Practical 2

Question 1

List muscles of inspiration

Answer 1

Diaphragm, external intercostals

Question 2

List accessory muscles of inspiration

Answer 2

SCM, Scalenes, Upper Trap, Pec Major, Pec Minor, Serratus Anterior, Rhomboids, Latissimus Dorsi, Serratus Posterior Superior, Thoracic Erector Spinae

-inspiration is always active

Question 3

List muscles of expiration

Answer 3

Abdominal Muscles, Internal Intercostals (forced expiration)

-normally passive from elastic recoil of lung and relaxation of inspiration musculature, unless it is forced

Question 4

Define respiration

Answer 4

Respiration – Gas Exchange – occurs at the alveolar-capillary interface, replenishing the blood’s oxygen supply and removing carbon dioxide. (Perfusion)

Question 5

Define ventilation

Answer 5

Ventilation - Breathing – the mechanical movement of gases into and out of the lungs

Question 6

List chart review points

Answer 6

• Primary and secondary diagnoses
• Vital signs history: BP, HR, RR, temp, SpO2, telemetry if indicated
• Medications
• Reports: CXR, ABG’s, PFT’s, smoking history, environmental exposure, nutritional status, psychological history

Question 7

List general observation

Answer 7

general appearance, positioning (professorial posturing), equipment/lines in place, facial characteristic (nasal flaring, pursed lip breathing), appearance of extremities (digital clubbing, signs of decreased peripheral circulation)

Observe bony landmarks, sternum, ribs, clavicles and scapula and note any deviations.

Compare AP and transverse diameter of chest by observation (AP diameter is ½ transverse diameter)

Hyperinflation of chest - COPD

Question 8

AP diameter of chest is normally ____ compared to transverse diameter?

Answer 8

AP is 1/2 diameter of transverse

Question 9

What could it mean if the chest’s AP diameter is equal to the transverse diameter?

Answer 9

Hyperinflated
Barrel-like = COPD
Diaphragm is flatter and less effective

Question 10

Normal rib angle expectations?

Answer 10

(assessed in sidelying)

norm = less than 90 degrees; attached to t-process of vertebra at 45 deg. angle

Question 11

Rib angle expectations for COPD/Hyperinflation?

Answer 11

the rib angles will be >90 degrees and ribs will attach to the vertebrae at >45 degrees

Question 12

State effect of hyperinflated chest on diaphragm function

Answer 12

• Hyperinflation results in rib angles greater than 90 degrees and attachments to vertebrae greater than 45 degrees, changing diaphragm effectiveness
• Hyperinflated chest leads to greater air in abdominal cavity that flattens the diaphragm and makes it less effective

Question 13

Conditions in which chest expansion may be diminished.

Answer 13

COPD, pulmonary fibrosis

Question 14

Conditions in which chest expansion may be asymmetrical.

Answer 14

Neurological impairments, or in post-surgical patients, and rib/hip fractures with splinting due to pain.

Question 15

4 phases of coughing

Answer 15

1. Inspiration,
2. Hold/closure of glottis,
3. Force from contraction of abdominal and intercoastal mm,
4. Expulsion/effectiveness

Question 16

4 things to look for with sputum assessments.

Answer 16

Volume, color, odor and consistency

Question 17

Describe procedure for auscultating lungs.

Answer 17

Sit the pt upright in sitting

Auscultate of the entire lung space (spaces designated on diagram - make sure there is at least one breath in between each bronchopulmonary segment

Progress cranial to caudal

Compare intensity, pitch and quality between R and L

Be systematic – from anterior to posterior

Question 18

List 4 normal breath sounds

Answer 18

1. Tracheal
2. Bronchial
3. Bronchiovesicular
4. Vesicular

Question 19

Where would you find a tracheal breath sound and what would it sound like?

Answer 19

over trachea (not routine) - loud, high pitched and hollow

Question 20

Where would you find a bronchial breath sound and what would it sound like?

Answer 20

just lateral to manubrium over mainstem bronchi - tubular, loud, high pitched, pause between insp and exp

Question 21

Where would you find a bronchiovesicular breath sound and what would it sound like?

Answer 21

junction of the mainstream bronchi with segmental bronchi; between 1st and 2nd intercostal space, posteriorly between scapulae - similar to bronchial but softer and with no pause between insp and exp

Question 22

Where would you find a vesicular breath sound and what would it sound like?

Answer 22

throughout lung parenchyma - soft, low-ptiched, no break between insp and exp sounds, heard primarily during insp

Question 23

List 3 adventitious lung sounds?

Answer 23

1. Wheezing
2. Crackles
3. Pleural rub

Question 24

Describe wheezing

Answer 24

most frequently heard on expiration, associated with airway obstruction- if on inspiration indicates more severe airway obstruction. Is specifically either high pitched or low-pitched. If continued sound in someone with airway obstruction is called stridor

Question 25

Describe crackles

Answer 25

common heard during inspiration may mean restrictive or obstructive respiratory disorder, could be from sudden opening of closed airways or due to movement of secretions. Discontinuous sounds, sound like brief bursts of popping bubbles

Question 26

Describe pleural rub

Answer 26

sounds like 2 pieces of leather or sandpaper rubbing together, occurs with insp and exp. Can indicate pleural inflammation.

Question 27

Describe egophony

Answer 27

patient is asked to say “E” and the sound is auscultated as “A” over consolidated areas.

Question 28

Describe bronchophony

Answer 28

patient is asked to say “99”. Over healthy lung it is not understandable. Over consolidated areas it is auscultated clearly.

Question 29

Describe whispering petroliloguy

Answer 29

patient is asked to whisper and whispered words are heard distinctly through the stethoscope. Over healthy lung, whispering is unintelligible.

Question 30

An increase in lung tissue density (consolidation) may cause ____ sound transmission.

Answer 30

increased

Question 31

A decrease in lung tissue density (emphysema) can cause ____ sound transmission.

Answer 31

decreased

Question 32

Give instructions for splinted coughing.

Answer 32

Hold a pillow or folded towel over surgical incision and push on your incision when coughing

Question 33

State when splinted cough may be indicated

Answer 33

Post-operatively with sternotomy, thoracotomy and abdominal surgical incisions. Reduces pain and improves cough.

Question 34

Instruct in diaphragmatic breathing

Answer 34

Start in supine position with posterior pelvic tilt Can position pt.’s hands on their abdomen for feedback Ask pt. To “sniff” to move diaphragm. Try 3 sniffs, then exhale. String together sniffs, then try one long sniff. Can progress using above techniques in sitting, standing, walking, functional activities

Question 35

What muscles do COPD patients use and why might diaphragmatic breathing not work with them?

Answer 35

They use accessory muscles b/c that is all they have. Diaphragm is flattened and inefficient so may not work well enough.

Question 36

Describe postural drainage

Answer 36

Positioning the body to allow gravity to assist with draining secretions from each of the lung segments

Question 37

List precautions for postural drainage.

Answer 37

pulmonary edema, hemoptysis, massive obesity, large pleural effusion, massive ascites (fluid build-up)

Question 38

List contraindications for postural drainage.

Answer 38

Increased intracranial pressure, hemodynamically unstable, recent esophageal anastomosis, spinal fusion or injury, recent head trauma, diaphragmatic hernia, recent eye surgery (prone position)

Question 39

List precautions for percussion or vibration.

Answer 39

uncontrolled broncospasm, osteoporosis, rib fractures, metastatic cancer to ribs, tumor obstruction of airway, anxiety, coagulopathy, convulsive or seizure disorder, recent pacemaker placement

Question 40

List contraindications for percussion or vibration.

Answer 40

Hemoptysis, untreated tension pnuemotnorax, platelet amount less than 20,000 / mm3, hemodynamically unstable, open wound burns in thoracic area, pulmonary embolism, subcutaneous emphysema, recent skin grafts on flaps of thorax

Question 41

Best position for patient with intercostal weakness.

Answer 41

Supine

Question 42

Best position for patient with kyphosis

Answer 42

Supine

Question 43

Best position for patient with limited diaphragmatic excursion

Answer 43

Supine

Question 44

Best position for patient with R lower lobe pneumonia

Answer 44

S/L

Question 45

Best position for patient with partial R paralysis (extremities and trunk).

Answer 45

S/L

Question 46

Best position for patient with weak spinal extensors

Answer 46

Sitting

Question 47

Best position for patient with COPD, significant accessory muscle use, rapid RR....and why?

Answer 47

Supine - puts the patient in a gravity eliminated position for both the diaphragm and accessory muscles for gas exchange

Question 48

Best position for patient with CVA, left sided weakness and tightness and limited L lateral costal expansion...and why?

Answer 48

L S/L - to allow the patient to let the R side expand for easier respiration * R S/L - for intervention

Question 49

Best position for patient s/p CABG (3 months) w/limited pec range, upper chest tightness

Answer 49

Sitting - to encourage more diaphragmatic breathing so gravity can facilitate the muscle OR Supine - gravity eliminated for upper accessory muscles and for diaphragm

Question 50

Best position for pediatric patient with CP, generally limited chest wall mobility

Answer 50

SITTING/STANDING - to support breathing in the diaphragm due to limited chest wall excursion OR SUPINE - gravity eliminated for upper accessory muscles and for diaphragm

Question 51

Best position for patient post-op thoracotomy with poor inspiratory effort, poor cough effort, shallow, upper chest breathing pattern.

Answer 51

SITTING/STANDING - to support diaphragmatic breathing and proper swallowing