"Thorax symmetric with moderate kyphosis and increased anteroposterior Suggests chronic obstructive lung (AP) diameter, decreased expansion. Lungs are hyperresonant. Breath disease sounds distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy. Diaphragms descend 2 cm bilaterally."

* Substance Abuse and Mental Health Services Administration, 1999 National Household Survey. www.samhsa.gov/hhsurvey/content/1999. Accessed 8/13/01.

* Centers for Disease Control and Prevention. Cigarette Smoking: Attributable Mortality and Years of Potential Life Cost—United States. MMWR 42: 645-649, 1993.

Combining clinician and group counseling with nicotine replacement therapy is especially effective for highly addicted patients.

Relapses are common and should be expected. Nicotine withdrawal, weight gain, stress, social pressure, and use of alcohol are often cited as explanations. Help patients to learn from these experiences: work with the patient to pinpoint the precipitating circumstances and develop strategies for alternative responses and health-promoting behaviors.

It is helpful to examine the posterior thorax and lungs while the patient is sitting, and the anterior thorax and lungs with the patient supine. Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate. Try to visualize the underlying lobes, and compare one side with the other, so the patient serves as his or her own control. Arrange the patient's gown so that you can see the chest fully. For women, drape the gown over each half of the anterior chest as you examine the other half. Cover the woman's anterior chest when you examine the back.

With the patient sitting, examine the posterior thorax and lungs. The patient's arms should be folded across the chest with hands resting, if possible, on the opposite shoulders. This position moves the scapulae partly out of the way and increases your access to the lung fields. Then ask the patient to lie down.

With the patient supine, examine the anterior thorax and lungs. The supine position makes it easier to examine women because the breasts can be gently displaced. Furthermore, wheezes, if present, are more likely to be heard. (Some authorities, however, prefer to examine both the back and the front of the chest with the patient sitting. This technique is also satisfactory).

For patients unable to sit up without aid, try to get help so that you can examine the posterior chest in the sitting position. If this is impossible, roll the patient to one side and then to the other. Percuss the upper lung, and auscultate both lungs in each position. Because ventilation is relatively greater in the dependent lung, your chances of hearing wheezes or crackles are greater on the dependent side.

H Initial Survey of Respiration and the Thorax_

Even though you may have already recorded the respiratory rate when you took the vital signs, it is wise to again observe the rate, rhythm, depth, and effort of breathing. A normal resting adult breathes quietly and regularly about

See Table 3-12, Abnormalities in Rate and Rhythm of Breathing (p. 93). Prolonged expiration suggests narrowed lower airways.

14 to 20 times a minute. An occasional sigh is to be expected. Note whether expiration lasts longer than usual.

Always inspect the patient for any signs of respiratory difficulty.

■ Assess the patient's color for cyanosis. Recall any relevant findings from earlier parts of your examination, such as the shape of the fingernails.

■ Listen to the patient's breathing. Is there any audible wheezing? If so, where does it fall in the respiratory cycle?

■ Inspect the neck. During inspiration, is there contraction of the sterno-mastoid or other accessory muscles, or supraclavicular retraction? Is the trachea midline?

Cyanosis signals hypoxia. Clubbing of the nails (see p. 110) in chronic obstructive pulmonary disease (COPD) or congenital heart disease

Audible stridor, a high-pitched wheeze, is an ominous sign of airway obstruction in the larynx or trachea.

Inspiratory contraction of the sternomastoids at rest signals severe difficulty breathing. Lateral displacement of the trachea in pneumothorax, pleural effusion, or atelectasis

Also observe the shape of the chest. The anteroposterior (AP) diameter may increase with aging.

The AP diameter also may increase in COPD.

The Smoker's Sanctuary

The Smoker's Sanctuary

Save Your Lungs And Never Have To Spend A Single Cent Of Ciggies Ever Again. According to a recent report from the U.S. government. Centers for Disease Control and Prevention, more than twenty percent of male and female adults in the U.S. smoke cigarettes, while more than eighty percent of them light up a cigarette daily.

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    Why examine the anterior thorax in supine position?
    7 years ago

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