prep U 16 thorax and lung assessment

orthopnea

(difficulty breathing when lying flat) often sleep on two or more pillows or even in recliners.

rhonchi

-are continuous, low-pitched, snoring sounds resulting from secretions moving around in airways

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?

Severe brain damage The respiratory pattern observed is Biot's respirations, which may be seen with meningitis or severe brain damage. Diabetic ketoacidosis would reveal Kussmaul's respirations, which are characterized by an increased rate and depth. Renal failure would reveal Cheyne-Stokes respirations characterized by a regular pattern of alternating deep and rapid breathing with periods of apnea. A narcotic overdose would reveal hypoventilation or possibly Cheyne-Stokes respirations.

A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect?

Hyperresonance Hyperresonance would be noted in a client with emphysema due to air trapping. Dullness is noted with fluid or solid tissue replacing air in the lung. Resonance is the normal finding on lung percussion. Tympany would be noted over areas of air, such as a gastric bubble in the stomach.

A client has a history of emphysema. The nurse percusses the chest, expecting to find which of the following? Hyperresonance Tympany Resonance Dullness

Dyspnea Dyspnea is a subjective term used when the client reports labored breathing and breathlessness. This response to exercise or heavy activity is normal if it rapidly disappears upon return to rest. Difficulty breathing, in appropriate medical terminology, is not tachypnea, shortness of breath, or anxiety.

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?

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?

hypoventilation or possibly Cheyne-Stokes

A narcotic overdose would reveal __________ respirations.

Biot's In people with irritation or brain damage, the respiratory pattern will be irregular and characterized by varying depth and rate followed by periods of apnea, which is known as Biot's respiration. Cheyne-Stokes is a regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Retractive is not an observable pattern of respirations. Kussmaul's is seen in clients with diabetic ketoacidosis and are characterized by deep but rapid respirations similar to hyperventilation.

A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is not arousable and pupils are fixed and dilated. When performing a respiratory assessment, the nurse recognizes which breathing pattern as normal for clients with brain damage?

hypercapnia Under normal circumstances, the strongest stimulus to breathe is an increase of carbon dioxide in the blood (hypercapnia). A decrease in oxygen (hypoxemia) also increases respiration but is less effective than a rise in carbon dioxide levels. Hypoventilation is a breathing pattern marked by a decreased rate, decreased depth, and irregular pattern. Hyperventilation is a breathing pattern marked by increased rate and depth.

A nurse is auscultating a client's chest for breath sounds. The nurse recognizes that which of the following is the strongest stimulus to breathe?

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?

Cheyne-Stokes Cheyne-Stokes respirations are described as respirations that gradually become faster and deeper than normal, then slower, alternating with periods of apnea. This pattern can be drug-induced, normal in frail elderly people while sleeping, or a sign of impending death. Kussmaul's respiratory pattern is described as faster and deeper respirations without pauses. Eupnea is a normal respiratory rate and rhythm. Tachypnea is an increased respiratory rate.

A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern?

Patient C Cardiac emergencies that necessitate rapid assessment and intervention include acute coronary syndromes, acute decompensated heart failure, hypertensive crisis, cardiac tamponade, unstable cardiac arrhythmias, cardiogenic shock, systemic or pulmonary embolism, and aortic dissection.

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?

D. Auscultate lungs. Rationale: Acute shortness of breath: Immediate assessments; lungs are auscultated; simultaneously, oxygen is administered and inhalers may be given; and the head of the bed is elevated

Acute shortness of breath is a medical emergency. Immediate assessments are necessary. What is the priority assessment the nurse would make with a patient who has acute shortness of breath? A. Administer inhalers. B. Administer oxygen. C. Raise the head of the bed. D. Auscultate lungs.

Have the client cough, then listen again If abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation. Auscultating voice sounds would be done as part of any assessment of the thorax.

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?

pleural friction rub, pleuritis

Auscultation Posterior chest:

Patients in respiratory distress or with COPD often assume a tripod position, leaning forward on a stationary object such as a table or with their elbows on their knees

Comprehensive physical assessment: general, abnormal findings

Kussmaul's respirations,

Diabetic ketoacidosis would reveal what type of respirations which are characterized by an increased rate and depth.

Associated Conditions Stridor

Epiglottitis, croup, partially obstructed airway; can indicate an emergency requiring immediate attention

Crackles (fine)

High-pitched, soft, brief crackling sounds that can be simulated by rolling a strand of hair near the ear or stethoscope Deflated small airways and alveoli will pop open during inspiration. In early CHF, small amounts of fluid in the alveoli may cause fine crackles. Late inspiratory crackles are associated with restrictive disease (e.g., fibrosis and heart failure). Early inspiratory crackles occur with obstructive diseases (e.g., asthma and COPD).

Biot respiration (rate variable, depth variable, irregular rhythm, suspect severe brain damage)

Inspection; abnormal respiratory patterns-Posterior chest:

Associated Conditions Stridor

Laryngeal or tracheal inflammation or spasm can cause stridor, as can aspiration of a foreign object.

eighth rib tenth rib.

Laterally, lung tissue reaches the level of the _______ rib; and posteriorly, the base lies at about the _________ rib.

pleural friction rub

Loud, coarse, and low-pitched grating or creaking sound similar to a squeaky door during inspiration and expiration; more common in the lower anterolateral thorax Inflamed pleural surfaces lose their normal lubrication and rub together during breathing. Pleuritis

Stridor Description

Loud, high-pitched, crowing or honking sound louder in upper airway

Rhonchi (low-pitched wheeze, snoring)

Low-pitched snoring or gurgling sound that may clear with coughing Airflow passes around or through secretions or narrowed passages. Pneumonia

Crackles (coarse)

Low-pitched, moist, longer sounds that are similar to Velcro slowly being separated

paroxysmal nocturnal dyspnea

Patients who awaken at night with sudden shortness of breath

white cells and bacterial infection.

Purulent yellow or green sputum, or creamy sputum, especially with a foul odor, indicates the presence of

In the mediastinum : The thoracic cavity consists of the mediastinum and the lungs, and is lined by the pleural membranes. The mediastinum refers to a central area in the thoracic cavity that contains the trachea, bronchi, esophagus, heart, and great vessels.

Question 4 See full question 12s A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body?

Midclavicular: bilateral, medial clavicles Anterior axillary lines: bilateral, axillary folds Midsternal: medial sternum

Reference lines of the chest, anterior

Cheyne-Stokes

Renal failure would reveal ____________ respirations characterized by a regular pattern of alternating deep and rapid breathing with periods of apnea.

TB and pneumococcal pneumonia.

Rust-colored sputum is found with

2nd rib

Site of the apex of the heart

Crackles (coarse) Mechanism

Small air bubbles flow through secretions or narrowed airways.

area slightly above the clavicle. The apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm. Laterally, lung tissue reaches the level of the eighth rib and posteriorly, the base lies at about the tenth rib.

The apex of each lung is located at the

B. Angle of Louis Rationale: From the suprasternal notch, walk your fingers down approximately 4 to 5 cm to the bony ridge that joins the manubrium to the sternum. This ridge, called the sternal angle (also known as the angle of Louis or sternomanubrial angle), varies in prominence and is usually easier to locate in thinner people. The sternal angle is continuous with the 2nd rib.

The nurse caring for a patient diagnosed with a 2nd rib fracture should know the location of the sternal angle also called what? A. Apex B. Angle of Louis C. Base D. 2nd ICS

Pulmonary embolism Risk factors for pulmonary embolism include postpartum or postoperative periods, prolonged bed rest, congestive heart failure, chronic lung disease, fractures of hip or leg, and deep venous thrombosis (often not clinically apparent).

The nurse is caring for a client who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect?

Adult patient with chronic obstructive pulmonary disease Adult patient caring for children under age 5 Older adult attending adult day care The Centers for Disease Control and Prevention recommend the annual influenza vaccination for any adult with a chronic pulmonary condition, any adult who attends a chronic care facility, and caregivers of children younger than 5 years. The Centers for Disease Control and Prevention do not specifically identify the populations that include a young adult patient who lives alone or the adolescent patient being home schooled for the annual influenza vaccination, although all people wishing to reduce the risk of infection should be vaccinated.

The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members would benefit from receiving this vaccination? (Select all that apply.) Adult patient with chronic obstructive pulmonary disease Young adult patient who lives alone Adolescent patient being home schooled Adult patient caring for children under age 5 Older adult attending adult day care

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 should not percuss all areas on the right side of the chest before assessing the left chest. The nurse should not percuss all areas on the left side of the chest before assessing the right chest. The nurse should not complete the assessment of the left chest and then reverse the process, assessing upward from the liver.

The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment?

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?

Air passing through constricted passageways Wheezes appear when air passes through constricted passages. Wheezes are not the result of diversion of air to the bronchi, increased turbulence, or air entering the pleural space.

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process?

Heart Most of the esophagus Lungs

The thoracic cavity contains which of the following organs? Select all that apply. Heart Lungs Most of the esophagus Stomach Pancreas

Suprasternal (jugular) notch

U-shape

Coarse crackles Coarse crackles are low-pitched bubbling moist sounds that are described as separating Velcro. Fine crackles are high-pitched, short, popping sounds heard during inspiration and not cleared with coughing. Sibilant wheezes are high-pitched musical sounds. Sonorous wheezes are low-pitched snoring or moaning sounds.

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?

Resonance over all lung fields All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax. Dullness is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological.

When percussing the posterior lung fields, which of the following findings is expected?

Listen at each site for at least one complete respiratory cycle 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. The bell is not used for breath sounds because it detects low pitched sound such as abnormal heart sounds.

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?

Diaphragm The diaphragm is the primary muscle of inspiration; when it contracts, its descent enlarges the thoracic cavity.

Which of the following muscles is primarily responsible for thoracic cavity enlargement?

upper lobe middle lobe lower lobe 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. The left lung has only two lobes, upper and lower. Neither base nor major are terms used to identify the lobes of the lung.

Which terms are used to identify the lobes of the right lung? Select all that apply. upper lobe middle lobe lower lobe base lobe major lobe

"Please say the number 'ninety-nine' for me."; To palpate for fremitus, the nurse uses the ball or ulnar edge of one hand to assess for vibrations of air in the bronchial tubes transmitted to the chest wall. As the nurse moves a hand to each area, the client is asked to say "ninety-nine." None of the other listed actions will allow the nurse to assess for vibration in the chest wall.

While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment? "When I say so, please exhale forcefully and hold the breath." "Say the letter 'e' and keep saying it until I tell you to stop." "Breathe in as deeply as you can and hold your breath until I say to stop." "Please say the number 'ninety-nine' for me.";

whisper "one-two-three" while you are listening to the chest, comparing sides

Whispered pectoriloquy is evaluated by asking the patient to

Dyspnea

_________ feeling "short of breath," is a subjective term used when patients report labored breathing and breathlessness.

hypertension and aortic stenosis.

displacement of PMI move laterally and

parietal pleura. : The parietal pleura line the chest cavity.

he thin double-layered serous membrane that lines the chest cavity is termed

1 .Increase the proportion of adults vaccinated against influenza and pneumococcal infections. Reduce the number of missed school or work days due to asthma exacerbations. Reduce the proportion of adults whose activity level is limited by symptoms associated with chronic lung disease and reduce mortality from respiratory-associated disorders. Reduce the proportion of previous smokers and never smokers (defined as people who have smoked 100 or fewer cigarettes in their lifetime) exposed to secondhand tobacco smoke. Increase the number of smoking cessation attempts by adolescent and adult smokers and during pregnancy. Establish laws prohibiting indoor smoking; alternately, limit indoor smoking to separately ventilated areas in public buildings and worksites.

health goals related to the respiratory system:

wheezes-

high-pitched, musical sounds

clear or white

mucoid sputum of bronchitis is

Ask the patient to say "ninety-nine."

palpation-tactile fremitus-Posterior chest:

first thing you do is assess the Lungs

patient has shortness of breath (acute)

have the client cough and then listen again

patient with Adventitious breath sounds

percussion-generalized hyperresonance (a low-pitched, louder sound with a hollow quality, sounding very close to tympany) may be heard over hyperinflated lungs found

patient with emphysema

generalized hyperresonance (a low-pitched, louder sound with a hollow quality, sounding very close to tympany) may be heard over hyperinflated lungs found in patients with emphysema

percussion- Posterior chest:

Associated Conditions Crackles (coarse)

respiratory fibrosis, respiratory edema, COPD

sputum

resulting from heart failure is thin and frothy and may be slightly pink

Biot's respiration

rregular and characterized by varying depth and rate followed by periods of apnea

crackles-

velcro opening

sibilant wheezes

what are high-pitched musical sounds.

fine crackles

what are high-pitched, short, popping sounds heard during inspiration and not cleared with coughing.

sonorous wheezes

what are low-pitched snoring or moaning sounds.

Phrenic nerve

what nerve stimulates diaphragm?

Intercostal nerves

what nerve stimulates inter costal muscles?

base

what part of the lungs is at the level of the diaphragm

The mediastinum

what refers to a central area in the thoracic cavity that contains the trachea, bronchi, esophagus, heart, and great vessels.