1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 18Thorax and Lungs Assessment

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function Overview Upper and lower divisions –Upper airway warms, moisturizes –Lower airway, where oxygenation and ventilation occur The thorax –One of the most dynamic regions of the body –Bony thoracic cage –Thoracic cavity –Thoracic nerves in the chest (T1 to T12) Phrenic nerve Intercostals nerves

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function 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

4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function 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

5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function Overview (cont.)

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function Overview (cont.) Posterior thoracic landmarks –Less important –Vertebral processes –Spinous process of T1 –Lower tip of the scapula –11 th floating rib –12 th floating rib

7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function Overview (cont.) Reference lines –Anterior Midsternal Midclavicular Anterior axillary lines – Posterior Vertebral line Scapular line Posterior axillary line Midaxillary line

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Lobes of the lungs –Oblique fissure –The left lung has two lobes –The right lung has three –Horizontal (minor) fissure –RML Structure and Function Overview (cont.)

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function Overview (cont.) Lobes of the lungs –Upper, middle, and lower lung fields –Base –Apex –Auscultate –Anteriorly –Posteriorly

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Lower respiratory tract –Trachea bifurcates –Right main bronchus –Dead space –Bronchioles –Breath sounds –Alveoli –Pulmonary arterioles –Pulmonary thromboembolism (PE) Structure and Function Overview (cont.)

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function Overview (cont.) Lower respiratory tract (cont.) –Pleurae Visceral pleurae Parietal pleura Pleural space –Mediastinum –Pulmonary cavities

12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function 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

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function 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

14. Copyright © 2011 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

15. Copyright © 2011 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.

16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Lifespan Considerations Pregnant women Infants and children Older adults Cultural and environmental considerations

17. Copyright © 2011 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

18. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Subjective Data Collection Begins with the health history Areas for health promotion/Healthy People –Patient education, health promotion, and risk reduction Assessment of risk factors

19. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Subjective Data Collection (cont.) Risk assessment and health-related patient teaching –Smoking cessation –Prevention of occupational exposure –Prevention of asthma –Immunizations

20. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Subjective Data Collection (cont.) Focused health history related to common symptoms –Common respiratory symptoms Lifespan considerations –Pregnant women –Newborns, infants, and children –Older adults –Cultural and environmental considerations Therapeutic dialogue: collecting subjective data

21. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Objective Data Collection Equipment Preparation Common and specialty or advanced techniques Initial survey Comprehensive physical examination –Breath sounds Documentation of normal findings Documenting abnormal findings

22. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Objective Data Collection (cont.) Lifespan considerations –Pregnant women –Newborns, infants, and children –Older adults

23. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Evidence-Based Critical Thinking Organizing and prioritizing Laboratory and diagnostic testing Diagnostic reasoning –Nursing diagnoses, outcomes, and interventions –Analyzing findings Collaborating with other health care professionals Pulling it all together: reflection and critical thinking

24. Copyright © 2011 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

25. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. 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.