Nursing 460, Week 1 Notes
Nursing 460, Week 1 Notes 460
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This 5 page Class Notes was uploaded by ndp33 on Thursday July 7, 2016. The Class Notes belongs to 460 at Niagara University taught by in Summer 2016. Since its upload, it has received 7 views. For similar materials see Nursing Concepts IV: Health of Maturing Adults / Chronic Disease in Nursing and Health Sciences at Niagara University.
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Date Created: 07/07/16
The Chest What is the Apex of the Lung? The top part of the lungs What is the Base of the lung? The bottom part of the lungs How many lobes does the right lung have? 3 lobes (right, middle, lower) How many lobes does the left lung have? 2 lobes (upper, lower) Where does the Apex of the lung lie anteriorly? Anteriorly, the apex of the lung lies above the clavicle. Where does the base of the lung lie anteriorly? Anteriorly, the base of the lung lies at the level of the 6 rib at the midclavicular line. Posteriorly, where does the apex and base lie? Posteriorly, the apex lies at the cervical area, and the base lies at the 10 thoracic vertebral area. Name the anterior, lateral and posterior lines of reference: Anterior lines of reference include: midsternal (middle of the sternum) and midclavicular (middle of the clavicle); lateral line of reference include: midaxillary; posterior lines of reference include: midscapular and midspinal. During inspiration, what do the externa intercostal muscles do? The external intercostal muscles contract, assisting the diaphragm with respiration. (The intercostal muscles pull the rib cage up, further expanding the rib cage and lung volume, as the diaphragm is pulled down, increasing the intrathoracic pressure of the thoracic cavity.) During expiration, what do the internal intercostals do? The internal intercostal muscles contract, pulling the ribs downward, assisting the diaphragm with breathing. (The diaphragm relaxes (or is pulled upward), decreasing the intrathoracic pressure of the thoracic cavity.) Define the following: barrel chest = A chest that is rounded or barrelshaped; has an increased AP diameter, and has not apparent movement during respiration CheyneStokes respirations= breathing that starts slow and shallow, increases in rapidity and depth until it reaches a maximum, and then decreases gradually until it stops for a period of apnea( usu for 10 to 20 seconds). The cycle repeats itself. kussmaul respirations = increase in respiratory rate (over 20 breathes/minute)and a change in depth in respirations. In your chest assessment you do the following: IPPA INSPECTION—state what you would evaluate A.Observe anteriorly and posteriorly for: rate, rhythm, and quality of respirations; counting the respirations for 1 minute; check the breathing pattern; depth and noise (whether it is shallow, noisy, labored); check whether the respirations are a result of a diaphragmatic contraction or abdominal; check for retractions of intercostal muscles, internasal flaring, presence of anxiety B. Chest configuration, size, shape; AP diameter (which should be 1:2) C.skin color; edema; any clubbing of the fingernails (at 180 degrees or greater); (The following 2 questions are not in the link, you can find them in any assessment book) What does pectus excavatum mean? What does pectus carinatum mean? This is in reference to the Normal A/P diameter PALPATION A.Palpate the skin, trachea, thorax, and ribs for lesions, tenderness, and skin temperature. B.Palpate the costal angle (the area at which the ribs meet the sternum anteriorly). C.Palpate respiratory excursion (to check for symmetric thoracic expansion) posteriorly. D.Use the tactile fremitus technique posteriorly on the lungs bilaterally, all the way down to the bases. (If decreased, a mass or fluid could be present). What is respiratory excursion? A technique used to check for symmetric respiratory expansion When would tactile fremitus increase/decrease? If a fluid or mass is present PERCUSSION A.Percuss lung boundaries and contents (which may be 23 inches deep on someone muscular or obese) B.Note differences in sounds, from tympany over lungs to flatness dullness over heart, muscle and bone. C.Follow a sequence in percussing. Start, at the apex of the lungs, percuss bilaterally and progress every 45 cm in order to compare both sides of the lungs for sound. Percuss the lateral sides of the lungs as well. D.Assess for diaphragmatic excursion, normal at 35 cm. Have the patient inhale, percuss from the upper lumbar area of the patient’s back towards the apex of the lungs. Once you here a difference in sound from dull to resonance, have the patient exhale normally, and mark your area. Then, have the patient inhale normally again, percuss from the lumbar area toward the bases, note where there is a difference in sound from dull to resonance. Have the patient exhale normally, and mark this area. Measure the distance between your marks. Normal diaphragmatic excursion is 35 cm. Define resonance and where you would percuss this Resonance is a hollowtype sound heard upon percussion. You would percuss this over the lungs fields Where would you percuss flat or dull sounds? You would percuss for these over the heart, muscle, and bones. AUSCULTATION A Listen for distinct sounds with the stethoscope during the patient’s respirations. B Instruct the patient to take breathes through the mouth at their own rate C Ausculate in the same sequence as that of percussion(starting at the apex and moving every 45 cm downward toward the bases, comparing lung sounds bilaterally, while also covering the lateral areas.) Note: The lateral area is where you hear the middle lobe of the right lung D Normal breath sounds are: bronchial (in the upper lungs), bronchiovesicular (in the midlungs), and vesicular (in the lower lungs). Bronchial sounds are highpitched, loud, and harsh; bronchivesicular sounds are moderate and mixed; vesicular sounds are low, soft, and rusting (like wind through leaves on a tree.) Where do you normally hear vesicular sounds and what is the ratio of Inspiration to expiration? In the lower lungs; ratio of inspiration to expiration is: 31 Where do you normally hear bronchial sounds and what is the ration of I to E? In the upper lungs; I:E ratio is 1:3 What do wheezes sound like and when would you hear them? Wheezes sound highpitched and musicallike, like a sqeauk ,during inspiration or expiration. You would hear them in narrowed airway disease such as asthma and emphysema. Rhonchi—low-pitched, loud, coarse, low snoring, moaning sound heard during inspiration or expiration (mainly expiration) from the narrowing of the large airways or from a bronchial obstruction Crackles Bubbling, popping, crackling sound during inspiration; can be coarse or fine; heard when there is fluid or consolidation in lungs, such as pneumonia, CHF Pleural Friction Rub—dry- rubbing, grating sound on both inspiration and expiration from the inflammation of the pleural spaces Define: Bronchophony: abnormal voice resonance , indicating increased lung density (the patient saying the word 99, as you are comparing both sides of the lungs, should barely be heard saying it, but instead, it comes out clearly) Egophony: increasd resonance of voice sounds heard during auscultation; a long “a” is heard when the patient is asked to say “e” as you are auscultating the lung fields on both sides for comparison; this can indicate increased tissue mass or inflammation Whispered Pectoriloqy Tests for increased consolidation while auscultating over the lung fields and the patient whispers “99;” if the whisper is heard clearly instead of as a faint, muffled, almost inaudible sound, this could indicate consolidation When would you hear hyperresonant breath sounds? emphysema, asthma, pneumothorax When would you hear decreased breath sounds? emphysema, pneumothorax, atelectasis, pneumonia When would have increased tactile fremitus? bronchophony, egophony and whispered pectoriloquy? lobar pneumonia What would you notice in the elderly patient pertaining to the AP diameter? AP diameter would increase
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