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thoracic & lung assessment
PrePared By: 
dr. MohaMMed Mohsen
thoracic & lung assessment
thoracic & lung assessment
thoracic & lung assessment
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
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
Thoracic & Lung Assessment 
Objective data: collected through: 
 Inspection 
 Palpation 
 Percussion 
 Auscultation
Anterior Posterior
thoracic & lung assessment
thoracic & lung assessment
thoracic & lung assessment
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 )
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.
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 )
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”
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
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
1. Inspect: 
Anterior, posterior, & Lateral thorax for
1. Inspect: (Continue) 
Anterior, posterior, & Lateral thorax for
thoracic & lung assessment
thoracic & lung assessment
1. Inspect: (Continue) 
Anterior, posterior, & Lateral thorax for
thoracic & lung assessment
II- chest palpation 
1- chest palpation 
2- Tracheal examination 
3- Tenderness 
4- tactile vocal fremitus 
5- Pulsation 
6- Palpable sound 
7- any abnormality
thoracic & lung assessment
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
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
thoracic & lung assessment
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
Assess lung expansion
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
3. Percussion: 
 Use mediate percussion over shoulder apices & 
intercostal spaces 
 Compare for symmetry of percussion notes, while 
moving from apex to base of lungs
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
Intercostal Landmarks for percussion of thorax
Thoracic landmarks of underlying lungs
thoracic & lung assessment
Technique of percussion
A lung affected by 
COPD displaces 
upper border of 
liver downward
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
thoracic & lung assessment
Pleural effusion, atelectasis, 
diaphragmatic paralysis
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
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
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
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
thoracic & lung assessment
thoracic & lung assessment
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
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
thoracic & lung assessment
thoracic & lung assessment
thoracic & lung assessment
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
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
thoracic & lung assessment
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)
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
thoracic & lung assessment
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
Possible Collaborative Problems 
Examples: 
 Respiratory insufficiency or failure 
 Pneumonia 
 Pulmonary edema 
 Airway obstruction/ atelectasis 
 Laryngeal edema 
 Pleural effusion 
 Respiratory acidosis 
 Respiratory alkalosis
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
thoracic & lung assessment

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thoracic & lung assessment

  • 2. PrePared By: dr. MohaMMed Mohsen
  • 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
  • 8. Thoracic & Lung Assessment Objective data: collected through:  Inspection  Palpation  Percussion  Auscultation
  • 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
  • 19. 1. Inspect: Anterior, posterior, & Lateral thorax for
  • 20. 1. Inspect: (Continue) Anterior, posterior, & Lateral thorax for
  • 23. 1. Inspect: (Continue) Anterior, posterior, & Lateral thorax for
  • 25. II- chest palpation 1- chest palpation 2- Tracheal examination 3- Tenderness 4- tactile vocal fremitus 5- Pulsation 6- Palpable sound 7- 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
  • 35. Intercostal Landmarks for percussion of thorax
  • 36. Thoracic landmarks of underlying lungs
  • 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
  • 42. Pleural effusion, atelectasis, diaphragmatic paralysis
  • 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
  • 61. Possible Collaborative Problems Examples:  Respiratory insufficiency or failure  Pneumonia  Pulmonary edema  Airway obstruction/ atelectasis  Laryngeal edema  Pleural effusion  Respiratory acidosis  Respiratory alkalosis
  • 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