Term
| Physiology of Respiration |
|
Definition
a. Inspiration occurs when diaphragm and external intercostal muscles contract
b. As intrapulmonary pressure drops, air rushes into the lungs until intrapulmonary and atmospheric pressure are equalized.
c. Oxygenated air is inhaled and in the alveoli oxygen is exchanged with the carbon dioxide in the blood and carbon dioxide is exhaled and the oxygen enters the blood stream and is brought to the heart (and systems)
|
|
|
Term
Relate surface landmarks of the thorax to underlying lung structures.
Apex
|
|
Definition
Posterior: C7 - T1 (bony prominance at base of neck)
Anterior: c - 4 cm above inner third of clavicles |
|
|
Term
Relate surface landmarks of the thorax to underlying lung structures.
Right horizontal fissure (anterior only) |
|
Definition
5th rib just posterior to midaxillary line to 4th rib at right sternal border
|
|
|
Term
Relate surface landmarks of the thorax to underlying lung structures.
Right Oblique Fissure |
|
Definition
a. Posterior: T3 to 5th rib midaxillary line
b. Anterior: 5th rib midaxillary line to 6th rib at midclavicular line
|
|
|
Term
Relate surface landmarks of the thorax to underlying lung structures.
Left Oblique Fissure
|
|
Definition
a. Posterior: T3 to 5th rib midaxillary line
b. Anterior: 5th rib midaxillary line to 6th rib at midclavicular line
|
|
|
Term
Relate surface landmarks of the thorax to underlying lung structures.
Base of Lungs
also landmark for diaphragm
|
|
Definition
Anterior: 6th rib at midclavicular line
Posterior: T10 - T12 (with inspiration) |
|
|
Term
Relate surface landmarks of the thorax to underlying lung structures.
Tracheal bifurcation
|
|
Definition
Anterior: Angle of Louis
Posterior: T4 - T5 |
|
|
Term
| Describe the technique to assess diaphragmatic excursio. What are the normal findings? What findings would be present with a pneumothorax? Pneumonia? |
|
Definition
| Diaphragmatic excursion: The level of diaphragm separating the lungs from the abdominal viscera. Have patient exhale and hold it. Percuss from scapular line until sound changes from resonant to dull on each side. Mark spot. Have patient take another deep breath and percuss from prior mark until sound changes from resonant to dull on each side. Mark spot. Remember the patient can’t hold their breath forever. Try doing this with own breath held as to not require the patient to hold their breath too long. a. Normal: Should be bilaterally equal and measure about 3 – 5 cm in adults (7 – 8 in well-conditioned adults) b. Pneumothorax: lag in expansion on one side, asymmetrical c. Pneumonia |
|
|
Term
| Describe the technique to assess thoracic expansion What are the normal findings? What findings would be present with a pneumothorax? Pneumonia? |
|
Definition
Thoracic expansion (detection easier to note on anterior chest) Anterior: place thumbs at costal martins, pointing toward xiphoid process. Pinch skin slightly together with the thumbs so the expansion is visible. Have patient take deep breath. Note expansion. Posterior: Same hand position (tub at T9 – T10) and process. approximately
a. Normal: Anterior / posterior thumbs separate 3 – 5 cm with deep inspiration, symmetrical
b. Pneumothorax: lag in expansion on one side, asymmetrical
c. Pneumonia: lag in expansion on one side, asymmetrical |
|
|
Term
| Describe the technique to assess tactile fremitus. What are the normal findings? What findings would be present with a pneumothorax? Pneumonia? |
|
Definition
| Tactile fremitus: Palpable vibration of thorax produced by talking. Patient repeats “99” while practitioner systematically palpates the thorax. Begin at apex (anterior and posterior), use palmar base (ball) of fingers or ulnar edge or hand or closed fist. Avoid scapulae. Compare both sides simultaneously or one at a time. a. Normal: (vibration) mild fremitus is normal. Varies from person to person. Symmetry is most important, but R> L is normal. More prominent in areas between scapulae and around sternum (bronchi are closest to wall) b. Pneumothorax: decreased fremitus. Barrier between lung and thoracic wall will obstruct c. Pneumonia: increased fremitus: compression / consolidation of tissue (bronchus patent). Decrease fremitus if bronchus obstructed. |
|
|
Term
Percussion Tones
Resonant |
|
Definition
|
|
Term
Percussion Tones
Dullness |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
Percussion Tones
Hyperresonant |
|
Definition
Lungs: normal in children
Adults: associated with air in pleural cavity |
|
|
Term
Adventitous Sounds
Crackles |
|
Definition
Crackling, popping sound
- usually located in periphery
- suggest secretions in periphery
- usually on inspiration
- do not clear with cough
- may be normal (atelectatic crackles) after sleep or in the elderly
|
|
|
Term
Adventitious Sounds
Rhonchi |
|
Definition
Low pitched wheeze or snorous rhonchi
- snorous bubbling sound
- usually expiratory, but may be inspiratory
- suggest secretions in large airway
|
|
|
Term
Adventitious Sounds
Wheezes |
|
Definition
Whistle like sound
- suggest narrowed airway from secretions, etc
- may be normal with maximum forced exhalation
- may be inspiratory or expiratory
|
|
|
Term
Adventitious Sounds
Friction Rub |
|
Definition
| Crackling / grating sound secondary to pleural irritation or inflammation |
|
|
Term
Adventitious Sounds
Absent Breath Sounds |
|
Definition
No sound
Seen with pneumothorax, obstruction, maxx |
|
|
Term
| Technique to assess vocal resonance |
|
Definition
Ask patient to repeat word or number while you listen through stethoscope in same areas as you would for general auscultation
Normal: spoken voice auscultates soft, muffled, indistinct
Abnormal: spoken word auscultates loud, clear, distinct |
|
|
Term
Relate blood circulation to the major structures in the heart.
|
|
Definition
Superior / inferior vena cava
Right atrium
Tricuspid (AV) valve
Right ventricle
Pulmonic valve
Pulmonary artery
Lungs
Pulmonary veins
Left atrium
Mitral (AV) valve
Left ventricle
Aortic valve
Aorta
Systemic vessels
Superior / inferior vena cava |
|
|
Term
| Name the major structures, location of the heart and great vessels |
|
Definition
a. Atrium: superior chambers
b. Ventricle: inferior chambers
c. AV Valves
a. Tricuspid
b. mitral
d. Semilunar valves
a. Aortic
b. Pulmonic
e. Great Vessels
a. Super / inferior Vena Cava
b. Pulmonary artery
c. Pulmonary veins
d. Aorta
|
|
|
Term
Describe the exam techniques and normal findings for assessment of the heart and carotid artery. Techniques…
Client Preperation
|
|
Definition
a. Quiet room
b. Good lighting
c. Assess in sitting, supine, Lateral, recumbent position
d. Sequence: inspect, palpate, auscultate
e. Move from apex to LSB to base
|
|
|
Term
Describe the exam techniques and normal findings for assessment of the heart and carotid artery. Techniques…
Head-to-toe systemic effects important to note
|
|
Definition
a. Skin: assess for edema, color, temperature
b. VS: BP, pulse
c. Nails: color, clubbing
d. Respiratory System: dyspnea, cough
|
|
|
Term
Describe the exam techniques and normal findings for assessment of the heart and carotid artery. Techniques…
Retractions, lifts, heaves
|
|
Definition
a. Retraction: pulling in of tissue on precordium related to position, activity of heart
i. Slight retraction at apical impulse normal; anywhere else abnormal
b. Lifts or heaves: sustained forceful thrust of ventricle during systole. Always abnormal
|
|
|
Term
Describe the exam techniques and normal findings for assessment of the heart and carotid artery. Techniques…
Palpation
|
|
Definition
a. Apical impulse
i. 4th to 5th intercostal space, left, midclavicular line
ii. 1 -2 cm in diameter
iii. Felt as short, gentle tap, may be able to see on inspection
b. Thrills: palpate only
i. Palpable vibration that signifies turbulent blood flow
ii. Felt best with ball of hand
|
|
|
Term
Describe the exam techniques and normal findings for assessment of the heart and carotid artery. Techniques…
Auscultation
|
|
Definition
a. Move apex to base or base to apex
b. Sitting, supine & L lateral position
c. Hold breath or breath normal
d. Use bell and diaphragm
e. Best sites to auscultate
i. Mitral: 5 ICS (L) MCL
ii. Tricuspid: 4 ICS (L)SB
iii. Erb’s point: aortic and pulmonic: 3 ICS (SB)
iv. Pulmonic: 2 ICS L(SB)
v. Aortic: 2 ICS (L) SB
f. S1
i. S1: closure of tricuspid and mitral valves
ii. Loudest at apex
iii. Beginning of ventricular systole
iv. Synchronous with carotid pulse
v. “lub”
g. S2
i. S2: closure of pulmonic and aortic valves
ii. Loudest at base
iii. Beginning of ventricular diastole
iv. “dub”
|
|
|
Term
Describe the exam techniques and normal findings for assessment of the heart and carotid artery. Techniques…
Peripherial Vascular System
|
|
Definition
|
|
Term
|
Definition
i. S1: closure of tricuspid and mitral valves
ii. Loudest at apex
iii. Beginning of ventricular systole
iv. Synchronous with carotid pulse
v. “lub”
|
|
|
Term
|
Definition
i. S2: closure of pulmonic and aortic valves
ii. Loudest at base
iii. Beginning of ventricular diastole
iv. “dub”
|
|
|
Term
| Split S1 sounds , etiology |
|
Definition
a. Asynchronous closure of mitral and tricuspid valve
b. Rare; may be normal or associated with disease
c. Etiology: ventricular pressure higher on left than right and depolarization faster on left
|
|
|
Term
|
Definition
a. During inspiration, intrathoracic pressure decreases
b. More blood is pushed into vena cava – therefore increasing venous return to the right side of the heart
c. Right ventricular stroke volume is increased – increased volume prolongs right ventricular systole and delays pulmonic valve closure
d. Meanwhile on the left side, more blood is sequestered in the lungs, decreasing left ventricular stroke volume
e. Left ventricular stroke volume is decreased, decreasing systole time in left ventricular; aortic valve closes earlier
f. Delayed pulmonic valve closure + early aortic valve closure = split S2
g. Split S2 may be normal and heard with inspiration; typically not fixed
h. Split S2 also associated with disease (atrial septal defect, right ventricular failure)
|
|
|
Term
What sound?
More to the right, less to the left
|
|
Definition
|
|
Term
|
Definition
S3 heard after S2 when tricuspid and mitral valves open and blood pours into ventricle during diastole
a. May be normal in kids and young adults; considered abnormal after age 40
b. May be associated with fluid overload, mitral / tricuspid incompetence, noncompliant cardiac muscle, high CO states such as pregnancy, anemia, cardiac failure (pathologic S3)
c. Occurs with early diastole
|
|
|
Term
|
Definition
heard just prior to S1 and associated with the atrial kick
a. Etiology: inflow of blood vibrates valves and structures of wall
b. May occur in middle age adults without CB disease after exercise; less likely to be found in well client
c. May be associated with decreased compliance of ventricle or valvular disease
d. Late diastole
|
|
|
Term
| Murmurs, sounds & etiology |
|
Definition
blowing, swishing sounds caused by turbulent blood flow through the heart
a. Innocent murmurs: without pathologic or structural abnormalities
b. Functional murmurs: physiologic alteration present causing murmur. (increased CO with exercise, pregnancy)
c. Pathologic murmur: structural abnormality causing murmur
d. Causes
e. Normal in first 2-3 days of life
f. Common in childhood 30% have innocent murmurs
g. Adolescent/young adults may also have innocent murmurs
h. Middle age/elderly – aortic systolic murmur common. 30% of 60-85 year olds have murmurs. 50% of 85+ have murmur
i. Grades on scale of i – vi
i. Grade i = soft
ii. Grade vi – audible with stethoscope, barely on chest
|
|
|
Term
| Pericardial rub: sounds & etiology |
|
Definition
inflammation of the pericardial and visceral surfaces rub together and produce a loud grating sound
a. Typically herd best at apex
|
|
|
Term
|
Definition
|
|
Term
Describe the technique used for jugular vein assessment, and etiology of normal and abnormal findings.
|
|
Definition
a. Indicates right heart activity and pressure
b. No neck veins are visible in healthy individual in siting positions, neck veins are slightly visible only if patient is in supine position
c. If unhealthy (right side heart failure), neck veins distended in sitting position
d. Have patient sit at 30 degrees
|
|
|
Term
Describe general inspection of the thorax and relate normal findings.
|
|
Definition
a. Transverse > anterior / posterior: no barrel chest
b. Ribs 45 degrees relative to spine
c. Spinous process straight: Abnormal: scoliosis, kyphosis, lordosis
|
|
|
Term
Describe palpation of the chest and normal findings.
|
|
Definition
a. Palpate for: pain/tenderness, masses/lesions, bulges, skin tem/moisture. Normal: no m/l/t, skin warm and dry
|
|
|
Term
|
Definition
| Found in the majority of lung tissue anterior and posterior |
|
|
Term
| Bronchovesicular breath sounds |
|
Definition
| found in bronchi, first and second interspaces anteriorly (especially on right), between scapulae on posterior |
|
|
