6. Thoracic and Lung Assessment
Equipment: Stethoscope & Tape measures
Subjective data: Focus Questions:
Difficulty in Breathing? Associated factors, relieving factors?
Difficulty in Breathing when sleeping?
Use of more than one pillow to sleep?
Coughing? (productive- not productive)
Sputum (type & amount)
Dyspnea or shortness of breath ( at rest or exertion)?
Chest pain Associated & precipitating factors?
History of asthma, bronchitis, emphysema TB?
Exposure to environmental inhalants
Smoking
7. Thoracic and Lung Assessment
Risk Factors
• Risk for respiratory disease related to
smoking
• Immobilization or sedentary life style?
• Aging
• Environmental exposures
• Morbid obesity
• Risk for lung cancer related to cigarette
smoking
• Genetic predisposition
13. I- inspection
1- Shape:
Expose patient chest
Stand at the head or at the foot of the patient.
Normal shape:
Symmetry
Ratio of side to side diameter to anterior-posterior
diameter ( 7 : 5 )
14. Abnormal shape
A. A- localized
B. B- generalized
A- localized
localized bulge
Localized retraction
ask the patient to take deep breath
Side that move well is normal side and the another side
is abnormal
Can be localized bulge as in cases of pleural effusion,
tension pneumothorax or mass.
OR Localized retraction as in cases of collapse or
fibrosis.
15. Cont,
B- Generalized :
increase anterior-posterior diameter
- barrel
- alar
2- chest expansion : movement of the chest wall during
respiration
Normal:
- Symmetrical and better chest movement.
Abnormal :
1- localized bulge or retraction.
2- Bilateral retraction : movement of both sides of chest is less
than normal as in ( COPD )
16. 3- Respiration
1- assess rate ( 12- 20 br/m).
2- Rhythm
3- types of respiration
Male: abdomino- thoracic respiration
Female : thoraco- abdomino respiration
4- accessory muscles:
Normally : Don´t use in respiration
Use accessory muscle when the patient is unable to breath.
The most important muscle that assist with respiration “ lower
intercostal muscle”
17. 4- pulsation
1- Apex
2- Epigastric
3- Left parasternal pulsation
4- 2nd left space
5- 2nd right space
1- Apex
Q- what is the cause of absent apical beat?
Apex behind a ribs
COPD due to hyper inflation of the lung with air
Pleural effusion
Pericardial effusion
Thick wall of chest
Shifting of heart to other side
18. 3- Left parasternal pulsation
Pulsated on 3rd, 4th & 5th left intercostal space just lateral to the
sternum due to right ventricular conduction.
4- 2nd left space
Equal pulmonary hypertension
5- 2nd right space
In case of systemic hypertension
5- any abnormality
27. 2. Palpation:
Drape anterior chest & use fingers pads or palms
to palpate posterior chest
Have client fold arms across anterior chest &
lean forward to area of lungs
Palpate, percuss, & auscultate posterior lung &
thorax while the client is setting
Palpate, percuss, & auscultate lateral lungs &
thorax while client is in the supine position
28. 2. Palpation:
Palpate thorax at three levels for:
Procedure Normal Deviations from normal
1. Sensation
2. Vocal
fremitus
as client
say “99”
No pain or
tenderness
Vibration ¯ over
periphery of lungs
Vibration over
major airways
Depressed or
projection
Vibration over lung
with consolidation
Vibration ¯ over airway
with obstruction, pleural
effusion, pneumothorax
30. 2. Palpation: (Continue)
Palpate thorax for thoracic expansion by:
Procedure Normal Deviations from
normal
1. Test respiratory
expansion
Place hands on
posterior thorax at
level of 10th
Vertebra.
*Gently press skin
between thumbs &
have client take
deep breath.
*Observe thumb
movement
Symmetrical
expansion
Thumbs move
apart equal distance
in both directions)
Asymmetrical
expansion
Thumbs
movement apart
is unequal
32. 2. Palpation: (Continue)
Palpate thorax for thoracic expansion by:
Procedure Normal Deviations from
normal
2. Anteriorly, press
skin together at
lower sternum &
have patient take
deep breath.
*observe thumb
movement
Symmetrical
expansion
Thumbs move
apart equal distance
in both directions)
Asymmetrical
expansion
Thumbs
movement apart
is unequal
33. 3. Percussion:
Use mediate percussion over shoulder apices &
intercostal spaces
Compare for symmetry of percussion notes, while
moving from apex to base of lungs
34. 3. Percussion:
Procedure Normal Deviations from normal
1. Percuss over
shoulder apices &
at posterior,
anterior, & lateral
intercostal spaces
Resonance Hyperresonance over
-emphysematous lungs
Dullness heard over
solid masses or fluid
-pneumonia
-Pleural effusion
-tumor
39. A lung affected by
COPD displaces
upper border of
liver downward
40. 3. Percussion: (Continue)
Procedure Normal Deviations from normal
2. Percuss over
posterior,
Diaphragmatic
excursions
bilaterally
Diaphragm
descends 3-6 cm
from T10 (with full
expiration held)
To T12 (with full
expiration held)
Diaphragm descends
less than 3 cm owing to
atelectasis of lower
lobes
-emphysematous
-ascites
-tumor
43. 4. Auscultation:
Use diaphragm of stethoscope, exert pressure
over intercostal space
Instruct client to take slow, deep breaths through
the mouth.
Listen for two full breaths & compare symmetrical
sides of thorax while moving stethoscope from
apex to base of lungs
44. 4. Auscultation:
Auscultate breath sounds over:
Procedure Normal Deviations from
normal
1. Trachea Bronchial (loud, tubular)
breath sounds heard over
trachea
Expiration > inspiration
Short silence between
inspiration & expiration
Bronchial
sounds heard
over lung
periphery
45. 4. Auscultation: (Continue)
Auscultate breath sounds over:
Procedure Normal Deviations from
normal
2. Large-stem
bronchi
Bronchovesicular
breath sounds heard
over
-mainstem bronchi
-below clavicles
-Between scapular
Expiration =inspiration
Bronchovesicular
breath sounds
heard over
periphery
46. 4. Auscultation: (Continue)
Auscultate breath sounds over:
Procedure Normal Deviations from
normal
3. Lung
periphery
vesicular breath
sounds heard over lung
periphery
Expiration < inspiration
¯ breath sounds
with:
-obstruction
-pleural
thickening
-Pleural effusion
-pneumothorax
49. 4. Auscultation: (Continue)
Auscultate breath sounds over:
Procedure Normal Deviations from
normal
4. Adventitious
sounds
( crackles,rhonchi,
wheezes)
If an abnormal
sound is heard, ask
client to cough.
Note if adventitious
sound is still
present or if it
cleared with cough
Lungs clear to
auscultation on
inspiration &
expiration
Crackles are
auscultated during
inspiration:
in late inspiration
-pneumonia
-congestive heart
failure
in early inspiration
-bronchitis
-asthma
-emphysema
50. 4. Auscultation: (Continue)
Auscultate breath sounds over:
Procedure Normal Deviations from normal
4. Adventitious
sounds
Abnormal sounds
-crackles,
-rhonchi,
-wheezes
Lungs clear to
auscultation on
inspiration &
expiration
Crackles are soft, high
or lower pitched
Rhonchi (snoring,
low-pitched sounds)
heard in inspiration &
expiration
Wheezes (high-pitched
musical
sounds) heard on
inspiration or expiration
in acute asthma &
chronic emphysema
54. 4. Auscultation:
Auscultate for altered voice sounds over lung
periphery:
Procedure Normal Deviations from normal
1. Bronchophony
Client says “99”
while examiner
auscultates
2. Whispered
pectoriloquy
Client Whispers “one,
two, three” while
Examiner auscultates
Sounds
muffled
Sounds
muffled
Sounds loud & clear
over consolidation from
-pneumonia
-atelectasis
-tumor
Sounds loud & clear
over consolidation
55. 4. Auscultation: (Continue)
Auscultate for altered voice sounds over lung
periphery:
Procedure Normal Deviations from normal
3. Egophony
Client says “ee”
while examiner
auscultates
Sounds like
muffled “ee”
Sounds like “ay” over
areas consolidation or
compression
57. Pediatric Variations
Subjective data: Focus questions
History of wheezing , asthma, or other breathing
problems
Exposure to passive smoke
Frequent cold or congestions
Occurrence of sudden infant death syndrome
(SIDS)
58. Pediatric Variations
1. Inspection
Infants: AP diameter = transverse (1:1)
By age 5: AP diameter (1:2)similar to adult
Thin chest wall with cartilaginous rib cage soft
& pliant
Respiration rate varies according to age
2. Percussion: infant & young children:
hyperresonant because of thinness of chest
wall
3. Auscultation
Breath sounds will be louder & harsher due to
proximity to origin of sounds from thin chest wall
60. Geriatric variations
Loss of elasticity , fewer functional capillaries & loss of
lung resiliency
¯ ability to cough effectively due to weaker muscles
and rigid thoracic wall
Kyphosis ( accentuated dorsal curve)
¯ thoracic expansion due to calcification of costal
cartilage
Hyperresonance of thorax due to age related to
emphasymic changes
¯ breath sounds & retention of mucous due to ¯
pulmonary function
AP diameter due to loss of resiliency & loss of
skeletal muscle strength
62. Teaching Tips for Selected Nursing Diagnoses
Example:
Opportunity to enhance respiratory function
Ineffective airway clearances related to shallow
coughing & thickened mucus
Impaired gas exchange related to chronic lung
tissue damage
Ineffective airway clearance related to chronic
allergy
Pediatric:
Ineffective airway clearance related to
bronchospasm and increased pulmonary
secretions