Week 3 NURS 190 Lungs & Thorax (Respiratory)/ Breasts & Axillae

pectus excavatum

"Funnel chest" Congenital deformity characterized by *depression of the sternum* & adjacent costal cartilage

peau d'orange

"Orange peel" appearance of breast d/t edema from blocked lymphatic drainage -> *Indication of malignancy or breast cancer*

pectus carinatum

"Pigeon chest" Congenital deformity characterized by *forward displacement of the sternum* w/depression of the adjacent costal cartilage Requires no tx

techniques for respiratory (lungs and thorax) assessment

(1) Inspection - Anterior/posterior thorax (2) Palpation - Anterior/posterior thorax (3) Percussion - Posterior thorax (4) Auscultation - Anterior/posterior thorax - Voice sounds (for *tactile fremitus*)

cyclic mastalgia

*Common* *Associated w/ menstrual cycle* > Onset of pain occurs in the days be4 menstruation + gradually increases, then subsides once menstruation begins *Affects younger women* *Occurs in both breasts* (*bilateral*) Typically *disappears after menopause*

abnormal breast and axillae finding in males

*Gynecomastia*: Abnormal development of breast tissue in males *Breast cancer*

tracheal breath sounds

*Harsh, high-pitched* sounds over the trachea I < E

bronchial breath sounds

*Loud, high-pitched* breath sounds found *next to the trachea*

respiratory assessment: percussion (posterior thorax)

*Lungs* - Resonance is the normal finding *Diaphragmatic excusion* 3-5 or 7 cm

order of auscultating client's posterior and lateral chest

> Expose the posterior chest with the client sitting with their arms folded across their chest > Auscultate 8 cm to one side of the spine around C7, then auscultate the other side of the spine in the same location > Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine is reached > Auscultate the lateral sides slightly below the axillary area, then down to the 7th or 8th rib

dyspnea

A change in this pattern, producing SOB or difficulty in breathing

coarse grating tone; heard on inspiration and expiration; pain with breathing

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. What descriptions should the nurse use to describe a pleural friction rub?

clubbing of the fingers indicates a chronic state of impaired perfusion

A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. What statement by the newly licensed nurse indicates an understanding of the teaching?

C: rhonchi

A client has thick sputum production or obstruction from a foreign body has _______, which are *dry, low-pitched*, *snoring-like noises produced in the throat*. What is this respiratory condition called? A wheezes B stridor C rhonchi D coarse crackles

high-pitched musical squeak

A client who has *wheezes* will manifest a ________ adventitious lung sound on inspiration or expiration through a narrow or *obstructed airway*

A: absence of breath sounds

A nurse in the ED is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of *pneumothorax*? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

unequal movement of the posterior chest

A nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. What findings is an indication of *pneumothorax*?

A, B, C

A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is *subjective data*? A. Report from client says they sleep while propped on two pillows at night B. Client says they quit smoking 2 years ago C. Client states: being SOB all of the time is making me depressed

scoliosis

Abnormal *lateral curvature* and *rotation* of the *thoracic* + *lumbar* spine Occurs frequently in *females and adolescents*

D

All of the topics should be addressed in the focused interview on breast health EXCEPT? A. medications B. menstruation C. exposure to environmental carcinogens D. marital status

thin T-shirt, using water or lotion to mat down the hair

Auscultation through clothing or coarse chest hair may produce deceptive sounds. What is your course of action?

abnormal findings of breast and axillae

Benign breast or *fibrocystic disease* Fibroadenoma Intraductal papillomas Mammary duct ectasia Breast cancer Peau d'orange Gynecomastia

benign breast or fibrocystic breast disease

Characterized by lumps, pain or tenderness, and nipple discharge as a result of thickening of breast tissue -> *Soft, moveable breast lump*

modifiable risk factors for breast cancer

Children + breast-feeding High-fat diet + lack of physical activity Overweight/Obesity Alcohol consumption Hormone replacement therapy Radiation exposure Night shift (*stress*, *lack of sleep*)

abnormal respiratory findings: asthma

Chronic hyperactive condition resulting in: >Bronchospasm mucosal edema > Increased mucus secretion > Px manifests *sibilant rhonchi* or *wheezing* Px experiences *expiratory wheezing* during an acute ______ attack

abnormal respiratory findings: chronic bronchitis

Chronic inflammation of the tracheobronchial tree Px manifests: Increased mucus production Blocked airway

palpating the axilla

Client is in sitting position Palpation continues to *tail of Spence* (*axillary tail*): - Take your thumb and make circles looking for swollen lymph nodes NORMAL No redness, rashes, lumps, or lesions ABNORMAL - Enlarged nodes that are *soft* + *moveable* -> Could be an infection in the breast, arm, or hand, or cancer - *Hard, fixed lymph nodes* -> Cancer or lymphoma

abnormal respiratory findings: atelectasis

Collapse or impaired expansion of one or more areas of the lung; the alveoli or an entire lung may collapse from *airway obstruction*: - Mucus plug - Lack of surfactant - Compressed chest wall

abnormal respiratory findings: pneumothorax

Condition in which *air moves into the pleural space and causes partial or complete collapse of the lung* Px manifests: Increased RR Decreased O2 sat Apnea (*absent breath sounds*) *Hyperresonance* Decreased expansion over affected area Caused by: Stab wound to chest

cough and deep breathing exercises

Coughing *removes mucous*, deep breathing *moves air into most parts of the lungs* > *Prevents complications such as pneumonia*

LHF and pneumonia

Crackles/rales sounds are common in which patients?

focused interview questions for respiratory assessment

Do you have any SOB? Do you have SOB with exertion? Have you smoked? Exposed to second-hand smoke? Allergies? What's your reaction? Occupational hazards (coal mining, abestos, painters, construction)? Coughing? Sputum? What color? COPD? Asthma? Bronchitis? Seat belt use? TB testing? Results? Exercise? Flu shot?

kyphosis

Exaggerated *posterior curvature* of the *thoracic spine* that's common in *elderly* patients (osteoporosis)

abnormal respiratory findings: pleural effusion

Fluid in pleural cavity

non-modifiable risk factors for breast cancer

GENDER - Prevalent in Caucasian females after age 40 than other ethnic/racial groups AGE - Increases esp after 35-40 y/o (early menopause) Genetics Family hx Past hx of breast cancer Menstrual periods (often associate w/mastalgia)

palpation of the posterior thorax

Have px breathe normal + lightly palpate using finger pads Include entire thorax: > Start @ area above each scapula + move side to side below the 12th rib + laterally to midaxillary line > Assess muscle mass > Growths, nodules, masses > Tenderness

assess for edema if it's LHF and assess patient's temperature (indicative symptom is fever) for pneumonia

How do you define the difference for LHF vs pneumonia?

2 lobes

How many lobes in the left lung?

3 lobes

How many lobes in the right lung?

6

How many lung sounds are heard *anteriorly*?

8

How many lung sounds are heard *posteriorly*?

1-3 years; yearly

How often should women ages 29-39 do a BSE? How about women ages 40 and over?

pneumothorax

Hyperresonance occurs when the patient has __________ -> results in the overinflation of the lungs/air that's trapped in the lungs

D: cyanosis

In a client with respiratory distress, which finding by the nurse is most compatible with a worsening clinical state? A Increased RR B Tachycardia C Agitation D Cyanosis

abnormal respiratory findings: pneumonia

Infection of the alveoli

mammary duct ectasia

Inflammation of the lactiferous ducts behind the nipple Thick, sticky discharge Nipple retraction -> Benign finding

abnormal respiratory findings: bronchitis

Inflammation of the tracheobronchial tree

breast and axillae assessment

Inspection Palpation - Look + lightly palpate Ex: Regular shaped size, no abnormal discharge discoloration

hypoventilation

Irregular, shallow breathing pattern (RR < 10)

right sided heart failure

Jugular vein distention (JVD) and peripheral edema

fibroadenoma

Mobile, firm, well delineated lumps -> Benign finding

noncyclic mastalgia

NOT associated w/the menstrual cycle Has NO apparent precipitating factor, although can be r/t large breasts that aren't supported sufficiently *Affects women ages 30 to 50* Occurs in *one breast* (*unilateral*) Pain is often described as *sharp* or *burning* sensation that occurs in one region of the breast Results from changes to breast structure: - *Fibroadenoma* - *Cysts* - *Trauma* - *Pain in the chest cavity* + *neck that radiates to the breast* - May require diagnostic studies such as*mammogram* or *biopsy*

respiration assessment: inspection

Nasal flaring > Indicates *labored breathing*, *hypoxia* Pursed lip breathing > Physiologic response to slow down expiration > Seen in patients with *CHF*, *emphysema*, *asthma* Color of face + lips > Cyanosis makes white and dark skin appear BLUE Color + nail shape > Cyanotic (blue) nails = HYPOXIA > Clubbed nails = LONG-TERM HYPOXIA (e.g., COPD px)

adventitious sounds: fine rales/crackles

OCCURRENCE *End inspiration*, don't clear with cough QUALITY *High pitched*, short, crackling CAUSES Collapsed or fluid-filled alveoli open (*lobar pneumonia*)

adventitious sounds: coarse rales/crackles

OCCURRENCE *End inspiration*; can't be cleared by coughing QUALITY *Low pitched*, *loud*, moist, *bubbling* CAUSES Collapsed or filled alveoli open

adventitious sounds: wheezes (sibilant)

OCCURRENCE Expiration/Inspiration *when severe* QUALITY High-pitched; continuous CAUSES Blocked airflow as in: - *Asthma* - Infection - Foreign body obstruction

adventitious sounds: friction rub

OCCURRENCE Inhalation/exhalation QUALITY *Low-pitched grating*, *rubbing* CAUSE *Pleural inflammation* Indicates *trauma, dehydration*

adventitious sounds: rhonchi (sonorous)

OCCURRENCE Expiration/Inspiration *change/disappear with cough* QUALITY *Low-pitched*; continuous, *snoring*, *rattling* CAUSES Fluid-blocked airways

abnormal respiratory findings: emphysema

Overinflation + damage to alveoli Manifestations: Dyspnea Barrel chest Poor tissue perfusion -> Clubbed finger nails

B: resonant

Percussion over the lung will emit what sound? A Dull B Resonant C Music like D Sharp

intraductal papillomas

Postmenopausal patient complains about bloody discharge -> Benign finding Tiny growths of epithelial cells project into the lactiferous ducts - Milk ducts of the breast

breast and axillae assessment: palpation

Press against the breast -dominate top -no dominate under Axillae Nipple and areolae Laying down -press against chest wall >strip or circular (in and out)

adventitious sounds: inspiratory stridor

QUALITY Loud, high-pitched *crowing-like sound* often heard w/o stethoscope -> d/t *anaphylaxis, choking on toys or food, obstruction* Known as WHOOPING COUGH or CROUP CAUSE Obstructed *upper airway*

hyperventilation

Rapid, deep breathing where RR > 24 breaths/min Common in px w/DKA

tachypnea

Rapid, shallow breathing Above 24 breaths/minute

male breast cancer

Rare <1% of all breast cancers Predisposing factors: - Family hx - Radiation exposure - Cirrhosis - Estrogen meds - Familiar hx of breast cancer in primary female relatives

Paget disease

Rare type of cancer described as red, scaly, eczema-like area over the nipple -> The area may exude fluid, scale, or crust

eupnea

Regular, even, rhythmic pattern of breathing

incentive spirometer

Resistive breathing device to help improve ventilation and air exchange

respiration assessment: percussion sounds

Resonance: loud, low-pitched, hollow sounds over the lungs Hyperresonance: Abnormally loud -> Air trapped in lungs Flatness: High-pitched, soft, sort, muscle or bone -> Over ribs

respiration assessment: palpation (posterior thorax)

Ribs Intercostal space Respiratory expansion Tactile fremitus; px says "ninety-nine" - *Palpable vibration* when the person coughs or speaks (should be equal) - Less vibration --> Fluid in lungs

Biot's ataxic

Shallow, deep respirations with periods of apnea; *irregular* pattern

breast self-examination (BSE)

Should be performed at the same time + day every month Inspect for any changes of one's own breasts Palpate - Concentric circles - Vertical strip Shower? Light, medium, deep 3-5 days after menstruation

bradypnea

Slow RR, below 10 respirations/minute

sternal border

Starts @ the sternal notch + descends through the xiphoid process; divides the sternum in half + ultimately identifies the L/R thoracic cage --> The *L/R midclavicular lines* are parallel to the sternal lines

respiration assessment: inspection for anterior and posterior thorax

Structures of thorax > Clavicles: *Same height*; *sternum midline* Structures of chest + movement > Must be *symmetrical* Chest configuration > *Elliptical*: Lateral diameter that's larger than the anteroposterior diameter in a *2:1 ratio* Respiratory rate > Normal is *12-20 breaths/min*; *even and smooth* > Females breathe more costlier vs males more abdominally

barrel chest

The anteroposterior diameter is = to the lateral diameter and ribs are horizontal Normally occurs with aging + accompanies COPD

A

The client has COPD and diminished air movement to the lungs. What is the most appropriate intervention to improve ventilation? A Instruct in incentive spirometer B Increase hydration C Instruct pursed lip breathing D Cough + deep breathing exercises

A, B, C

The nurse is preparing to assess lung sounds in a client. Which of the following measures are appropriate prior to this assessment? (SATA) A Ask the client + family to refrain from talking B Turn off the TV C Close the room door D Ask the client to take deep breaths through the mouth every time you move the stethoscope

C

The nurse places their hands over the client's ribs, with thumbs together + fingers spread, and asks the client to take a deep breath. Which of the following is the nurse assessing? A Crepitus B Fremitus C Respiratory expansion D Resonance

mastalgia

The term for breast pain is called ________

respiratory assessment: auscultation of the anterior thorax

Trachea Bronchi Lungs For normal lung sounds - Trachea - Bronchial - Bronchovesicular - Vesicular

palpation of the male breast

Use finger pads of the first 3 fingers Gently palpate tissue using dime-size *concentric circles* until you reach the nipple Male breasts: Feel like a "thin disk" Should be flat, and free of lumps or lesions

Dimpling of the skin, deviation of nipple, nipple retraction, changed shape of breast, edema, discharge, peau d'orange

What are common assessment findings of breast cancer (carcinoma of the breast)?

concentric circles or vertical strip method

What are palpation techniques used for breast and axillae assessment?

sternal line, left and right midclavicular lines, and the right and left anterior axillary lines

What are the 5 imaginary vertical lines identified on the anterior aspect of the thoracic cage?

vertebral line, right and left scapular lines, right and left posterior axillary lines

What are the 5 imaginary vertical lines identified on the posterior aspect of the thoracic cage?

anterior axillary, posterior axillary, and midaxillary lines

What are the three imaginary lines in the lateral aspect of the thoracic cage?

collapsed lung or pneumothorax and pain

What are two factors that lead to unequal respiratory expansion?

95%-100%; 88%-92%

What is a normal result of using the pulse oximeter? How about in COPD px?

less than 1% of all breast cancer occurs in men (rare)

What is the breast cancer rate in men?

approximately 12%

What is the breast cancer rate in women?

report the patient to the MD immediately for further evaluation

When a patient has lump in the breast that has gotten bigger, the nurse must...

20 years of age

When should women begin performing monthly BSEs?

upper outer quadrant of the breast; cancer

Where does a lump on the breast usually occur? This location has a high incidence of what?

B: axillary

Which lymph nodes can directly be affected in a patient with breast cancer: A. inguinal B. axillary C. femoral D. submental

45 years; every 2 years; annual

Women ages _____ and older *should have annual mammogram*. For women *ages 55 years and over*, clients may decide to change this schedule to _____ or continue with _____ mammograms

abnormal respiratory findings: congestive heart failure (CHF)

edema around alveoli

palpation of the breast

• Client supine position • Cover breast not being examined • Place small pillow or rolled towel under shoulder of side to be palpated • Explain that you will be touching the breast • Palpate skin texture • Palpate the nipple and areolae: compress tissue between thumbs and forefinger, observe for discharge and drainage, should be nontender • Abnormal: discomfort or tenderness, thickening of the skin, discharge, masses • Abnormal: unilateral discharge from the nipple can be benign breast disease such as intraductal papilloma or cancer • Technique Concentric circles: take two fingers and go in circles starting at axillary • Technique- Vertical strip method: use both hands make circles back and forth to cover the whole area • If the patient has had a mastectomy, you still need to assess

bronchovesicular breath sounds

*Medium-pitched* sounds normally heard over the *sternal border between the scapula*

breast and axillae assessment: inspection

*SIZE & SYMMETRY* One breast may normally be slightly larger than the other *COLOR* - *Consistent w/rest of body* - Observe for thickness, tautness, redness, rash, or ulcerations *VENOUS PATTERNS* - Equal bilaterally; may be more predominant in pregnancy or obesity *MOLES* Normal: Unchanged, nontender, long-standing Abnormal: Striae (present in pregnancy) or recent weight loss/gain may appear PURPLE in color + can turn WHITE over time *AREOLA & NIPPLES* Areola: - Round or oval + almost = in size - *Pink in light-skinned ppl* + *brown in dark-skinned ppl* - Can darken in pregnancy Nipples: - Same color as areolae + are = in size and shape; can be flat, everted, or inverted - Should point in the same direction outward + slightly upward - Free of cracks, crusts, erosions, ulcerations, pigment changes, or discharge *Observe the breasts for shape, surface characteristics, and bilateral pull of suspensory ligaments*

vesicular breath sounds

*Soft, low-pitched* sounds heard in the *remainder of the lungs*

palpating for tactile fremitus

- Palpable vibration on chest wall when client speaks - Strongest over trachea, diminishes over bronchi, almost nonexistent over alveoli of lungs INSTRUCTIONS: - Client repeats phrase "ninety-nine" - Use ulnar or palmar surface of hand on scapula

palpate for respiratory expansion

- Place hands on lower ribcage + ask client to *take a deep breath* - Use *palmar surface of hands*, thumbs up, close vertebrae at level T10 NORMAL FINDING Movement + pressure against your hands should feel *smooth and even*

nail beds, oral mucosa, lips

A nurse is assessing a client who is dark-skinned. In which areas of the client's body should the nurse assess the client for adequate oxygenation?

rhonchi; gurgling sounds

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear *over the trachea AND the bronchi if the airways are narrow d/t secretions or swelling*? What are its characteristics?

bronchovesicular; moderately loud with medium pitch

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear on *either side of the sternal border anteriorly and between the scapulae posteriorly*? What are its characteristics?

D: encourage the client to cough

A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? A. Limit the client's fluid intake B. Assist the client into a supine position C. Administer oxygen @ 2L/min D. Encourage the client to cough

heard to the right and left of the trachea and larynx (anterior thorax)

A nurse is auscultating the breath sounds of a client who has pneumonia and hears bronchial crackles. In which areas of the chest is the nurse auscultating?

wheeze

A nurse is auscultating the lateral lobes of a client who has bronchitis. The nurse should document the sound of as?

A: coarse crackles

A nurse is caring for a client who had an MI 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates *loud, bubbly sounds on inspiration*. Which of the following adventitious breath sounds should the nurse document? A. Coarse crackles B. Wheezes C. Rhonchi D. Friction rub

Cheyne-Stokes breathing

A nurse is caring for a client who is dying and is having periods of *deep breathing alternating with periods of apnea*. The nurse should identify this as which type of breathing?

numbness and tingling of extremities; lightheadedness; chest pain

A nurse is caring for a client who is experiencing episodes of hyperventilation. What manifestations should the nurse expect during hyperventilation?

elevate the head of the client's bed

A nurse is caring for a client who is having difficulty breathing. What actions should the nurse take first?

you should make an effort to receive a flu vaccine every year

A nurse is providing discharge instructions to a client who has COPD regarding the influenza vaccine. What statement should the nurse make?

B: upright with hands on hips

One of the positions best to assess the breasts is? A. prone B. upright with hands on hips C. trendelenburg D. upright with hands behind back

loud crowing noise heard without stethoscope

The nurse should assess the client for which of the following manifestations of *inspiratory stridor*?

in a seated position have patient inhale and exhale (full respiratory cycle) while moving the stethoscope

What instructions should you give the client while auscultating for lungs sounds?

B: wheezing

What is an assessment finding of asthma? A Barrel chest B Wheezing C Stridor D Tracheal deviation

thins secretions in the lungs; must drink 1 1/2 to 2 liters of water

What is the purpose of hydrating for a patient with respiratory problems or conditions?

palpation; vibration should be equal

What kind of technique do you use for tactile fremitus? What is a normal finding?

indirect percussion (middle finger tap on middle finger)

When examining the lungs, what type of percussion do you do?

hypothermia (cold extremities), nail polish, poor circulation

When using the pulse oximeter, what factors should the nurse consider that can impact accuracy?

C7-T12

Where can you find the *vertebral line*?

6th intercostal space at the midclavicular line - halfway between clavicle and lower ribcage for left lower lobe

Where do you auscultate for the left lower lobe of the lung?

through the right midaxillary around the 4th-6th intercostal space (lateral area of lung)

Where do you auscultate for the right middle lobe?

A: vesicular

Which normal breath sounds is auscultated over the *periphery of the major lung fields*? A Vesicular B Bronchial C Tracheal D Bronchovesicular

A, B, D: kyphosis, scoliosis, pectus excavatum

Which of the following conditions may impact the client's breathing? (SATA) a. Kyphosis b. Scoliosis c. Pectus Carinatum d. Pectus Excavatum e. Barrel chest

B

Which of the following nursing interventions is DIRECTLY RELATED to the client's diagnosis of ineffective breathing pattern? a. Assessing for orthostatic blood pressure b. Reassessing lung sounds after the client coughs c. Using the diaphragm of the stethoscope to listen to lung sounds d. Educating the client on handwashing measures to prevent infection