Chapter 18 Thorax and Lungs Assessment Copyright 2012

Anatomy and Physiology Overview • Upper and lower tracts – Upper airway warms, moisturizes

Anatomy and Physiology Overview (cont. ) • The thorax (cont. ) – Thoracic muscles

Anatomy and Physiology Overview (cont. ) • Anterior thoracic landmarks – Involve the ribs

Anatomy and Physiology Overview (cont. ) Copyright © 2012 Wolters Kluwer Health | Lippincott

Anatomy and Physiology Overview (cont. ) • Posterior thoracic landmarks – Less important –

Anatomy and Physiology Overview (cont. ) • Reference lines – Anterior • Midsternal •

Anatomy and Physiology Overview (cont. ) • Lobes of the lungs – Oblique fissure

Anatomy and Physiology Overview (cont. ) • Lobes of the lungs – Upper, middle,

Anatomy and Physiology Overview (cont. ) • Lower respiratory tract – Trachea bifurcates –

Anatomy and Physiology Overview (cont. ) • Lower respiratory tract (cont. ) – Pleurae

Anatomy and Physiology Overview (cont. ) • Upper respiratory tract – Responsible for moisturizing

Anatomy and Physiology Overview (cont. ) • Mechanics of respiration (cont. ) – Expiration

Question • The nurse caring for a patient diagnosed with a 2 nd rib

Answer • B. Angle of Louis • Rationale: From the suprasternal notch, walk your

Lifespan Considerations • Women who are pregnant • Infants and children • Older adults

Acute Assessment • Acute shortness of breath – Immediate assessments – Lungs are auscultated

Subjective Data Collection • Begins with the health history • Areas for health promotion

Subjective Data Collection (cont. ) • Risk assessment and health promotion – Smoking cessation

Subjective Data Collection (cont. ) • Focused health history related to common symptoms –

Objective Data Collection • Equipment • Preparation: patient comfort, dignity, and safety • Common

Objective Data Collection (cont. ) • Lifespan considerations – Women who are pregnant –

Evidence-Informed Critical Thinking • Organizing and prioritizing • Laboratory and diagnostic testing • Collaborating

Question • Acute shortness of breath is a medical emergency. Immediate assessments are necessary.

Answer • D. Auscultate lungs • Rationale: Acute shortness of breath: Immediate assessments; lungs

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Anatomy and Physiology Overview • Upper and lower tracts – Upper airway warms, moisturizes – Lower airway, where oxygenation and ventilation occur • The thorax – One of the most dynamic regions of the body – Thoracic cage – Thoracic cavity – Thoracic nerves in the chest (T 1 to T 12) • Phrenic nerve • Intercostals nerves Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • The thorax (cont. ) – Thoracic muscles – Arterial blood supply – Numerous veins – Lung: pulmonary artery and two pulmonary veins – Locations must be identified • Vertically (up and down): ribs • Horizontally (side to side): a series of lines provides horizontal reference marks Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • Anterior thoracic landmarks – Involve the ribs and their associated interspaces – Suprasternal (jugular) notch – Sternal angle • Site of the apex of the heart • Bifurcation of the right and left mainstem bronchi – Intercostal space (ICS) – Costal angle Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • Posterior thoracic landmarks – Less important – Vertebral processes – Spinous process of T 1 – Lower tip of the scapula – 11 th floating rib – 12 th floating rib Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • Reference lines – Anterior • Midsternal • Midclavicular • Anterior axillary lines – Posterior • Vertebral line • Scapular line • Posterior axillary line • Midaxillary line Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • Lobes of the lungs – Oblique fissure – The left lung has two lobes – The right lung has three lobes – Horizontal (minor) fissure – RML Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • Lobes of the lungs – Upper, middle, and lower lung fields – Base – Apex – Auscultate – Anteriorly – Posteriorly Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • Lower respiratory tract – Trachea bifurcates – Right main bronchus – Dead space – Bronchioles – Breath sounds – Alveoli – Pulmonary arterioles – Pulmonary thromboembolism (PE) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • Lower respiratory tract (cont. ) – Pleurae • Visceral pleurae • Parietal pleura • Pleural space – Mediastinum – Pulmonary cavities Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • Upper respiratory tract – Responsible for moisturizing inhaled air and filtering noxious particles • Mechanics of respiration – Primarily an automatic process – Main trigger for breathing – Some medications (e. g. , opiates) or an overdose of drugs – The diaphragm Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology Overview (cont. ) • Mechanics of respiration (cont. ) – Expiration is primarily passive – Pressure in the lungs • Diseases or problems of the spinal cord • Extreme obesity • Progressive loss of muscle function Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • The nurse caring for a patient diagnosed with a 2 nd rib fracture should know the location of the sternal angle also called what? A. Apex B. Angle of Louis C. Base D. 2 nd ICS Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer • B. Angle of Louis • Rationale: From the suprasternal notch, walk your fingers down approximately 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 manubriosternal angle), varies in prominence and is usually easier to locate in thinner people. The sternal angle is continuous with the 2 nd rib. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Acute Assessment • Acute shortness of breath – Immediate assessments – Lungs are auscultated – Simultaneously, oxygen is administered and inhalers may be given – Head of the bed is elevated – Patients are stable, but fatigue limits collection of assessment data • Prioritize the subjective data collected Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Subjective Data Collection • Begins with the health history • Areas for health promotion – Patient education, health promotion, and risk reduction • Assessment of risk factors Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Subjective Data Collection (cont. ) • Risk assessment and health promotion – Smoking cessation – Prevention of occupational exposure – Prevention of asthma – Immunizations Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Subjective Data Collection (cont. ) • Focused health history related to common symptoms – Common respiratory symptoms and signs • Lifespan considerations – Women who are pregnant – Newborns, infants, and children – Older adults – Cultural considerations Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Objective Data Collection • Equipment • Preparation: patient comfort, dignity, and safety • Common and specialty or advanced techniques • Initial survey • Comprehensive physical examination • Documentation of normal findings • Documenting abnormal findings Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Objective Data Collection (cont. ) • Lifespan considerations – Women who are pregnant – Newborns, infants, and children – Older adults Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Informed Critical Thinking • Organizing and prioritizing • Laboratory and diagnostic testing • Collaborating with the interprofessional team • Clinical reasoning – Nursing diagnoses, outcomes, and interventions – Analyzing findings • Pulling it all together Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • 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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer • 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. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins