Thorax and Lungs Assessment PDF

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VI. THORAX AND LUNGS 1. Gather equipment (gown and drape, gloves, stethoscope, exam light, mask, skin marker, metric ruler) 2. Explain the procedure to client 3. Ask a client to put on a gown.

ASSESSMENT PROCEDURE A. INSPECTION 1. Inspect the shape and configuration of the chest wall and position of scapulae While the client sits with arms at the sides, stand behind him or her and observe the position of scapulae and the shape and configuration of the chest wall.

2. Inspect for use of accessory muscles Observe the client’s use of accessory muscles when breathing 3. Inspect the client’s positioning noting posture and ability to support weight while breathing Note the client’s posture and the ability to support weight while breathing comfortably B. PALPATION 4. Palpate for tenderness and sensation with gloved fingers Follow the palpation sequence in palpating the thorax. Use your fingers to palpate for tenderness, warmth, pain or other sensations.

5. Palpate for surface

POSTERIOR THORAX & LUNGS NORMAL FINDINGS The scapulae are symmetric, and non-protruding. Shoulders and scapulae are equal horizontal positions. The ratio on anteroposterior diameter is 1:2 Kyphosis –an increased curve of the thoracic spine is common in older clients. It results from a loss of skeletal muscles, it may be a normal finding

The client does not use accessory (Trapezius/ shoulder) muscle to assist breathing. The diaphragm is the major muscle at work. This is evidenced by expansion of the lower chest during inspiration Client should be sitting up and relaxed , breathing easily with arms at sides or in lap

No tenderness, pain or unusual sensations reported by client. Warmth should be equal bilaterally.

Skin and subcutaneous tissue are

ABNORMAL FINDINGS Spinal process that deviates laterally in the thoracic area may indicate scoliosis. Spinal configurations may have respiratory implications. Ribs appearing horizontal at an angle greater than 45 degrees with the spinal column are frequently the result of an increased ratio between the anteroposterior transverse diameter- barrel chest. This condition is commonly the result of emphysema due to hyperinflation of the lungs. Trapezius or shoulder , muscles are used to facilitate inspiration in cases of acute and chronic airway obstruction or atelectasis

Client leans forward and uses arms to support weight and lift chest to increase breathing capacity in chronic obstructive pulmonary disease (COPD). This is referred to as tripod position.

Tender or painful areas may indicate inflamed fibrous connective tissue. Pain over the intercostal spaces may be from inflamed pleurae. Pain over the ribs , especially at the costal condral junctions is a symptom of fractured ribs. Also muscle soreness from exercise or the excessive work of breathing as in COPD may be palpated as tenderness . Increased warmth may be r/t local infection. Any unusual palpable mass,

characteristics such as lesions or masses with gloved fingers Put on gloves and use fingers to palpate any lesions that you noticed during inspiration. Also feel unusual masses 6. Palpate for fremitus, using the ball or ulnar edge of one hand while client says “ ninety- nine”. Assess for symmetry and intensity of vibration Use the ball or ulnar edge of one hand to assess for fremitus ( vibrations of air in the bronchial tubes transmitted to the chest wall, felt by the examiner when the client says ninety nine

free of lesions and masses

which should be evaluated further by a physician or other appropriate professional

Fremitus is symmetric and easily identified in the upper regions of the lungs. If fremitus is not palpable on either side, the client may need to speak louder. A decrease in intensity of fremitus is normal as the examiner moves toward the base of the lungs. However, fremitus should remain symmetric for bilateral positions

Unequal fremitus is usually the result of consolidation that increases fremitus or bronchial obstruction, air trapping in emphysema, pleural effusion or pneumothorax that decreases fremitus. Diminished fremitus even with a loud spoken voice may indicate an obstruction of the tracheobronchial tree.

The ball of the hand is best for assessing the tactile fremitus because the area is especially sensitive to vibratory sensation. As you move your hand to each area, ask the client to say ninety nine. Assess all areas for symmetry and intensity of vibration. 7. Palpate for chest expansion. When the client takes a deep Place hands on posterior chest breath, the examiner ‘s thumbs wall with your thumbs at the should move 5 to 10 cm apart level of T9 or T10 and observe symmetrically the movement of your thumbs as the client takes a deep breath. Because of calcification of the costal cartilages and loss of the accessory musculature, the older client’s thoracic expansion may be decreased, although it should still be symmetric C. PERCUSSION 8. Percuss for tone, starting at the Resonance is the percussion tone apices above , scapulae and elicited over normal lung tissue across the tops of both shoulder Starting at the apices above the scapulae, across the tops of both shoulders, percuss the intercostal spaces, across and down, comparing sides. Percuss to the lateral aspects at the bases of the lungs and compare sides. Follow the sequence. 9. Percuss the intercostal spaces across and down, comparing sides

Unequal chest expansion can occur with severe atelectasis (collapse / incomplete expansion), pneumonia, chest trauma or pneumothorax (air in the pleural space). Decreased chest excursion at the base of the lungs is characteristic of COPD. This is due to decreased diaphragmatic function.

Hyperresonance is elicited in cases of trapped air such as in emphysema, pneumothorax. Dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space. Examples include lobar pneumonia, pleural effusion, or tumor

10. Percuss to the lateral aspects at the bases of the lungs and compare sides 11. Percuss for diaphragmatic excursion Ask the client to exhale forcefully and hold the breath. Beginning at the scapular line T7, percuss the intercostal spaces of the right posterior chest wall. Percuss downward until the tone changes from resonance to dullness. Mark this level and allow the client to breathe. Next, ask the client to inhale deeply and hold it. Percuss the intercostal space s from the mark downward until resonance changes to dullness. Mark this level and allow the client to breath. Measure the distance between the two marks. Repeat the procedure on the left posterior thorax, D. AUSCULTATION 12. Auscultate for breath sounds (normal: bronchial, bronchovesicular and vesicular) noting location Normal Breath Sounds Bronchovesicular breath sounds are heard over major bronchi. Moderate pitch and loudness. The upper sternum area is where major bronchi are located. Vesicular breath sounds are heard over the peripheral lung fields. It is low pitch soft sound. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. It is high pitched loud and harsh. The percussion sound usually heard over most of the lungs is resonance 13. Auscultate for adventitious sounds (crackles, fine or course pleural friction rub, wheeze, sibilant or sonorous)

Excursion should be equal bilaterally and measure 3-5 cm in adults. The level of the diaphragm may be higher on the right because of the position of the liver In well- conditioned clients, excursion can measure up to 7-8 cm.

Diaphragmatic descent may be limited by atelectasis of the lower lobes or by emphysema, in which diaphragmatic movement and air trapping are minimal. The diaphragm remains in a low position on inspiration and expiration. Other possible causes for limited descent can be pain, or abdominal changes such as extreme ascites, tumors or pregnancy.

Three types are normal. Bronchial, bronchovesicular and vesicular

Diminished or absent breath sounds often indicate that little or no air is moving in or out of the lung area being auscultated. This may indicate obstruction within the lungs as a result of secretions, mucus plug, or foreign object. Abnormalities of pleural space like pleural effusion, pneumothorax. In cases of emphysema, because of hyperinflated nature of the lungs, together with the loss of elasticity of lung tissue may result in diminished inspiratory breath sounds When you hear an abnormal sound during auscultation, always have the client cough then listen again and note any change. Adventitious lung sounds such as Crackles – Discrete and discontinuous sounds (formerly called Rales) and wheezesmusical and continuous (Formerly called Rhonchi) are evident.

No adventitious breath sound

14. Auscultate for voice sounds over chest wall: Bronchophony is assessed by using the diaphragm of stethoscope, listen to posterior chest as patient repeat the phrase “ninety-nine”

Voice transmission is soft, muffled and distinct. The sound of the voice may be heard, but the actual phrase cannot be distinguished.

The words will be easily understood and louder over areas of increased density. This may indicate consolidation from pneumonia, atelectasis or tumor.

Egophony is assessed by auscultating the chest and listen to the posterior chest as the patient says prolonged “E”. A normal finding - muffled sounds are heard

Voice transmission will be soft and muffled, but the letter “E” should be distinguishable.

Over areas of consolidation or compression, the sound will be louder and change to “A”

Whispered pectoriloquy- ask the client to whisper the phrase “ one- two- three” while you listen over the chest wall

Transmission of sounds is very faint and muffled. It may be inaudible

Over areas of consolidation or compression the sound will be transmitted clearly and distinctly. In such areas, it will sound as if the client is whispering directly into the stethoscope

ASSESSMENT PROCEDURE A. INSPECTION 1. Inspect for shape and configuration to determine the ratio of anterposterior diameter to transverse diameter (normally 1:2) The client should be sitting at his or her sides. Stand in front of the client and assess shape and configuration 2. Inspect for position of sternum from anterior and lateral viewpoints

3. Inspect for slope of the ribs from anterior and lateral viewpoints

4. Inspect for quality and pattern of respiration, noting breathing

ANTERIOR THORAX & LUNGS NORMAL FINDINGS

ABNORMAL FINDINGS

The anteroposterior diameter is less than the transverse diameter. The ration of anteroposterior diameter to the transverse diameter is 1:2

Anteroposterior diameter equals transverse diameter, resulting in a barrel chest. This s often seen in emphysema because of hyperinflation of the lungs.

Sternum midline and straight

Pectus excavatum is a markedly sunken sternum and adjacent cartilages- often referred as funnel chest. Pectus carinatum ia a forward protrusion of the sternum causing the adjacent ribs to slope backward. However both of thse conditions may restrict expansion of the lungs capacity. Barrel chest configuration results Rib slope downward with in more horizontal position and symmetric intercostal spaces. Costal angle is within 90 degrees. costal angle of more than 90 degrees. This often results from long-standing emphysema Respirations are relaxed, Labored and noisy breathing is effortless and quiet. Regular often seen with severe asthma

characteristics, rate, rhythm and depth. When assessing respiratory patterns, it is more objective to describe the breathing pattern, rather than just labeling the pattern 5. Inspect intercostal spaces while client breathes normally Ask the client to breath normally and observe the intercostal spaces 6. Inspect for use of accessory muscles Ask the client to breath normally and observe for use of accessory muscle

rhythm and normal depth. Tachypnea and bradypnea may be normal in some clients

Inspect for nasal flaring

Not observed

or chronic bronchitis, tachypnea, bradypnea, hyperventilation, hypoventilation cheyne- strokes respiration, Biot’s respiration

No retractions or bulging of intercostal spaces noted

Use of accessory muscles ( sternomastoid and rectus abdominis) is not seen with normal respiration

Neck muscles ( sternomastoid , scalene and trapezius are used to facilitate inspiration in cases of acute or chronic airway obstruction or atelectasis. The abdominal muscles and the internal costal muscles are used to facilitate in COPD Seen with labored respirations especially in small children and indicative of hypoxia Pursed lip breathing may be seen in asthma, emphysema, CHF as a physiologic response to help slow down expiration and keep alveoli open longer

Observe color of face, lips, chest . Also color and shape of nails B. PALPATION 7. Palpate for tenderness and sensation, using fingers Follow the guidelines for palpating the thorax and use your fingers to palpate for tenderness and sensation. Palpate for tenderness at costacondral junctions of ribs. Assess for crepitus as you would on the posterior thorax.

Ambient skin color with pink undertones

8. Palpate surface characteristics such as lesions or masses, using fingers of gloved hand 9. Palpate for fremitus while the client says “ninety nine” Follow guidelines in palpating thorax. Assess for symmetry and intensity of vibrations.

No unusual surface masses or lesions

No tenderness or pain palpated over the lung area with respirations. No crepitus palpated

Fremitus symmetric and easily identified in the upper regions of the lungs. A decreased intensity of fremitus is expected toward the base of the lungs, however,

Cyanosis In areas of extreme congestion or consolidation, crepitus may be palpated, particularly in clients with lung disease. Tenderness over the thoracic muscles can result from exercising ( push-ups and the like) especially in previously sedentary client. Tenderness or pain at costachondral junction of the ribs is seen with fractures, especially in older clients with osteoporosis. Masses or lesions palpated

Diminished vibrations, even with a loud spoken voice may indicate an obstruction of the tracheobronchial tree Clients with emphysema may

When you assess for fremitus on the female client, avoid palpating the breast. Breast tissue damps the vibrations. 10. Palpate for chest expansion by placing hands on anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process. Observe movement of the thumbs as the client takes a deep breath Place your hands on the anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process. As the client takes a deep breath, observe the movement of your thumbs. C. PERCUSSION 11. Percuss for tone above the clavicles, and then the intercostal spaces across and down, comparing sides Percussion elicits dullness over breast tissue, heart and the liver. Tympany is detected over the stomach and flatness is detected over the muscles and bones. D. AUSCULTATION 12. Auscultate for breath sounds, adventitious and voice sounds Follow auscultation guidelines. Listen for breath, adventitious and voice sounds

fremitus should be symmetric bilaterally.

have considerably decreased fremitus as a result of air trapping.

Thumbs move outward in a symmetric fashion from the midline.

Unequal chest expansion can occur with severe atelectasis, pneumonia, chest trauma, pleural effusion or pneumothorax. Decreased chest excursion at the bases of the lungs is seen with COPD

Resonance is the percussion tone elicited over normal lung tissue

Hyperresonance- in cases of trapped air such as emphysema, pneumothorax. Dullness may be characterizing areas of increased density such as consolidation, pleural effusion or tumor.

Norma adventitious and vocal vibrations

PALPATING THE THORAX Palpating the thorax helps you evaluate the client’s level of sensation, degree of fremitus (vocal vibrations) and efficiency of thorax expansion. Palpation may be performed with one or both hands whereas the sequence of palpation is established- staring near the neck and proceeding from one side to side areas just above the waist A. POSTERIOR THORAX 1. As a beginning examiner palpate the posterior (and anterior thorax) with one hand. (Two hands may be used as you gain experience). A two handed method may be used and enables simultaneous comparison of palpation. The part of the hand that is used to palpate depends on what you are assessing. a. fingers- best for assessing sensation, lumps and lesions b. palm- tactile fremitus, either at the base of the fingers or the heel of the hand c. thumbs together and fingers apart on the client’s back below the lungs-symmetric expansion2. Start toward the midline at the level of the left scapula ( over the apex of the left lung.) and move your hand left to right, comparing findings laterally. 3. Move systematically downward and out to cover the lateral portions of the lungs at the bases

B. ANTERIOR THORAX The sequence in palpating the anterior thorax is similar to that for the posterior thorax. And again, the part of the hand that you use depends on what characteristic you are assessing – sensation, vibration or expansion 1. Start with your hand positioned over the left clavicle –over the apex of the left lung. And move your hand left to right, comparing findings bilaterally 2. Move your hands symmetrically downward toward the midline at the level of the breasts and outward at the base to include the lateral aspect of the lung. The established sequence for palpating the anterior thorax serves as a guide for positioning your hand

AUSCULTATING THE THORAX TO best assess lung sounds, you will need to hear sounds as directly as possible. Do not attempt to listen through clothing or drape, which may produce additional sound or muffle lung sounds that exist. A. POSTERIOR THORAX 1. To begin, place the diaphragm of the stethoscope firmly and directly on the posterior chest wall at the apex of the lung at C7. 2. Ask the client to breathe deeply through his/her mouth for each of auscultation (each placement of the stethoscope) in the auscultation sequence so you can best hear the inspiratory and expiratory sounds. Deep mouth breathing may be especially difficult for the older client , who may fatigue easily. 3. Auscultate from the apices of the lungs at C7 to the bases of the lungs at T10 and laterally from the axilla own to the seventh or eighth rib. 4. listen at each site for at least one complete respiratory cycle. Follow the auscultating cycle. B. ANTERIOR THORAX 1. Place the diaphragm of the stethoscope firmly and directly on the anterior chest wall. Do not listen on clothing or other material. 2. Auscultate apices of the lungs slightly above the clavicles to the bases of the lungs at the sixth rib. 3. Ask the client to breathe deeply though his/ her mouth in an effort to avoid transmission of sounds that may occur with nasal flaring 4. Listen at each site for at least one complete respiratory cycle. Follow the auscultating cycle.

ABNORMAL SOUND A. Discontinuous Sounds Crackles ( fine)

Crackles ( Course)

B. Continuous Sounds

ADVENTITIOUS BREATH SOUNDS Characteristics

Conditions

High pitched, short, popping sounds heard during inspiration and not cleared when coughing, sounds are discontinuous and can be simulated by rolling a strand of hair between your fingers near your ear.

Restrictive diseases like Pneumonia, CHF, bronchitis, asthma, emphysema

Low-pitched, bubbling, moist sounds tha...