The Thorax and Lungs Assessment [Autosaved]

7/28/2019 The Thorax and Lungs Assessment [Autosaved]

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Arlyn C. Mendenilla, RN


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Nurses encounter clients with respiratory problems in virtually everyarea of practice and virtually every practice setting.

Nursing care of clients with respiratory problems may range fromprevention of the spread of common cold in a school setting to sustainingthe life of a client in respiratory failure in the intensive care unit.


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Thorax identifies the portion of the bodyextending from the base of the necksuperiorly to the level of the diaphragm.

The thoracic cage is constructed of thesternum, 12 pairs of ribs, 12 thoracicvertebrae, muscles, and cartilage.

The thorax consists of the anterior thoraciccage and the posterior thoracic cage.


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The thoracic cavity consists of themediastinum and the lungs.

The lungs are cone-shaped, elastic structuressuspended within the thoracic cavity.

The apex of the lungs extends slightly abovethe clavicle.

The base of the lungs is at the level of thediaphragm.


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Before beginning the assessment, the nursemust be familiar with series of imaginarylines on the chest wall and be able to locatethe position of each rib and some spinous

processes.

These landmarks help the nurse to identify

the position of underlying organs ( ex. Lobesof the lung) and to record abnormal findings.


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A B C


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Anterior chest landmarks and underlying lungs; Posterior chest landmarks and underlying lungs

Lateral chest landmarks and underlying lungs.


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In adults, thethorax is oval.

Its anterioposteriordiameter is half its

traverse diameter. Overall shape is

eleptical; that is, itsdiameter is smaller

at the top than atthe base.


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Chest deformities: A, pigeon chest; B, funnel chest; C, barrel chest;D, kyphosis; E, scoliosis.


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Normal breath sounds Vesicular

Broncho vesicular

Bronchial

Adventitious breath sounds Crackles (rales) best heard on inspiration

Gurgles (rhonchi) best heard on expiration

Friction rub inspiration and expiration Wheeze - best heard on expiration


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Planning For efficiency, the nurse usually examines the posteriorchest first, then the anterior chest wall. For posterior and lateral chest examinations, the clientis uncovered to the waist and in a sitting position. The sitting or lying position maybe used for anteriorchest examination. The sitting position is preferred because it maximizes

chest expansion. Good lighting is essential, especially for chest expansion


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Assemble equipment: Stethoscope Skin marker/pencil Centimeter ruler Assessment of thorax and lungs is notdelegated to nursing aide


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1. Introduce yourself and verify the clientsidentity. Explain to the client what you aregoing to do, why it is necessary, and how theclient can cooperate.2. Perform hand hygiene and observe otherappropriate infection control procedures.3. Provide for client privacy.4. Inquire if client has any history of the following:

Family history of illness, including cancer Allergies Tuberculosis Lifestyle habits, such as smoking, and occupational

hazards Any medications being taken Current problems such as swellings, coughs, wheezing,

pain


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Assessment Normal Findings Deviation from NormalPosterior thorax

5. Inspect the shape,color and symmetryof the thorax fromposterior and

lateral views.Compare theanteroposteriordiameter to thetransversediameter.

Anteroposterior totransverese diameterratio of 1:2

Pink

Chest symmetric

Barrel chest;increasedanteroposterior totransverse diameter

Pallor, cyanosis

Chest asymmetric


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Assessment Normal Findings Deviation from Normal6. Inspect the spinal

alignment for

deformities.Have the client stand.From a lateralposition, observe thethree normal

curvatures: cervical,thoracic, and lumbar.

Spine verticallyaligned

Exaggerated spinalcurvatures( kyphosis, lordosis)

To assess for lateraldeviation of the spine(scoliosis), observe

the standing clientfrom the rear. Havethe client bendforward at the waistand observe from

behind.

Spinal column isstraight, right andleft shoulders and

hips are the sameheight

Spinal columndeviates to one side,often accentuated

when bending over.Shoulder or hips noteven


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Assessment Normal Findings Deviation from Normal7. Palpate theposterior thorax.

For clients who have norespiratory complaints,rapidly assess thetemperature andintegrity of all chestskin.

Skin intact, uniformtemperature

Skin lesions: areas ofhyperthermia

For clients who do haverespiratory complaints,palpate all chest areasfor bulges, tenderness,or abnormal

movements. Avoid deeppalpation for painfulareas, especially if afractured rib issuspected.

Chest wall intact; notenderness; no masses

Lumps, bulges;depression; areas oftenderness; movablestructures (ex. Rib)


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Assessment Normal Findings Deviation from Normal8.Palpate theposterior chest for

respiratoryexcursion.Place the palms ofboth your handsover the lower

thorax, with yourthumbs adjacent tothe spine and yourfingers stretchedlaterally. Ask the

client to take a deepbreath while youobserve themovement of yourhands and any lag inmovement.

Full and symmetricchest expansion. Whenthe client takes a deep

breath, your thumbsshould move apart anequal distance at thesame time; normallythe thumbs separate 3to 5 cm ( 1 to 2 in)

during deepinspiration

Asymmetric and/ordecreased chestexpansion


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9. Palpate the chest for vocal(tactile) fremitus.Place the palmar surfaces ofyour fingertips or the ulnaraspect of your hand or closedfist on the posterior chest,

starting near the apex of thelungs.

Bilateral symmetry of vocalfremitus.Fremitus is heard mostclearly at the apex of the

heart

Decreased or absentfremitus (asso. Wdpneumothorax)

Ask the client to repeat suchwords as bluemoon or one,two, three, or 99

Low-pitched voices ofmales are more readilypalpated than the higherpitched voices of females

Increased fremitus (asso.wd consolidated lungtissue, as in pneumonia

Repeat the two steps, movingyour hands sequentially to the

base of the lungs.Compare the fremitus on bothlungs and between the apexand the base of each lung,either 1) using one hand and

moving it from one side of theclient to the correspondingarea on the other side or 2)using two hands that areplaced simultaneously on thecorresponding areas of each

side of the chest.


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Assessment Normal Findings Deviation fromNormal10. Percuss the thorax. ask the client to bend

the head and fold thearms forward acrossthe chest.

Percuss in theintercostal spaces at

about 5 cm (2in)intervals in systematicsequence

Compare one side ofthe lung with the

other Percuss the lateral

every few inches,starting at the axillaand working down to

the eight rib

Percussion notesresonate, except over

scapula

Lowest point ofresonance is at thediaphragm

Percussion on the ribnormally elicitsdullness

Assymetry inpercussion

Areas of dullnessor flatness overlung tissue (asso.With consolidationof lung tissue or amass or fluid.

Hyperresonance isheard overemphysematous

lungs.


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Assessment Normal Findings Deviation fromNormal11. Percuss for diaphragmatic excursion.

Ask the client to take a deep breath andhold it while you percuss downward alongthe scapular line until dullness is produced atthe level of the diaphragm. Mark this pointwith a marking pencil, and repeat theprocedure on the other side of the chest.

Percussion 3 to 5cm bilaterally inwomen and 5 to 6cm in men

Diaphragm is

usually slightlyhigher on theright side

Restrictedexcursion (asso.Wd lung disorder)

Ask the client to take a few normal breathsand then expel the last breath completelyand hold it while you percuss upward from

the marked poingt to assess and mark thediaphragmatic excursion during deepexpiration on each side

Measure the distance between two marks


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Assessment NormalFindings Deviation fromNormal12. Auscultate the chest using

the flat-disc diaphragm of thestethoscope.

Normal breathsounds

Adventitiousbreath soundssounds

No breath sounds

Use the systematic zigzag

procedure used in percussion.

Ask the client to take slow,deep breaths through themouth. Listen at each point tothe breath sounds during acomplete inspiration and

expiration.

Compare findings at eachpoint with the correspondingpoint on the opposite side of

the chest.


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Assessment Normal Findings Deviation from NormalAnterior Thorax

13. Inspect

breathingpatterns.(ex.RR, rhythm)

Quiet, rhythmic, and

effortless respirations

Abnormal breathing

pattern tachypnea,bradypnea, apnea etc.

14. Inspect thecostal angleand the angle atwhich the ribs

enter the spine.

Costal angle is 90, andthe ribs insert into thespine at approximatelyat 45 angle

Costal angle is widenedassocaited with COPD

15. Palpate the

anterior chest.


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Normal17. Palpate tactile fremitus inthe same manner as for the

posterior chest.

Same as posteriorvocal fremitus;

Same as posteriorvocal fremitus;

If the breasts are large andcannot be retracted adequatelyfor palpation, this part of theexamination usually is omitted.

Fremitus is normallydecreased over heartand breast tissue

18. Percuss the anterior chest

systematically.

Percussion notes

resonate down to thesixth rib at the levelof diaphragm

Asymmetry in

percussion notes

Begin above the clavicles in thesupraclavicular space, and

proceed downward to thediaphragm.

But are flat over areasof heavy muscle and

bone

Areas of dullness orflatness over lung

tissue

Compare one side of the lungto the other.

,dull on areas overthe heart & the liver

Displace female breasts forproper examination.

and tympanic over

the underlyingstomach


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Assessment Normal Findings Deviation fromNormal19. Auscultate the

trachea.

Bronchial and tubularbreath sounds

Adventitioussound

20. Auscultate theanterior chest.Use the sequence usedin percussion, beginningover the bronchibetween the sternumand the clavicles.

Bronchovesicular andvesicular breathsounds

Adventitioussound

Document findings in

the client record usingforms or checklistsupplemented bynarrative notes when

appropriate.


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In infants thorax isrounded; that is, thediameter from the

front to the back(anteposterior) isequal to the

transverse diameter.

It is also cylindrical,nearly equal diameter

at the top and thebase.


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Also known aspectus carinatum.

A narrow transversediameter, anincreaseanteroposteriordiameter, and a

protruding sternum.


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Sternum isdepressed,narrowing theanteroposterior

diameter.

Also known aspectus excavatum.


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5

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What are the four types of AdventitiousBreath Sounds?


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Enumerate the structures that makes up the

thoracic cage.


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What are the 5 imaginary lines of the

anterior chest


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What is the preferred position during

chest examination?


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What is the normal overall shape of the

thorax?

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The Thorax and Lungs Assessment [Autosaved]

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