1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 18Thorax and Lungs Assessment

2. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 (T1 to T12) Phrenic nerve Intercostals nerves

3. 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

4. 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

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

6. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology Overview (cont.) Posterior thoracic landmarks –Less important –Vertebral processes –Spinous process of T1 –Lower tip of the scapula –11th floating rib –12th floating rib

7. 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

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

9. 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

10. Copyright © 2012 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) Anatomy and Physiology Overview (cont.)

11. 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

12. 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

13. 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

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

15. 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 2nd rib.

16. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Lifespan Considerations Women who are pregnant Infants and children Older adults Cultural considerations

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. 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.