Jarvis Chapter 18 Study Guide

Lungs and Thorax

Medical terminology:
Alveoli small outpouchings along the walls
of the alveolar sacs and alveolar ducts;
through them, gas exchange takes place
between alveolar gas and pulmonary
capillary blood.
Apnea cessation of breathing, especially
during sleep.
Asthma Reactive Airway Disease is an
allergic hypersensitivity to certain inhaled
allergens, irritants, microbes, stress or
exercises. Produces complex response
characterized by bronchospasm and
inflammation, edema in walls of
bronchioles and secretion of highly viscous
mucus into airways. These factors greatly
increase airway resistance, esp. during
expiration. Symptoms: wheezing, dyspnea
and chest tightness.
Atelectasis, Collapsed shrunken section of
alveoli or an entire lung as a result of
airway obstruction, compression of the
lung, lack of surfactant
Angle of Louis an anatomical landmark
located on the sternum; it can be felt as a
notch or ridge at the top of the sternum.
Bradypnea slow breathing. A decreased
but regular rate (<10 per minute), as in
drug induced depression of the respiratory
center in the medulla, increased intracranial
pressure, and diabetic coma.
Bronchiole: one of the successively
smaller channels into which the segmental
bronchi divide within the
bronchopulmonary segments.
Bronchitis is an acute infection of the
trachea and larger bronchi characterized by
cough (lasting up to 3 weeks, for acute).
Acute is viral, chronic caused by smoking.
Bronchophony: Increased intensity and
clarity of voice sounds heard over a

Consolidation - lung as it fills with

exudate in pneumonia.
Crackles discontinuous, popping sounds
heard over inspiration.
Crepitus: coarse, crackling sensation
palpable over the skin surface. It occurs in
subcutaneous emphysema when air escapes
from the lung and enters the subcutaneous ,
as after openthoracis injury or surgery.
Dyspnea: breathlessness or shorthess of
breath; labored or difficult breathing. It is a
sign of a variety of disorders and is
primarily an indication of inadequate
ventilation or of insufficient amounts of
oxygen in the circulating blood
Egophony: auscultation of chest while
person phonates a long ee-ee sounds
Emphysema caused by destruction of
pulmonary connective tissue; characterized
by permanent enlargement of air sacs distal
to terminal bronchioles and rupture of
interalveolar walls. Airway resistance on
expiration increased, producing a
hyperinflated lung.
Fremitus: a vibration perceptible on
palpation or auscultation;
Pleural friction rub: produced when
inflammation of the parietal or visceral
pleura causes a decrease in the normal
lubricating fluid. The opposing surfaces
make a coarse grating sound when rubbed
together during breathing.
Hypercapnia: excessive carbon dioxide in
the blood
Hyperventiliation: abnormally fast and
deep breathing, the result of either an
emotional state or a physiological condition
Hypoxemia: deficient oxygenation of the
blood

bronchus surrounded by consolidated lung

tissue. Normal voice is muffled and
indistinct; abnormal words distinct and
sound close to heart.
Bronchovesicular over major bronchi
where fewer alveoli are located.

Intercostal space: the space between two

adjacent ribs.
Orthopnea: difficulty breathing when
supine
Paroxymal Nocturnal Tachypnea is
awakening from sleep with SOB and
needing to be upright to achieve comfort
Vesicular breath sounds: the gentle
rustling sounds of normal breathing heard
by auscultation over most of the lung
fields; the inspiratory phase is usually
longer than the expiratory.
Wheezes: a continuous musical sounds
heard over expiration.

List subjective questions are important to ask when obtaining a health history:
1. COUGH
Is there cough, when did it start, gradual or sudden, how long, how often,
what time of day or night?
Phlegm or sputum, how much, what color
Cough up blood? If so, streaks or frank blood? Is there foul odor?
Describe cough: hacking, dry, barking, hoarse, congested, bubbling?
Does cough seem to come with anything (activity, position, fever,
congestion, talking, anxiety)? Does activity make it better or worse?
Which treatment has been tried (prescription or OTC, vaporizer, rest,
position change). Does the cough bring any pain in chest or ear? Is it
tiring?
2. SHORTNESS OF BREATH (SOB)
Have you had any shortness of breath, do you have it now, or in the last day?
When did it start, what brings it on, how severe is it, how long does it last?
Is it affected by position (lying down)?
Does it occur at any specific time of day or night?
SOB episodes associated with night sweats? diaphoresis
Or cough, chest pain, bluish color arp9ound lips or nails?
Episodes related to food, pollen, dust, animals, season, emotion or exercise?
What do you do in a hard-breathing attack? (special position pursed lips
breathing, oxygen, inhalers or medications?)
How does SOB affect your work or home activities?
3. CHEST PAIN W/BREATHING

Is there chest pain, point exact location to distinguish from cardiac origin chest
pain and heartburn chest pain.
When did it start, constant or comes and goes?
Describe pain: burning, stabbing?
What brought it on: resp.infection, coughing, trauma? Is it associated w/fever,
deep breathing, unequal chest inflation
What have you done to treat it? (medication, heat application)
4. HISTORY OF RESP. INFECTIONS
Any past history of breathing trouble or lung diseasessuch as bronchitis,
emphysema, asthma, pneumonia?
Any unusually frequent or severe colds?
Family history of allergies, TB or asthma?
5. SMOKING HISTORY
Do you smoke cigarettes/cigars? At what age did you start? How many packs per
day do you smoke now? How Long?
Have you ever tried to quit? What helped? Why do you think it did not work?
What activities do you associate with smoking? Do you live with someone who
smokes?
6. ENVIRONMENTAL SMOKE
Are there any environmental conditions that may affect your breathing? Where do
you work? At a factory, chemical plant, coal mine, farming, outdoors in a heavy
traffic?
Do you do anything to protect your lungs (mask or ventilator system at work)? Do
you do anything to monitor your exposure? Do you have periodic examinations,
pulmonary function tests, x-ray image?
Do you know which specific symptoms to note that may signal breathing
problems?
7. PATIENT CENTERED CARE
Last TB skin test, chest x-ray study, pneumonia vaccine or influenza immunization?
CHILDREN: what have you done to child-proof your home and yard? Is there
any possibility of the child inhaling or swallowing toxic substances? Has anyone
reviewed with you that small things are choking hazards? Has anyone taught you
emergency care measures in case of accidental choking or a hard-breathing spell?
Any smokers in home or car w/child?
AGING ADULT: SOB or fatigue with daily activities? Tell me about your usual
amount of physical activity. (History of COPD, lung cancer or TB): How are you
getting along each day? Any weight change in the past 3 months? How much?
How about energy level? Do you tire more easily? How does your illness affect
you at home or work?
Do you have any chest pain w/breathing? Any chest pain after a bout of
coughing? After a fall?
Know how and why a nurse would apply the following objective assessments:

Anterior/posterior to transverse ratio- What would a barrel chest signify? How

does the AP/Transverse ratio change with a barrel chest?
Barrel chest occurs in COPD because the lungs are chronically overinflated with
air, so the rib cage stays partially expanded all the time. This makes breathing less
efficient and aggravates shortness of breath. The anteriorposterior diameter (AP)
should be less than the transverse diameter (.70 to .75 in adults). In barrel chest
AP=transverse.

Skin color, condition and patient position:

Skin color should be consistent with persons genetic background, with
allowance for sun-exposed areas on chest and back. No cyanosis or pallor should
be present. Any lesions should be noted, inquire about any change in a nevus on
the back (where the persona may have difficulty monitoring). Cyanosis occurs
with hypoxia.
Chest expansion:
Symmetric chest expansion confirmed by placing your warmed hands sideways
on posterolateral chest wall with thumbs pointing together at the level of T9 or
T10. Slide your hands medially to pinch up a small fold of skin between your
thumbs, ask the person to take deep breath. Hands serve as a mechanical amplifier
as person inhales deeply, your thumbs should move apart symmetrically. Note any
lag in expansion. Unequal chest expansion occurs with marked atelectasis, lobar
pneumonia, pleural effusion, thoracic trauma such as fractured ribs or
pneumothorax. Pain accompanies deep breathing when pleurae are inflamed.

Tactile fremitus:
Access tactile or vocal fremitus, this is a palpable vibration. Use either ball of
fingers or ulnar edge of one hand and touch the persons chest while he or she
repeats the words ninety nine or blue moon. Start over lung apices and
palpate from one side to another. Symmetry is most important vibrations should
feel the same in the corresponding area on each side. Avoid palpating over
scapulae because bone will damp out sound transmission. Fremitus is most
prominent between the scapulae and around the sternum (where major bronchi are
closest to the chest wall), and normally decreases as you progress down because
more and more tissue impedes sound transmission. Decreased fremitus occurs
with obstructed bronchus, pleural effusion or thickening, pneumothorax, or
emphysema. Increased fremitus occurs with compression or consolidation of lung
tissue (like in lobar pneumonia). Rhoncal fremitus is palpable with thick bronchial
secretions. Pleural friction fremitus is palpable with inflammation of the pleura.

Percussion: when and why would resonance and dullness be present?

Resonance is the low-pitched, clear, hollow sound that predominates in healthy lung
tissue in the adult. However, it is a relative term and there is no constant standard, i.e. it
may be duller in an athlete with heavily muscular chest wall or in a heavily obese adult
with subcutaneous fat. Asymmetry in percussion is important as it indicates underlying
disease. Hyperresonance is a lower-pitched, booming sound found when too much air is

present (emphysema or pneumothorax). A dull note, soft, muffled thud, signals

pneumonia, pleural effusion, atelectasis or tumor.
Understand where to auscultate for normal bronchial, broncho-vesicular and vesicular
breath sounds.
Bronchial (tracheal) trachea and larynx
Bronchiovesicular over major bronchi where fewer alveoli are located:
Posterior - between scapulae (esp. on right)
Anterior around upper sternum in 1st and 2nd intercostal spaces
Vesicular over peripheral lung fields where air flows through smaller bronchioles and
alveoli