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Chapter 18Thorax and Lungs
Assessment
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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 (T1 to T12)
• Phrenic nerve
• Intercostals nerves
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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
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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
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Anatomy and Physiology Overview (cont.)
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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
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Anatomy and Physiology Overview (cont.)
• Reference lines
– Anterior
• Midsternal
• Midclavicular
• Anterior axillary lines
–
Posterior
• Vertebral line
• Scapular line
• Posterior axillary line
• Midaxillary line
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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
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Anatomy and Physiology Overview (cont.)
• Lobes of the lungs
– Upper, middle, and lower lung fields
– Base
– Apex
– Auscultate
– Anteriorly
– Posteriorly
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Anatomy and Physiology Overview
(cont.)
• Lower respiratory tract
– Trachea bifurcates
– Right main bronchus
– Dead space
– Bronchioles
– Breath sounds
– Alveoli
– Pulmonary arterioles
– Pulmonary thromboembolism (PE)
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Anatomy and Physiology Overview (cont.)
• Lower respiratory tract (cont.)
– Pleurae
• Visceral pleurae
• Parietal pleura
• Pleural space
– Mediastinum
– Pulmonary cavities
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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
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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
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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
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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.
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Lifespan Considerations
• Women who are pregnant
• Infants and children
• Older adults
• Cultural considerations
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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
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Subjective Data Collection
• Begins with the health history
• Areas for health promotion
– Patient education, health promotion, and risk
reduction
• Assessment of risk factors
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Subjective Data Collection (cont.)
• Risk assessment and health promotion
– Smoking cessation
– Prevention of occupational exposure
– Prevention of asthma
– Immunizations
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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
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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
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Objective Data Collection (cont.)
• Lifespan considerations
– Women who are pregnant
– Newborns, infants, and children
– Older adults
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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
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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
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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.
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