Assessing The Thorax and The Lungs

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Assessing the Thorax and the Lungs

Learning Objectives:

At the end of the respiratory system assessment the learner should be able to:

 Review the anatomy and physiology


 Describe the component of health history that should be elicited during the assessment of
thorax and lungs
 Identify the structural landmarks of the Thorax and Lungs.
 Describe specific assessment to be made during the assessment of the above system.
 Identify the equipment needed for assessment of thorax and lungs.
 Discuss the importance of assessing the thorax and lungs.
 Identify normal and abnormal findings in the assessment of the thorax and lungs.
 Demonstrate proper assessment of assessing thorax and lungs.

Structure and Function Overview

 Reference lines
- Anterior
 Midsternal
 Midclavicular
 Anterior axillary lines
- Posterior
 Vertebral line
 Scapular line
 Posterior axillary line
 Midaxillary line

 Lobes of the lungs


- Oblique fissure
- The left lung has two lobes
- The right lung has three
- Horizontal (minor) fissure
- RML
 Lobes of the lungs
- Upper, middle and lower lung fields
- Base
- Apex
- Auscultate
- Anteriorly
- Posteriorly

 Anterior thoracic landmarks


- Involve the ribs and their associated interspaces
- Suprasternal (jugular) notch
- Sternal angle
• Site of the apex of the heart
• Bifurcation of the right and left mainstem
- bronchi
- Intercostal space (ICS)
- Costal angle
 Posterior thoracic landmarks
- Vertebral processes
- Spinous process of T1
- Lower tip of the scapula
- 11th floating rib
- 12th floating rib

Trachea and Pleurae

 Pleurae
 Visceral pleura- lines outside of lungs, dipping down into the fissures
 Parietal pleura- lines inside of chest wall and diaphragm
 Lubricating fluid between the pleurae prevents friction
 Trachea and Bronchi
 Transport gasses between environment and lung
 Dead space is space filled with air (about 150 ml) but not available for gaseous exchange
 Goblet cells in bronchi secrete mucus that entraps particles
 Cilia in bronchi sweep particles upward
Considerations

General Considerations

 Warm equipment, such as a stethoscope, before using it to prevent chilling the patient.
 Attempt to reduce the noise level in the room while auscultating for breath sounds to
ensure accuracy in listening. Also, the presence of chest hair may mimic the sound of
crackles and bumping the stethoscope against clothing may distort the sound.
 Obtain the patient’s subjective data as well as the physical examination findings. For
example, the physical data may be normal; however, the patient may verbalize that he
or she is having difficulty breathing. In this case, the patient needs to be monitored
closely to assess for possible complications.

Lifespan Considerations

Infant and child Considerations

 Avoid anterior thorax chest percussion in an infant because it is often unreliable due to
the infant’s small chest size.
 Auscultate a child’s lungs before performing other assessment techniques that may
cause crying.
 Expect to hear breath sounds that are harsher or more bronchial than those of an adult.

Older Adult Considerations

 In the older adult patient, expect to find a reduction in respiratory effort due to age
related changes. A common finding in the elderly is kyphoscoliosis, a skeletal deformity
affecting the spinal column, which causes the anteroposterior (AP) diameter to increase
and the thorax to shorten. Also, the alveoli of the lung tissue decreases, which reduces
the amount of alveolar surface area available for gas exchange.

Equipment Needed

 Examination gown or drape


 Clean gloves
 Stethoscope
 Light source
 Mask
 Skin marker
 Metric ruler
GENERAL STEPS

STEPS

- Introduce yourself
- Identifies client using 3 identifiers
- Explain the procedure and purpose of the client
- Gather necessary equipment
- Perform medical asepsis (hand wash) don gloves if necessary/ if situation requires
- Provide privacy for the client
- Position the client comfortably, seated if possible

Inquire if the client has any history of the following:

 Family history of illness (cancer, allergies, tuberculosis)


 Lifestyle habit (smoking and occupational hazards
 Medications being taken
 Current problems (swelling, coughs, wheezing pain)

Posterior Thorax

STEPS NORMAL FINDINGS ABNORMAL FINDINGS


Inspect the shape and symmetry Anteroposterior to transverse Barrel chest; increased
of the thorax from posterior and diameter in ratio of 1:2 Thorax anteroposterior to transverse
lateral views. Compare symmetric diameter Thorax asymmetric
anteroposterior diameter to the
transverse diameter

Inspect the spinal alignment for Spine vertically aligned Exaggerated spinal curvatures
deformities: Have the client (kyphosis, lordosis)
stand. From a lateral position, Spinal column is straight, right
observe the three (3) normal and left shoulders and hips are Spinal column deviates to one
curvature: cervical, thoracic, and at same height. side, often accentuated when
lumbar. To assess for lateral bending over. Shoulders or hips
deviation of the spine (scoliosis), not even.
observe the standing client from
the rear. Have the client bend
forward at the waist, and
observe from behind.

Palpation

General Palpation – Respiratory Expansion – Tactile Fremitus


STEPS NORMAL FINDINGS ABNORMAL FINDINGS
Palpate the posterior thorax
For clients who do not have Skin intact; uniform temperature Skin lesions; areas of
respiratory complaints, rapidly hyperthermia
assess the temperature and
integrity of all chest skin.
For clients who do have Chest wall intact; no tenderness; Lumps, bulges; depressions;
respiratory complaints, palpate no masses areas of tenderness; movable
all chest areas for bulges, structures (e.g., rib)
tenderness, and abdominal
movements. Avoid deep
palpation for painful areas,
especially if a fractured rib is
suspected.

STEPS NORMAL FINDINGS ABNORMAL FINDINGS


Palpate the posterior chest for
respiratory excursion (thoracic
expansion):
Place the palms of both hands Full and symmetric thorax Asymmetric and/or decreased
over the lower thorax, with your expansion (i.e., when the client thorax expansi
thumbs adjacent to the spine takes a deep breath, your
and your fingers stretched thumbs should move apart an
laterally. Ask the client to have a equal distance and at the same
deep breath while you observe time; normally the thumbs
the movement of your hands separate 3 to 5 cm [1.2 to 2 in.]
and any lag in movement during deep inspiration)

STEPS NORMAL FINDINGS ABNORMAL FINDINGS


Palpate the chest for vocal
(tactile) fremitus.
Place the palmar surfaces of Bilateral symmetry of vocal Decreased or absent fremitus
your fingertips of the ulnar fremitus Fremitusis heard most (associated with pneumothorax)
aspect of your hand or closed fist clearly at the apex of the lungs Increased fremitus (associated
on the posterior chest, starting with consolidated lung tissue, as
near the apex of the lungs in pneumonia)

Ask the client to repeat such Low-pitched voices of males are


words as “99” or “1,2,3” more readily palpated than
higher pitched voices of females
Repeat the two steps, moving
your hands, sequentially to the
base of the lungs
STEPS NORMAL FINDINGS ABNORMAL FINDINGS
Compare the fremitus on both
lungs and between the apex and
the base of each lung, either:
Using one hand and moving it to
one side of the client to the
corresponding area on the other
side. Using two hands that are
placed simultaneously on the
corresponding areas of each side
of the chest.

Percussion

- Determines whether underlying tissue is filled with air, liquid or solid material
- Position and boundaries of certain organs

Percussion

Thorax – Diaphragmatic Excursion

PROCEDURE

1. Positioning
 Make sure the patient is undressed down to the waist.
 Position the patient on the examination table at a 30- to 45-degree angle and approach
from the right side. Examining the posterior of the lung requires the patient to be
leaning forward or sitting on the edge of the bed.
2. Percussion
 Place non-dominant hand with middle finger (pleximeter finger) pressed and
hyperextended firmly on the patient's right or left mid-back area (lower levels of lungs
posteriorly). The firmer the finger is pressed to the chest wall, the louder the percussion
note tends to be.
 Make sure the other fingers and palm are not pressed against the patient's chest.
 Use the tip of the middle finger (plexor finger) of the dominant hand to tap firmly on the
top third (middle or distal phalanx) of the pleximeter finger of the nondominant hand at
least twice (it is advisable to keep fingernails short). The sound should be hollow,
representing an air-filled lung.
Pattern of Assessment for Percussion

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