HA Chapter 19 Assessing Thorax and Lungs
Dyspnea
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?
Pneumothorax (PTX) - air in the pleural space Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD).
A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause?
pneumothorax
A client is brought to the emergency department by ambulance after being involved in a motor vehicle accident. The nurse finds that he has decreased breath sounds over the left lung fields. What might the nurse suspect is the cause?
"Are you taking any medications on a regular basis?" A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors, which are prescribed for hypertension.
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
Impaired Gas Exchange
A client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?
It is normal for elderly clients to feel short of breath or dyspneic with activities of daily living due to age related changes of loss of elasticity, fewer functional capillaries, and loss of lung resiliency.
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?
bronchial sounds are heard
over the manubrium
tracheal lung sounds are heard
over the trachea in the neck
early inspiratory crackles
COPD and asthma usually produce?
left lung
The left lung has only two lobes, upper and lower.
tachypnea
a respiratory rate greater than 24 breaths per minute
vesicular sounds are heard
over most of both lungs
Biot's respirations
(irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis.
Angiotensin-converting enzyme (ACE) inhibitors
- Lower blood pressure by inhibiting the conversion of angiotensin I (an inactive enzyme) to angiotensin II (a potent vasoconstrictor) - Vasodilators
right lung
3 lobes Anteriorly, this fissure runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib. The right lung is thus divided into upper, middle, and lower lobes.
Heart failure The timing of crackles within inspiration provides important clues. These late inspiratory crackles, which appeared suddenly, would be most consistent with heart failure.
A client complains of shortness of breath for the past few days. Examination reveals late inspiratory crackles in the lower third of the chest that were not present 1 week ago. What is the most likely explanation? Think: late inspiratory crackles
There is loss of involuntary respiratory control (The brainstem contains the medulla and the pons, which control involuntary respiratory effort).
A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort?
Asthma
A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?
Pneumonia Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull, and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased sound transmission of high-pitched components of sounds. The multiple air-filled chambers of the alveoli usually filter out these higher frequencies.
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?
Chronic obstructive pulmonary disease (COPD) This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance; during auscultation there is often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this client's exercise capacity because it may affect his employment and also allows examiners to follow the progression of his disease. Clinicians must offer smoking cessation as an option.
A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?
Fluid in the alveoli
A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?
When fluid fills the alveoli, fine crackles may be audible on auscultation. Excessive fluid in the alveoli may lead to airway collapse and decreased breath sounds.
A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?
Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing. Think sharp, stabbing chest pain
A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?
Opiates, which may cause hypoventilation
A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?
Stridor Stridor, a high-pitched crowing sound from the upper airway, results from tracheal or laryngeal spasm. In severe laryngospasm, the larynx may completely close off. This life-threatening emergency requires immediate medical assistance. Crackles, wheezes, and rales are adventitious breath sounds heard upon auscultation of the lungs.
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? Occurs with severe broncholaryngospasms, such as croup (Daniel). Think: - High-pitched - Upper Airway - Tracheal or Laryngeal spasm
PR interval represents the time from the firing of the SA node to the beginning of ventricular depolarization (includes a slight pause at the AV junction).
A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event?
Instruct the client to cough forcefully When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes.
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?
Bacterial Infection Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections. Lung cancer and sleep apnea are chronic conditions, which would be more likely to result in a gradual onset of dyspnea.
A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?
The right and left costal margins meeting at the level of the xiphoid process form an angle between them. This angle, commonly referred to as the costal angle, is an important landmark for assessment. It is normally less than 90 degrees but may be increased in instances of long-standing hyperinflation of the lungs, as in emphysema.
A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?
A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min Decreased level of consciousness, respiratory rate above 30 breaths/min, cyanosis, retractions, and use of accessory muscles may indicate hypoxia (a medical emergency). The only scenario in line with these criteria is the man with COPD.
A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?
Observe for the use of accessory muscles The tripod position is often assumed by the client with chronic obstructive pulmonary disease (COPD) in order to help elevate the diaphragm during inspiration. This is often accompanied by the use of accessory muscles of the neck.
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?
Decreasing intensity is normal at the base
A nurse palpates for tactile fremitus and notes that the vibrations diminish towards the base of the lungs. What should the nurse recognize about this finding?
bradypnea
A respiratory rate of less than 10 breaths per minute is called?
Patient C
A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority?
a foreign body obstruction
A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is
Sibilant wheezes
Are high-pitched musical sounds. Often heard in cases of acute asthma or chronic emphysema.
Fine crackles
Are high-pitched, short, popping sounds heard during inspiration and not cleared with coughing. Associated with restrictive diseases such as pneumonia and congestive heart failure.
Sonorous wheezes
Are low-pitched snoring or moaning sounds. Often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea.
egophony test (An increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis. It is due to enhanced transmission of high-frequency sound across fluid, such as in abnormal lung tissue, with lower frequencies filtered out.)
Ask the client to repeat the letter "E" while you listen over the chest wall. Normal - Voice transmission will be soft and muffled but the letter "E" should be distinguishable. Abnormal - Over areas of consolidation or compression, the sound is louder and sounds like "A."
Whispered pectoriloquy
Ask the client to whisper the phrase "one-two-three" while you auscultate the chest wall. Normal - Transmission of sound is very faint and muffled. It may be inaudible. Abnormal - Over areas of consolidation or compression, the sound is transmitted clearly and distinctly. In such areas, it sounds as if the client is whispering directly into the stethoscope.
mid-inspiratory
Bronchiectasis, as seen in cystic fibrosis, classically produces _________________________ crackles, but this is not always reliable.
Beta Blockers
Decrease heart rate and dilate arteries by blocking beta receptors
Coarse crackles Think pneumonia - coarse crackles
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?
Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea.
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?
Hyperresonance
Elicited in cases of trapped air such as in emphysema or pnemothorax.
asthma
End-expiratory crackles can be heard in ___________________ on occasion
Dullness on percussion
Fluid or mass under area being percussed
Suprasternal notch
In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?
diaphragm
Lung sounds should be listened to with the ____________________ because they are high-pitched sounds.
Diaphragmatic excursion
Movement of the thoracic diaphragm during breathing. Normal diaphragmatic excursion should be 3-5 cm, but can be increased in well-conditioned persons to 7-8 cm. 1. This measures the contraction of the diaphragm. It is performed by asking the patient to exhale and hold it. Mark the level. 2. Breath normally. Then inhale and hold. Mark the level.
Pigeon chest or pectus carinatum
Occurs when the sternum protrudes backward. Intercostal bulging is noted with trapped air.
fremitus
Refers to vibratory tremors that can be felt through the chest by palpation. To assess for tactile ________________, ask the patient to say "99" or "blue moon". While the patient is speaking, palpate the chest from one side to the other.
labored breathing
Retraction of intercostal spaces occurs in ______________________?
bell
The _________ is used for low-pitched sounds such as abnormal heart sounds.
The apex of each lung extends slightly above the clavicle.
The apex of each lung is located at the
Manubrium
The clavicles extend from the acromion of the scapula to the part of the sternum termed the
Inflammation of the parietal pleura produces pleuritic pain with deep inspiration, e.g., in pleurisy, pneumonia, and pulmonary embolism. The visceral pleura lies next to the lung, and the parietal pleura lines the inner rib cage and upper surface of the diaphragm. The visceral pleura lacks sensory nerves, but the parietal pleura is richly innervated by the intercostal and phrenic nerves. Think Parietal Pluera - Pain - Pleurisy, Pneumonia, Pulmonary Embolism
The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?
endotracheal tube (T4)
The lower end of an endotracheal tube is usually at the level of T4.
Chronic bronchitis
The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible
Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.
The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible
Auscultation of the bases is important because it is where fluid occurs with pulmonary edema and the location for fluid accumulation with a pleural effusion. It does not indicate infection or health of the lungs.
The nurse auscultates the base of the lungs to assess for what reason?
Kussmaul respirations are rapid, deep, and labored. They are considered a type of hyperventilation associated with diabetic ketoacidosis.
The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates
The risk for lung cancer is thought to be partially based on genetics. A history of certain respiratory diseases (asthma, emphysema) in a family may increase the risk for development of the disease. Reference:
The nurse is planning a presentation to a group of high school students on the topic of lung cancer. Which of the following should the nurse plan to include in the presentation?
To best assess lung sounds, you will need to hear the sounds as directly as possible. Ask the client to breathe deeply through the mouth for each area of auscultation.
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
Begin above the right clavicle and percuss each section comparing the right chest with the left chest. When percussing a patient's anterior chest, the nurse should begin above the level of the clavicles to assess the lung apex. The nurse should assess the right lung area and then the left. The nurse should proceed in a methodical manner and assess each lung area, comparing right to left.
The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment?
Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented.
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?
Chronic obstructive pulmonary disease The tripod position is when the client leans forward and uses the arms to support weight and lift the chest to increase breathing capacity. This position is not routinely assessed in a client with asthma, heart failure, or tuberculosis.
The nurse observes the client sitting at the side of the bed in the position shown. What health problem should the nurse suspect the client is experiencing?
Pleural effusion When a flat sound is percussed over lung tissue, this is an indication of a pleural effusion.
The nurse obtains a flat sound when percussing the right lower lobe of a patient. What does this assessment finding indicate to the nurse?
Resonance
The percussion tone elicited over normal lung tissue.
C7 (vertebral prominens)
The spinous processes of the vertebrae are also useful anatomic landmarks. When the neck is flexed forward, the most protruding process is usually the vertebra of C7, known as the vertebral prominens.
The sternal angle, also termed the angle of Louis
The sternal angle, also termed the angle of Louis, is approximately 5 cm above the horizontal bony ridge joining the manubrium to the body of the sternum.
The cavity contains the heart, lungs, thymus, distal part of the trachea, and most of the esophagus.
The thoracic cavity contains which of the following organs? Select all that apply.
Under normal circumstances, the strongest stimulus to breathe is an increase of carbon dioxide in the blood (hypercapnia).
Under normal circumstances, the strongest stimulus to breathe is
Chronic obstructive pulmonary disease
Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?
touching the chest with only the pleximeter finger Middle finger to middle finger
What action by the nurse when percussing a client's chest will help maximize the resulting vibrations?
Tactile fremitus
What helps to assess for the presence of a consolidation such as pleural effusion or pneumonia. consolidation - a region of (normally compressible) lung tissue that has filled with liquid instead of air.
Dullness
What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?
Crackles
What sounds are present in pneumonia or fluid in the lungs.
Cheyne-Stokes Explanation: Cheyne-Stokes respirations, regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure.
What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?
Friction Rub In pleuritis, inflamed pleural surfaces lose their normal lubrication and rub together during breathing. Reduced volume of pleural fluid increases the transmission of lung sounds and leads to a possible friction rub.
What would the nurse expect to hear when auscultating the lungs of a client with pleuritis?
Coarse crackles are low-pitched bubbling moist sounds that are described as separating Velcro.
When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding? May indicate pneumonia, pulmonary edema, or pulmonary fibrosis.
One deep inspiration and expiration through the open mouth. Lung auscultation is performed for one full breath over symmetrical lung fields. The client should be encouraged to breathe deeply through an open mouth.
When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?
Resonance over all lung fields All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax.
When percussing the posterior lung fields, which of the following findings is expected?
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath
Which action by a nurse demonstrates proper technique for assessment of chest expansion?
The client is instructed to breathe deeply though the mouth for each area as the nurse listens through inspiration and expiration. The sequence should be performed in an anterior then posterior sequence to avoid missing any areas.
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
Atelectasis Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest.
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?
Bronchial
Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.
There is a great deal of free air in the chest with a large pneumothorax, which produces a hyperresonant note. Lots of air, think hyperresonance
Which of the following conditions would produce a hyperresonant percussion note?
Skin between the ribs moves inward with inspiration. This description is consistent with retractions, which occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing in which the client exhales against the lips, which are pressed together.
Which of the following occurs in respiratory distress?
Bronchitis is marked by a chronic, productive cough that results from excess mucus production. Hemoptysis is uncommon in younger clients. It would be simplistic to differentiate cardiac from respiratory chest pain based on severity alone. Similarly, it is inaccurate to characterize all loud percussion sounds as pathological.
Which of the following statements relating to assessment of the lungs and thorax is most accurate?
The inferior tip of the scapula is another useful bony landmark—it usually lies at the level of the 7th rib or intercostal space.
Which statement regarding the location of landmarks is associated with the assessment of the respiratory system?
To assess bronchophony ask the client to repeat the phrase "ninety-nine" while you auscultate the chest wall.
While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to
Anteroposterior to lateral diameter An important component of chest inspection is assessment of the anteroposterior diameter versus the transverse diameter. This is achieved by viewing the client from the back and side.
While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?
Dullness
________________ is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological.
Decreased breath sounds
________________ may indicate an obstruction due to little air moving in and out.
Kussmaul's
____________________ respirations are associated with diabetic ketoacidosis.
Pleural friction rub
___________________________ is low-pitched, dry, grating sound that is superficial and occurs during both inspiration and expiration.
bronchovesicular sounds are heard
between the scapulae
Hypoventilation
is a rate that is decreased, with a decrease in depth and with an irregular pattern.
Hyperventilation
is used to describe respirations that are increased in rate and depth.