health assessment -- lung & breast (intro, resp. assessment steps, normal vs abnormal lung sounds)

cyanosis

bluish discoloration of the skin

assessment of respiratory system

#1 inspect #2 palpate #3 percuss #4 aucultate

fine crackles

-high pitched, brief, discont. popping lung sounds -sound like wood burning in a fireplace -usually starts at a base of lungs where ther is fluid in the lungs -as fluid fills the lungs more, it can be heard closer and closer to top of lungs

tracheal breath sounds

-higher up on the lungs -sound very different from vesicular breath sounds (located lower in lungs), are louder and higher-pitched than vesicular sounds

coarse crackles

-heard over most of anterior and posterior chest walls -coarse, rattling, crackling sounds --> louder, longer, and lower in pitch than fine crackles -described as a bubbling sound as when pouring water out of a bottle or like ripping open Velcro -often heard just in certain spots in lungs (possibly only one side or in diff spots on both sides) -usually caused by mucus in the bronchi

wheezing

-continuous w/ a musical quality -caused by narrowing airways -associated with asthma, bronchitis, pneumonia, COPD, smoking, heart failure, inhaling a foreign object into lungs, allergic rxn -may occur during inspiration or expiration

percussion of respiratory system

-do this bilaterally -sound does change!

anatomy of left lung

-left superior/upper lobe -oblique fissure (separates upper lobe from lower lobe) -left inferior/lower lobe

tips for auscultating lungs

-listen directly on patient chest (no clothes!) with the diaphragm of stethescope -if patient is a woman, have her lift her breast so you can accurately hear the lung sounds -auscultate both anterior and posterior chest -when listening, note a full cycle of inspiration and expiration --> listeing to pitch (high, medium, or low), sound quality, duration (is inspiration longer/shorter than expiraiton or are they equal?), any extra sounds? -have patient sit up so that you can get better sounds -have patient breath in and out slowly through mouth

palpation of respiratory system

-palpate for tenderness --> ex: if patient comes in for chest discomfort/lung pain, if you push on the rib and they say "ow", it's usually going to be an issue with the rib, NOT the lungs (which is good!) -tactile fremitus --> palpating with palm of hands; do you have an increased sensation on the hand when palpating while the patient is speaking? do this symetrically/ bilaterally -palpate ribs -trachea position --> if the trachea is deviated, it is important to not only inspect but to also palpate bc this gonna show you subtle differences!

auscultation of respiratory system

-pay attention to patient -make sure you auscultate all marks -make sure that you are auscultating the apices and bases of lungs!

bronchial breath sounds

-pitch: high -quality: harsh or hollow -amplitude: loud -duration: SHORT during INSPIRATION, LONG in EXPIRATION location: trachea and thorax -only heard anteriorly! --> bc mainly heard in tracheal area -it is abnormal to hear bronchial sounds in the peripheral lung fields, if this is found it could represent lung consolidation (ex: pneumonia)

vesicular breath sounds

-pitch: low -quality: breezy -amplitude: soft -duration: LONG during INSPIRATION, SHORT during EXPIRATION -location: peripheral lung fields -heard both anteriorly and posteriorly --> heard throughout peripheral lung field (ant and post.)

bronchovesicular breath sounds

-pitch: moderate/medium -quality: mixed -amplitude: moderate -duration: SAME during inspiration and expiration -location: over the major bronchi—posterior: between the scapulae; anterior: around the upper sternum in the first and second intercostal spaces -heard both anteriorly and posteriorly --> anteriorly: 1st and 2nd intercostalspace -posteriorly: in between scapula

what's the difference between the lobes of the right and left lungs?

-right has THREE lobes (superior, middle, and inferior lobes) -left lobe has TWO lobes (superior and inferior lobes)

anatomy of right lung

-right superior/upper lobe -horizontal fissue (separates middle lobe from upper lobe) -right middle lobe -oblique fissure (separates middle lobe from lower lobe) -right inferior/lower lobe

rhonchi/low-pitched wheezing

-snoring or moaning sound -continous, snoring, gurgling, or rattle-like quality -occur in bronchi as air moves through tracheal-bronchial passages coated with mucous or respiratory secretions -often heard in pneumonia, chronic bronchitis, or cystic fibrosis -usually clear after coughing

stridor

-sound is louder over the throat -air is moving roughly over partially-obstructed upper airway -caused by something blocking the larynx -ex: person choking on object, person w/ infection, swelling in throat, laryngospasm ** can indicate a medical emergency if not enough air is able to get to the lungs!

inspection of respiratory system

-start off high (at the lips) -lips: -->how is the patient breathing? --> does patient have pursed lip breathing? --> are they short of breath? --> hard time finishing words/speaking with only few, short words? --> any cyanosis (poor oxygen circulation in the blood that causes bluish discoloration of the skin)? -trachea: --> any shift or deviation (instead of it being midline, it has shifted over to the side)? -AP to transverse (1 to 2 ratio), barrel chest

pleural friction rub

-two inflamed pleural surfaces rub against each other during respiration -heard in pleurisy (inflammation of pluera) -may be continuous or broken, and creaking or grating -similar to sound of walking on fresh snow or rubbing leather together -occurs every time the patient inhales or exhales -pleural rubs come and go -not altered by coughing -can usualy be localized to specific location on chest wall -will stop when patient holds breath

lung auscultation steps (anterior)

1. start at apex of lungs --> above clavicle, both the right and left side 2. find 2nd intercostal space (midclavicular) --> left: upper lobe --> right: upper lobe 3. find 3rd intercostal space --> left: upper lobe --> right: upper lobe 4. find 4th intercostal space (midclavicular) --> left lung: upper lobe --> right lung: middle lobe 5. find 5th intercostal space --> left: upper lobe --> right: middle lobe 6. find 6th intercostal space (midaxillary) --> left: lower lobe --> right: lower lobe 7. find 7th intercostal space --> left: lower lobe --> right: lower lobe

lung auscultation steps (posterior)

1. start right above scapula to listen to apex of lungs on both sides 2. find C7 (vertebral prominence!) and assess through to T3 on both sides (in between scapula/shoulder blades and spine) --> left: upper lobe --> right: upper lobe 3. assess T3 through T10 on both sides (in between scapular and spine) --> left: lower lobe --> right: lower lobe 4. move down (almost midaxillary) to assess lower lobes

what are the 4 types of lung sounds?

1. tracheal breath sounds 2. bronchial breath sounds 3. bronchovesicular breath sounds 4. vesicular breath sounds

barrel chest is increased in patients who have

COPD

what are types of abnormal lung sounds?

Continuous (extra sound that is lasting MORE than 0.2 seconds with full respiration) -high pitched polyphonic wheeze --> mainly heard in expiration (but can also be during inspiration) --> is a high pitched, musical instrument sound w/ many diff sounds -rhonchi/low pitched monophonic wheeze --> mainly heard in expiration (but can also be during inspiration) --> low pitched whistle/wine (only one sound) -stridor --> heard upon inspiration bc airway is being obstructed by inflammation or some foreign object --> high pitched whistling or grasp w/ harsh quality Discontinuous (extra sound lasting LESS than 0.2 seconds) -coarse crackles/rales --> mainly heard during inspiration (can extend into expiration) --> low pitched, wet/bubbling sound -fine crackles/rales --> heard during inspiration --> high pitched, crackly sound --> does not clear when patient coughs -pleural friction rub --> heard during inspiration and expiration --> low pitched, harsh/grating sound --> caused by the 2 layers of pleura rubbing against each other, due to absence of thin layer of serous fluid around lungs bc of inflammation --> can sound similar to pericardial friction rub (have patient hold breath and see if sound is still there, if it is then it's pericardial not pleural FR)

barrel chest

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse

tactile fremitus

a tremor or vibration in any part of the body detected on palpation

you may frequently hear stridor in ______________

children --> bc they are more likely to choke and to get childhood infections like croup

COPD

chronic obstructive pulmonary disease

summary of some abnormal lung sounds (part 2)

crackles, plueral friction rub

true or false: auscultate heart sounds after lung sounds

false! auscultate heart sounds BEFORE lung sounds (tip: H comes before L in the alphabet, so you listen to heart sounds first)

true or false: only auscultate lungs on anterior side of patient

false! auscultate lungs on BOTH the anterior AND posterior side

what should you NOT do when auscultating the lungs?

make sure that you aren't auscultating over the sternum or the scapula bc that will change what you hear! --> make sure that you are auscultating LUNG TISSUE

AP (anterior-posterior) to transverse ratio

normal: 1:2 ratio barrel: 1:1 ratio

if there is a loss of breath sounds in an area, it probably indicates ___________________

pneumothorax (collapsed lung) --> no air movement in that area

if sound is louder over the throat it is ____________ not ___________

stridor, wheezing

when auscultating the lungs over tracheal breath sounds, they sound rougher and louder. if you were to hear those sounds lower in the lungs, what would this mean?

that this sound is being transmitted easier due to an issue (an infection like pneumonia or something else)

trachea deviation

trachea deviates away from pneumothorax, hemothorax, pleural effusion. Trachea deviates towards atelectasis (key point: trachea shifts away from midline, which is bad!)

summary of some abnormal lung sounds (part 1)

wheezing, stridor, rhonci