chapter 52

1. adventitious breath sounds<br />Abnormal lung sounds heard when listening to the chest as the person breathes. These may be wheezes, crackles (rales), or stridor. They do not include sounds produced by muscular activity in the chest wall or friction of the stethoscope on the chest. <br />crackle<br />An adventitious lung sound heard on auscultation of the chest, produced by air passing over retained airway secretions or the sudden opening of collapsed airways. It may be heard on inspiration or expiration. A crackle is a discontinuous adventitious lung sound as opposed to a wheeze, which is continuous. Crackles are described as fine or coarse.<br />coarse crackles<br />Louder, rather long, low-pitched lung sounds. Coarse inspiratory and expiratory crackles indicate excessive airway secretion. <br />fine crackles<br />Soft, very short, high-pitched lung sounds. Fine, late-inspiratory crackles are often heard in pulmonary fibrosis and acute pulmonary edema. <br />diminished breath sound<br />A soft, decreased, or distant vesicular lung sound as heard through a stethoscope. <br />ETIOLOGY Diminished breath sounds are common in patients with poor respiratory effort, splinting, emphysema, and other lung conditions. <br /> bronchial sounds<br />Sounds not heard in the normal lung but occurring in pulmonary disease, indicating infiltration and solidification of the lung. <br />pleural friction rub<br />The creaking, grating sounds made when inflamed pleural surfaces move during respiration. It is often heard only during the first day or two of a pleurisy. <br />Rhonchus/Rhonchi<br />pl. A low-pitched wheezing, snoring, or squeaking sound heard during<br />auscultation of the chest of a person with partial airway obstruction.Mucus or other secretions in the airway, bronchial hyperreactivity, or tumors that occlude respiratory passages can all cause rhonchi. <br />adventitious lung sounds<br />Crackles and wheezes superimposed on the normal breath sounds; indicative of respiratory disease. Most adventitious lung sounds can be divided into continuous (wheezing) and discontinuous (crackles) according to acoustical characteristics. <br />apnea<br />[″ + pnoe, breathing] Temporary cessation of breathing and, therefore, of the body's intake of oxygen and release of carbon dioxide. It is a serious symptom, esp. in patients with other potentially life-threatening conditions. <br />bradypnea<br />[″ + pnoe, breathing] Abnormally slow breathing.<br />BREATHING PATTERN, INEFFECTIVE<br />BREATHING PATTERN, INEFFECTIVE<br /> Diagnostic Division: Respiration Definition: Inspiration and/or expiration that does not provide adequate ventilation. <br />RELATED FACTORS Neuromuscular dysfunction; Spinal cord injury; Neurological immaturity; Musculoskeletal impairment; Bony/chest wall deformity; Anxiety [/panic attack]; Pain; Perception/cognitive impairment; Fatigue; [Deconditioning]; Respiratory muscle fatigue; Body position; Obesity; Hyperventilation; Hypoventilation syndrome; [alteration of patient's normal O2 : CO2 ratio (e.g., O2 therapy in COPD)] <br />DEFINING CHARACTERISTICS Subjective [Feeling breathless] Objective Dyspnea; Orthopnea; Bradypnea; Tachypnea; Alterations in depth of breathing; Timing ratio; Prolonged expiration phases; Pursed-lip breathing; Decreased minute ventilation/vital capacity; Decreased inspiratory/expiratory pressure; Use of accessory muscles to breathe; Assumption of three-point position; Altered chest excursion, [paradoxical breathing patterns]; Nasal flaring; [Grunting]; Increased anterior-posterior diameter<br />bronchovesicular sounds<br />A mixture of bronchial and vesicular sounds. <br />Bruits<br />A blowing or swishing sound created by turbulence of blood flow<br />Capillary refill test<br />Immediate return of color<br />clubbing<br />An enlarged terminal phalanx of the finger. Excessive growth of the soft tissues of the ends of the fingers gives the fingers a sausage or drumstick appearance when viewed from above, and a beaked appearance when viewed from the side. Increased soft tissue is deposited beneath the cuticle, resulting in a fingertip that is thinner at the distal interphalangeal joint than at the base of the nail. Clubbing may be present in chronic obstructive pulmonary disease, interstitial fibrosis of the lungs, cyanotic congenital heart disease, carcinoma of the lung, bacterial endocarditis, and many other illnesses. SYN: clubbed finger; ; hippocratic finger <br />cyanosis<br />[″ + osis, condition] A blue, gray, slate, or dark purple discoloration of the skin or mucous membranes caused by deoxygenated or reduced hemoglobin in the blood. Cyanosis is found most often in hypoxemic patients and rarely in patients with methemoglobinemias. Occasionally, a bluish skin tint that superficially resembles cyanosis results from exposure to the cold. In the very young patient, cyanosis may point to a congenital heart defect. <br />ETIOLOGY This condition usually is caused by inadequate oxygenation of the bloodstream. <br />TREATMENT Supplemental oxygenation is supplied to cyanotic patients who are proven to be hypoxemic. See: asphyxia <br />Oximetry or arterial blood gas analysis should be used to determine whether a patient is adequately oxygenated. Relying only on the appearance of the skin or mucous membranes to determine hypoxemia may result in misdiagnosis. <br />deep venous thrombosis D.V.T.<br />A blood clot in one or more of the deep veins of the legs (the most common site) or the veins of arms, pelvis, neck, axilla, or chest. The clot may damage the vein or may embolize to other organs (e.g., the heart or lungs). Such emboli are occasionally fatal. See: embolism, pulmonary <br />ETIOLOGY DVT results from one or more of the following conditions: blood stasis (e.g., bedrest); endothelial injury (e.g., after surgery or trauma); hypercoagulability (e.g., factor V Leiden or deficiencies of antithrombin III, protein C, or protein S); congestive heart failure; estrogen use; malignancy; nephrotic syndrome; obesity; pregnancy; thrombocytosis; or many other conditions. DVT is a common occurrence among hospitalized patients, many of whom cannot walk or have one or more of the other risk factors just mentioned. <br />SYMPTOMS The patient may report a dull ache or heaviness in the limb, and swelling or redness may be present, but just as often patients have vague symptoms, making clinical diagnosis unreliable. <br />DIAGNOSIS Compression ultrasonography is commonly used to diagnose DVT (failure of a vein to compress is evidence of a clot within its walls). Other diagnostic techniques include impedance plethysmography and venography. <br />TREATMENT Unfractionated heparin or low molecular weight heparin (LMWH) is given initially, followed by several months of therapy with an oral anticoagulant such as warfarin. The duration of therapy depends on whether the patient has had previous thrombosis and whether, at the end of a specified period of treatment, the patient has an elevated D-dimer level: patients with increased D-dimers after several months of treatment with anticoagulants are more likely than other patients to have recurrent clots if their anticoagulant regimen is discontinued.. <br />COMPLICATIONS Pulmonary emboli are common and may compromise oxygenation or result in frank cardiac arrest. Postphlebitic syndrome, a chronic swelling and aching of the affected limb, also occurs often. <br />PREVENTION In hospitalized patients and other immobilized persons, early ambulation, pneumatic compression stockings, or low doses of unfractionated heparin, LMWH, or warfarin may be given to reduce the risk of DVT. <br />edema<br />oedema pl. [Gr. oidema, swelling] A local or generalized condition in which body tissues contain an excessive amount of tissue fluid in the interstitial spaces. Ascites and hydrothorax and pericardial effusion are words for third spacing of excess fluid in the peritoneal and pleural cavities and the pericardium, respectively. Generalized edema was previously termed dropsy; it is now known as anasarca. <br />ETIOLOGY Edema may result from increased permeability of the capillary walls; increased capillary pressure due to venous obstruction or heart failure; lymphatic obstruction; disturbances in renal function; reduction of plasma proteins; inflammatory conditions; fluid and electrolyte disturbances, particularly those causing sodium retention; malnutrition; starvation; or chemical substances such as bacterial toxins, venoms, caustics, and histamine. Diagnostic studies (e.g., a thorough history, physical examination, urinalysis, serum chemistries and liver functions, thyroid function, and chest x-ray) help to determine the cause and guide treatment. <br />TREATMENT Bed rest helps relieve lower extremity edema. Sitting with the feet and legs elevated also may reduce edema in the lower extremities. Dietary salt should be restricted to less than 2 g/day. Fluid intake may be restricted to about 1500 ml in 24 hr. This prescription may be relaxed when free diuresis has been attained. Diuretics relieve swelling when renal function is good and when any underlying abnormality of cardiac function, capillary pressure, or salt retention is being corrected simultaneously. One of various effective diuretics may be used. Diuretics are contraindicated in pre-eclampsia and when serum potassium levels are very low (e.g., less than 3.0 mEq/dl). They may be ineffective in edema associated with advanced renal insufficiency. The diet in edema should be adequate in protein, high in calories, and rich in vitamins. Patients with significant edema should weigh themselves daily to gauge fluid loss or retention. <br />PATIENT CARE Edema is documented according to type (pitting, nonpitting, or brawny), extent, location, symmetry, and degree of pitting. Areas over bony prominences are palpated for edema by pressing with the fingertip for 5 sec, then releasing. Normally, the tissue should immediately rebound to its original contour, so the depth of indentation is measured and recorded. The patient is questioned about increased tightness of rings, shoes, waistlines of garments, and belts. Periorbital edema is assessed; abdominal girth and ankle circumference are measured; and the patient's weight and fluid intake and output are monitored. Fragile edematous tissues are protected from damage by careful handling and positioning and by providing and teaching about special skin care. Edematous extremities are mobilized and elevated to promote venous return, and lung sounds auscultated for evidence of increasing pulmonary congestion. Prescribed therapies, including sodium restriction, diuretics, ACE inhibitors, protein replacement, and elastic stockings or other elastic support garments, are provided, and the patient is instructed in their use. <br />Gallop rhythm<br />An extra heart sound (i.e., a third or fourth heart sound), typically heard during diastole.<br />apex of the heart<br />The tip of the left ventricle, opposite the base of the heart. The apex of the heart moves considerably with each heartbeat, and the point of maximal impulse (PMI) can be felt on the chest wall above the apex. <br />Heart Base<br />An aneurysmal murmur (bruit) is usually loud and booming, systolic, and heard best over the aorta or base of the heart. It is often associated with an abnormal area of dullness and pulsation and with symptoms resulting from pressure on neighboring structures.<br />intercostal space<br />The interval between ribs, filled by the intercostal muscles. <br />intermittent claudication<br />Cramping or pain in leg muscles brought on by a predictable amount of walking (or other form of exercise) and relieved by rest. This symptom is a marker of peripheral vascular disease of the aortoiliac, femoral, or popliteal arteries. It may be present in patients with diffuse atherosclerosis, for example, with arterial insufficiency in the coronary or carotid circulations as well as the limbs. See: peripheral vascular disease <br />PHYSICAL EXAMINATION The patient often has thin or shiny skin over the parts of the limb with decreased blood flow. Diminished pulses and bruits (audible blood flow through partially blocked arteries) may also be present. <br /> DIAGNOSIS In patients with a suggestive history, the blood pressure (BP) is measured in the affected limb and divided by the BP in the arm on the same side of the body. This ratio is called the ankle-brachial index (ABI); patients with significant peripheral vascular disease have an ABI of less than 85%. If surgery is contemplated for the patient, angiography may be used to define anatomical obstructions more precisely. <br />TREATMENT Affected patients are encouraged to begin a program of regular exercise, to try to maximize collateral blood flow to the legs. Oral pentoxifylline improves the distance patients can walk without pain. For severely limiting claudication, patients may require angioplasty or arterial bypass surgery to respectively open or bypass obstructed arteries. <br />Altered Heart Rate/Rhythm <br />[Dys]arrhythmias (tachycardia, bradycardia); EKG [ECG] changes <br />Altered Preload Jugular vein distention (JVD); Edema; Weight gain; Increased/decreased central venous pressure (CVP); Increased/decreased pulmonary artery wedge pressure (PAWP); Murmurs <br />Altered Afterload Dyspnea; Clammy skin; Skin [and mucous membrane] color changes [cyanosis, pallor]; Prolonged capillary refill; Decreased peripheral pulses; Variations in blood pressure readings; Increased/decreased systemic vascular resistance (SVR); Increased/decreased pulmonary vascular resistance (PVR); Oliguria; [Anuria] <br />Altered Contractility Crackles; Cough; Decreased cardiac output/cardiac index; Decreased ejection fraction; Decreased stroke volume index (SVI)/left ventricular stroke work index (LVSWI); S3 or S4 sounds [gallop rhythm] <br />Behavioral/Emotional Restlessness <br />apex of the lung<br />The superior, subclavicular portion of the lung. <br />Lung Base<br />ANATOMY The lungs are connected with the pharynx through the trachea and larynx. The base of each lung rests on the diaphragm, and each lung apex rises from 2.5 to 5 cm above the sternal end of the first rib, the collarbone, supported by its attachment to the hilum or root structures. The lungs include the lobes, lobules, bronchi, bronchioles, alveoli or air sacs, and pleural covering.<br />murmur<br />An abnormal sound heard when listening to the heart or neighboring large blood vessels. Murmurs may be soft, blowing, rumbling, booming, loud, or variable in intensity. They may be heard during systole, diastole, or both. A murmur does not necessarily indicate heart disease, and many heart diseases do not produce murmurs.<br />nasal flaring<br />Intermittent outward movement of the nostrils with each inspiratory effort; indicates an increase in the work of breathing.<br />percussion<br />[L. percussio, a striking] 1. Striking the body surface (usually with the fingers or a small hammer) to determine the position, size, or density of underlying structures. <br />2. A technique for mobilizing secretions from the lungs by striking the chest wall with cupped hands.<br />precordium<br />(prē-kor′dē-ă) pl. The area on the anterior surface of the body overlying the heart and lower part of the thorax. precordial, (prē-kor′dē-ăl)<br />S1, S2 Normal first and second heart sounds.<br />S1, S2, etc. first sacral nerve, second sacral nerve, and so forth. <br />S3 Ventricular gallop heard after S2, an abnormal heart sound. <br />S4 Atrial gallop, heard before S1, an abnormal heart sound.<br />SpO2 The saturation of arterial blood with oxygen as measured by pulse oximetry, expressed as a percentage.<br />substernal<br />[L. sub, under, below, + Gr. sternon, chest] Situated beneath the sternum. <br />Supraclavicular<br />[″ + clavicula, little key] Located above the clavicle. <br />suprasternal<br />L. supra, above, on top, beyond, + Gr. sternon, chest] Located above the sternum.<br />ischemia<br /> [Gr. ischein, to hold back, + haima, blood] A temporary deficiency of blood flow to an organ or tissue. The deficiency may be caused by diminished blood flow either through a regional artery or throughout the circulation. <br />tactile fremitus<br />The vibration or thrill felt while the patient is speaking and the hand is held against the chest. <br />crepitus<br />A crackling or rattling sound made by a part of the body, either spontaneously or during physical examination. <br />varicose<br />[L. varicosus, full of dilated veins] Pert. to varices; distended, swollen, knotted veins. <br />venous hum<br />A murmur heard on auscultation over the larger veins of the neck.<br />ventricular systole<br />Ventricular contraction. <br />breath sounds<br />Respiratory sounds heard on auscultation of the chest. In a normal chest, they are classified as vesicular, tracheal, and bronchovesicular. <br />diminished breath sound<br />A soft, decreased, or distant vesicular lung sound as heard through a stethoscope. <br />ETIOLOGY Diminished breath sounds are common in patients with poor respiratory effort, splinting, emphysema, and other lung conditions. <br />vesicular sound<br />A normal breath sound heard over the entire lung during breathing. <br />bronchophony<br />[″ + phone, voice] An abnormal increase in tone or clarity in vocal resonance.<br />egophony<br />[Gr. aix, goat, + phone, voice] An abnormal change in tone, somewhat like the bleat of a goat, heard in auscultation of the chest when the subject speaks normally. It is associated with bronchophony and may be heard over the lungs of persons with pleural effusion, or occasionally pneumonia.<br />whispered pectoriloquy<br />A sound heard in auscultation of the chest over a lung with a cavity of limited extent when the patient whispers. <br />