pleural cavities are lined with parietal and visceral pleurae.

The lungs have three lobes on the right and two on the left, which contain blood vessels, lymphatics, nerves, and alveolar ducts. The lungs are conical with broad and concave bases that rest on the diaphragm. The medial surfaces of the lungs are concave and cradle the heart. The apices extend 4 cm above the first rib.

The trachea lies anterior to the esophagus and posterior to the isthmus of the thyroid. The main bronchi are divided into three right and two left branches that subdivide into terminal and respiratory bronchioles, each associated with one acinus. The acini consist of respiratory bronchioles, alveolar ducts and sacs, and alveoli. The bronchial arteries supply blood to the lung parenchyma and stroma.

Topographic markers on the chest include the nipples, the angle of Louis, the suprasternal notch, the costal angle (usually no more than 90 degrees, with ribs inserted at 45-degree angles), the vertebra prominens, and the clavicles.

The purpose of respiration is to supply oxygen to and remove excess carbon dioxide from the body. Chemoreceptors in the medulla oblongata respond to changes in hydrogen ion concentration. Chemoreceptors in the carotid body respond to arterial oxygen and carbon dioxide levels. These chemoreceptors send signals to the respiratory center in the medulla oblongata. Excess levels of carbon dioxide stimulates the rate and depth of respiration.

Breath sounds - Vesicular Bronchovesicular Bronchial/tracheal Amphoric Cavernous Adventitious breath sounds - Crackles: fine, medium, coarse Rhonchi Wheezes Friction rub Mediastinal crunch Vocal resonance – Bronchophony Pectoriloquy Egophony

Older Adults - Chest expansion decreased Bony prominences marked . Kyphosis with flattening of lumbar curve Increased anteroposterior diameter , Hyperresonance common

Critical Thinking The older adult – take care that the client does not hyperventilate and become dizzy. If the client feels faint, holding the breath for a few seconds will restore equilibrium **If alone the nurse would roll the client from one side to another* This obviously prevents you from comparing findings from one side to another

Adult Anteroposterior diameter is half the size of transverse diameter. Respiratory rate is 12 to 20/minute. Ratio of respirations to heartbeat is 1:4. Chest expansion is equal bilaterally. Bronchial, bronchovesicular, and vesicular breath sounds heard on auscultation Older Adults With aging, there is loss of muscle strength of thorax and diaphragm, resulting in decreased lung resiliency. Alveoli are less elastic and more fibrous

Typical variations Decreased tactile or vocal fremitus is associated with emphysema. Hyper-resonance indicates hyperinflation of lungs. Dullness indicates lung consolidation. Work-related exposure to irritants and allergens and use of protective devices should be explored. Older adults have less chest expansion; larger anteroposterior diameter; and marked, bony prominences. Aging is associated with kyphosis, use of accessory muscles, and hyper-resonance

History of Present Illness Explore the following: whether the patient coughs or complains of coughing, the onset and nature of the cough, sputum characteristics, pattern and severity of the cough, associated symptoms (e.g., hoarseness), and efforts to treat. Document the following data: whether the patient has or complains of shortness of breath, the onset of the problem, pattern and factors facilitating or relieving it, and associated symptoms (e.g., such as diaphoresis), and efforts to treat. Complaints or signs of chest pain should be noted, along with their onset and duration, associated symptoms (e.g., fever), and any treatment efforts.

Past Medical History Pertinent data include past thoracic trauma or surgery, the use of oxygen, chronic pulmonary diseases, other systemic disorders (e.g., cancer), related respiratory tests, immunization against pneumonia, influenza, and the use of daily medications, both prescription and nonprescription. Family History A family history of tuberculosis, cystic fibrosis, emphysema, allergies, smoking, malignancy, clotting disorders, the risk of pulmonary embolism, bronchiectasis, and bronchitis should be noted.

Personal and Social History Work-related exposure to irritants, allergens, and hazards should be explored. Use of protective devices should be documented. Environmental factors in the home include type of heating, air conditioning, and humidification. Other relevant data include drug and alcohol consumption; tobacco use; exercise tolerance; travel history; potential exposure to respiratory infections, such as influenza, or tuberculosis; nutritional status: weight loss or obesity; hobbies: owning pigeons, parrots or other animals, woodworking, welding; and exercise tolerance: diminished ability to perform up to expectations. .

Older adults. Pertinent data include exposure and frequency of respiratory infections, effects of weather and activity on respiratory status, and any difficulty swallowing. Specific inquiry into smoking history, respiratory symptoms, fatigue, weight changes, fever, and night sweats should also be made

Shallow respirations are associated with injured rib, pleurisy, liver enlargement, or abdominal ascites. Slow respirations may mean neurologic or electrolyte problems, infection, or pleurisy. Barrel chest with kyphosis, prominent sternal angle, and obstructive pulmonary disease is associated with chronic disease. Asymmetric, unequal expansion of the lungs may be caused by extrapleural air, fluid, or mass. Expiratory bulging may indicate enlarged heart, tumor, or aneurysm. Chest asymmetry suggests pneumothorax.

Cheyne-Stokes respiration implies serious condition. Chest pain should be noted along with onset, duration, and associated symptoms of diaphoresis or shortness of breath. Common Abnormalities p. 399 Pneumothorax-presence of air /gas in pleural cavity=trauma or spontaneous (407) Hemothorax-presence of blood in pleural cavity =trauma/invasive medical procedure (408) Lung cancer-bronchogenic carcinoma (malignant tumor) p 408 Cor pulmonale- acute/chronic condition involving right-sided heart failure. P.409 Pulmonary hypertension Pulmonary hypertension begins when tiny arteries in your lungs, called pulmonary arteries and capillaries, become narrowed, blocked or destroyed. This makes it harder for blood to flow through your lungs, which raises pressure within the pulmonary arteries. As the pressure builds, your heart's lower right chamber (right ventricle) must work harder to pump blood through your lungs, eventually causing your heart muscle to weaken and sometimes fail completely. (MAYO clinic 2008)

Risk Factors and disability opportunities for health education

** Why is this important – Client has not been exposed to 2nd hand smoke at work ?PTA? New acronym “Prior to Assessment – Prior to admission” ** Discuss use of approved abbreviations Clueless to its meaning then try http://www.acronymfinder.com/

ANSWER: hold his or her breath during auscultation A respiratory friction rub results from inflamed pleura rubbing against each other during the respiratory cycle, so if the breath is held, the rub stops.   DIF: Cognitive Level: Application REF: Page 388

ANSWER: transmits high-pitched sounds Unless specially modified, the stethoscope does not amplify sound, nor does it filter sound or pinpoint focal sounds. The stethoscope does transmit sound waves from the source to the ear. The diaphragm is the better source because it transmits the normally high-pitched sounds of the lung and it has a broader area to listen from.   DIF: Cognitive Level: Comprehension REF: Page 384

Respiratory Chapter 13 RNRS 210

Objectives

Resources Aging and the Respiratory System By Brian K. Ross, MD, PhD; Asthma An extensive interactive tutorial; from the University of California at San Diego School of Medicine The Auscultation Assistant By Christopher Cable, MD, UCLA School of Medicine; this site requires considerable disk cache space. Gas Exchange In Humans From The Human Respiratory System site. Influenza: The Disease From the Centers for Disease Control and Prevention. Includes a section on Diagnosis / Testing Methods. Tuberculosis Online learning module from the HealthCare Wide Hazards Module of the Occupational Safety and Health Administration. Includes sections on screening and identification and on respiratory protection.

Equipment Marking pencil or eyeliner (silver good for dark skin) Centimeter ruler and tape measure Stethoscope with bell and diaphragm (may use smaller diaphragm for children) Drapes

Anatomy Chest or thorax, a cage of bone, cartilage, and muscle Sternum Manubrium Xiphoid process 12 pairs of ribs connected to the thoracic vertebrae and to the sternum by the costal cartilages Get Body Smart Respiratory Tutorial

Anatomy Primary muscles of respiration Diaphragm—the primary muscle—contracts during inspiration. External intercostal muscles increase the anteroposterior chest diameter during inspiration. Interior intercostal muscles decrease the transverse chest diameter during expiration Sternocleidomastoid and trapezius accessory muscles are brought into play when there are pulmonary problems and compromise

Anatomy Interior divided into three spaces Mediastinum Situated between lungs Contains all thoracic viscera except the lungs Right and left pleural cavities Lined with parietal and visceral pleurae Lungs enclosed by serous membrane

Anatomy Highly elastic lungs paired but not symmetric Right lung: three lobes. Left lung: two lobes and a lingula Lobes contain Blood vessels Lymphatics Nerves Alveolar ducts connecting with alveoli Alveoli, as many as 300 million in adult Lung Mechanics

Anatomy Tracheobronchial Tree Components Trachea divides into right and left main bronchi. Right bronchus divides into three branches. Left bronchus divides into two branches. Each branch divides into bronchioles and ultimately into respiratory bronchioles so that each is associated with only one acinus. Acini are the terminal respiratory units Bronchial functions Air transport Trap and dispose of foreign particles Supply blood to lung parenchyma and stroma bronchial arteries branch from anterior thoracic aorta and intercostal arteries Pulmonary Circulation

Anatomy Anatomic Landmarks Topographic markers Nipples Manubriosternal junction Suprasternal notch Costal angles Vertebra prominens Clavicles

Physiology Chemical and Neurologic Control of Respiration Respiration keeps body supplied with oxygen and protects it from excess accumulation of carbon dioxide. Transport of air to and from alveoli Diffusion and perfusion, gas exchange across alveolar membranes Circulatory system transport to and from the peripheral tissues Respiratory control processes involving chemo-receptors are only partially understood Circulatory system

Assessment Process - Inspection Chest Shape and symmetry, Chest wall movement Superficial venous patterns, Prominence of ribs Anteroposterior vs. transverse diameter Sternal protrusion, Spinal deviation Peripheral clues may suggest pulmonary or cardiac difficulties Fingers: clubbing, Breath: odor Skin, nails, and lips: cyanosis or pallor Lips: pursing, Nostrils: flaring Chest Inspection

Assessment Process - Inspection Respiration Rate, Quality, Pattern Count rate while palpating pulse Modes of respiration Thoracic (costal), Diaphragmatic Abdominal, Paradoxic Inspect for airway obstruction Stridor, Nostril flaring, Cough Chest retraction Descriptors of respiration Dyspnea, Tachypnea, Bradypnea, Hyperpnea Hypopnea, Kussmaul Inspection Rate-Pattern Inspection Pattern

Assessment Process - Palpation Thoracic muscles/skeleton Pulsations, Tenderness, Bulges/depressions Unusual movement/positions, Elasticity of rib cage Immovability of sternum, Rigidity of thoracic spine Crepitus, Friction rub, Thoracic expansion, Tactile fremitus Position of trachea Palpate Thoracic Expansion Palpate Tactile Fremitus

Assessment Process - Percussion Percuss chest Anterior Lateral Posterior Compare tones bilaterally Measure diaphragmatic excursion Anterior Percussion Posterior Percussion

Assessment Process - Percussion Percussion tone indicators for lungs Resonance is normal Hyper-resonance indicates hyperinflation. Dullness indicates diminished air exchange. Percussion Lung Fields Diaphragmatic Excursion

Assessment Process - Auscultation Breath sounds Vesicular, Bronchovesicular, Bronchial/tracheal Amphoric, Cavernous Adventitious breath sounds Crackles: fine, medium, coarse Rhonchi, Wheezes, Friction rub, Mediastinal crunch Vocal resonance Bronchophony, Pectoriloquy, Egophony Auscultation Breath Sounds

Assessment Process - other Cough Describe, Moisture, Onset Frequency, Regularity Pitch/loudness, Postural influences, Quality Sputum Describe Color Consistency Odor

Preparing Patient for the Exam The older adult May fatigue easily Especially during auscultation with deep mouth breathing Nursing Action Allow brief rest periods or quiet breathing The acutely ill client Have a second examiner to hold the person’s arms to support in upright position If alone the nurse would roll the client from one side to another*

Performing the Exam Inspect the chest, front and back, noting thoracic landmarks, for the following: Size and shape (anteroposterior diameter compared with transverse diameter) Symmetry, Color, Superficial venous patterns Prominence of ribs Evaluate respirations for the following: Rate, Rhythm or pattern Inspect chest movement with breathing for the following: Symmetry, Bulging, Use of accessory muscles Note any audible sounds with respiration (i.e., stridor or wheezes)

Performing the Exam Palpate chest for the following: Symmetry, Thoracic expansion, Pulsations Sensations such as crepitus, grating vibrations Tactile fremitus Perform direct or indirect percussion on chest, comparing sides, for the following: Diaphragmatic excursion, Percussion tone intensity, pitch, duration, and quality Auscultate the chest with the stethoscope diaphragm, from apex to base, comparing sides for the following: Intensity, pitch, duration, and quality of expected breath sounds Unexpected breath sounds (crackles, rhonchi, wheezes, friction rubs) Vocal resonance

Health History Questions History of Present Illness Coughing Onset, Nature, Pattern, Severity Associated symptoms, Efforts to treat Medications Shortness of breath Onset, Pattern, Severity, Associated symptoms Chest pain Onset and duration Associated symptoms Efforts to treat Medications

Health History Questions Past Medical History Thoracic trauma or surgery, dates of hospitalization for pulmonary disorders Use of oxygen and ventilation-assisting devices Chronic pulmonary diseases Chronic disorders Testing Family History Tuberculosis (TB) Cystic fibrosis Emphysema Allergy Asthma Atopic dermatitis Malignancy

Health History Questions Personal and Social History Employment Home environment Tobacco use Exposure to respiratory infections, flu, TB Nutritional status Regional/travel exposures Hobbies Use of alcohol/drugs Exercise tolerance

Health History Questions Older Adults Exposure to and frequency of respiratory infections History of pneumococcal and flu vaccine Effects of weather on respiratory efforts and infection occurrence Immobilization and sedentary habits Difficulty swallowing Altered activities from respiratory symptoms Emphasize Smoking history, Cough Dyspnea on exertion or breathlessness Fatigue, Weight changes Fever and night sweats

Common Respiratory Disorders Asthma (reactive airway disease) Atelectasis Bronchitis Pleurisy Pleural effusion Empyema Lung abscess Pneumonia Influenza Tuberculosis

Common Respiratory Disorders Pneumothorax Hemothorax Lung cancer Cor pulmonale Pulmonary hypertension Tuberculosis Older Adults Chronic obstructive pulmonary disease Emphysema Bronchiectasis Chronic bronchitis

Health Promotion Teaching Respiratory Disability: Barriers to Competent Function   Gender greater in men, but the difference between the genders diminishes with advancing age Age increases inexorably with advancing age Family history of asthma, cystic fibrosis, tuberculosis and other contagious disease, neurofibromatosis Smoking Sedentary lifestyle or forced immobilization Occupational exposure to asbestos, dust, or other pulmonary irritants and toxic inhalants Extreme obesity Difficulty swallowing for any reason Weakened chest muscles for any reason History of frequent respiratory infections

Documentation A healthy client Subjective No cough, shortness of breath (SOB), or chest pain with breathing No past history of respiratory diseases Has “one or no” colds per year. Has never smoked Works in well-ventilated office Coworkers who smoke are restricted to smoke in lounge** Last TB skin test 4 years PTA (?), negative Never had chest x-ray (Jarvis, 2000)

Documentation A healthy client Objective Inspection – AP < transverse diameter Respirations 16 per minute, relaxed, and even Palpation – Chest expansion symmetric Tactile fremitus equal bilaterally No tenderness to palpation No lumps or lesions Percussion – Resonant to percussion over lung fields Diaphragmatic excursion is 1 cm and = bilaterally Auscultation – Vesicular breath sounds clear over lung fields No adventitious sounds (Jarvis, 2000)

Documentation An un-healthy client Subjective 1 year prior to admission (PTA) client noticed more “winded” than usual when walking > 3-4 blocks. Early morning cough present daily x 10 years, but now increased sputum production to 2T per morning, frothy white 6 months PTA client had a “cold” w/severe harsh coughing, productive of ½ cup thick white sputum/day Noted mid-sternal chest pain (mild) w/cough. Lasted 2 weeks. Treated self w/humidifier and over the counter (OTC) cough syrup 3 months PTA client noticed increasing SOB w/less activity. Fatigue and SOB when working outside . Unable to take evening walks (usually 2-3 blocks) due to SOB and fatigue. Has two-pillow orthopnea. Wakes 3-4 times during night (Jarvis, 2000)

Documentation An un-healthy client Subjective cont’. Currently client feels he is “worse and needs some help.” Continues w/2-pillow orthopnea. Unable to walk > 2 blocks or climb > one flight of stairs. Morning cough productive ¼ Cup thin white sputum, cough continues throughout the day No chest pain, hemoptysis, night sweats, or paroxysmal nocturnal dyspnea. No history of allergies, hospitalizations, or injuries to chest. No family history of TB, allergies, asthma, or cancer. Smokes cigarettes 2 packs per day (PPD) x 30 years. Alcohol < one 6-pack beer/week summer months only (Jarvis, 2000)

Documentation An un-healthy client Objective Inspection – Sitting on side of bed with arms propped on bedside table Respirations at rest 24 per minute, regular, shallow with prolonged expiration Respirations with ambulation 34 per minute Increased use of accessory muscles, AP=transverse diameter with widening of costal angle, slightly flushed face, tense expression Palpation – Minimal but symmetric chest expansion Tactile fremitus = bilaterally No lumps, masses, or tenderness to palpation Percussion – Diaphragmatic excursion is 1 cm and = bilaterally Hyper-resonance over lung fields Auscultation – Breath sounds diminished Expiratory wheeze throughout posterior chest, R>L, No crackles (Jarvis, 2000)

NCLEX To distinguish between a respiratory friction rub and a cardiac friction rub, the nurse would direct the patient to perform which activity? hold his or her breath during auscultation lean forward during auscultation say “ninety-nine” while you palpate the anterior chest identify the location of his or her pain 

NCLEX The nurse understands that the diaphragm of the stethoscope is better than the bell for auscultation lungs because it supports sound in which way? amplifies all types of sounds filters extraneous sounds pinpoints focal sound areas transmits high-pitched sounds   

References Anderson, D. M., Keith, J., Novak, P. A., & Elliot, M. A. (2002). Mosby's Medical, Nursing, & Allied Health Dictionary (6th ed.). St. Louis, MO: Mosby. Jarvis, C. (2000). Thorax and lungs. In Physical Examination and Health Assessment (3rd ed., pp. 479-480). Philadelphia, PA: W. B. Saunders Company. (Potter P A Perry A G 2009 Fundamentals of Nursing)Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing (7th ed.). St. Louis, MO: MOSBY Elsevier. Seidel H., Ball J., Dains J., Benedict G. ( 2006). Mosby's Guide to Physical Examination (6th ed.). St. Louis, MO: MOSBY Elsevier.