DE VEYRA, AJ

BSN 1C
NCM57

THORAX AND LUNGS

NORMAL FINDINGS ABNORMAL FINDINGS

POSTERIOR THORAX Anteroposterior to transverse Barrel chest; increased
1. Inspect the shape and diameter anteroposterior to transverse
symmetry of the thorax from in ratio of 1:2 diameter
posterior and lateral views. Thorax symmetric
Compare the anteroposterior
diameter to the transverse
diameter. Thorax asymmetric
2. Inspect the spinal alignment Spine vertically aligned Exaggerated spinal curvatures
for deformities if the client can (kyphosis,lordosis)
stand. From a lateral position,
observe the three normal
curvatures: cervical, thoracic,
and lumbar.
• To assess for lateral deviation Spinal column is straight, right Spinal column deviates to one
of spine(scoliosis), observe the and left shoulders and hips are at side, Shoulders or hips not even
standing client from the rear. same height.
Have the client bend forward at
the waist and observe from
behind.
3. Palpate the posterior thorax. Skin intact; uniform temperature Skin lesions; areas of
hyperthermia
• Assess the temperature and Chest wall intact; no tenderness;
integrity of all chest skin. • For no masses Lumps, bulges; depressions;
clients who have respiratory areas of tenderness; movable
complaints, palpate all thorax structures (e.g., rib)
areas for bulges, tenderness, or
abnormal movements. Avoid
deep palpation for painful areas,
especially if a fractured rib is
suspected.
4. Palpate the posterior thorax Full and symmetric thorax Asymmetric and/or decreased
for respiratory excursion expansion (thumbs should move thorax expansion
(thoracic expansion). Place the apart an equal distance and at
palms of both your hands over the same time; normally the
the lower thorax with your thumbs separate 3 to 5 cm [1.2
thumbs adjacent to the spine and to 2 in.] during deep inspiration)
your fingers stretched laterally. (
Ask the client to take a deep
breath while you observe the
movement of your hands and
any lag in movement)
5. Palpate the thorax for vocal Bilateral symmetry of vocal Decreased or absent fremitus
(tactile) fremitus, the faintly fremitus Fremitus is felt mostly (associated with pneumothorax)
perceptible vibration felt at the apex of the lungs Increased fremitus (associated
through the chest wall when the with pneumonia)
client speaks. Low-pitched voices of males are
• Place the palmar surfaces of more readily palpated than
your fingertips or the ulnar higher pitched voices of females
aspect of your hand or closed
fist on the posterior thorax,
starting near the apex of the
lungs • Ask the client to repeat
such words as “blue moon” or
“one, two, three.” • Repeat the
two steps, moving your hands
sequentially to the base of the
lungs
6. Percuss the thorax. Percussion Percussion notes resonate, Areas of dullness or flatness
of the thorax is performed to except over scapula over lung tissue (associated with
determine whether underlying consolidation of lung tissue or a
lung tissue is filled with air, mass)
liquid, or solid material and to
determine the positions and
boundaries of certain organs. •
Ask the client to bend the head
and fold the arms forward across
the chest. Rationale: (This
separates the scapula and
exposes more lung tissue to
percussion.) • Percuss in the
intercostal spaces at about 5-cm
(2-in.) intervals in a systematic
sequence. • Compare one side of
the lung with the other. •
Percuss the lateral thorax every
few inches, starting at the axilla
and working down to the eighth
rib.
7. Auscultate the thorax using Vesicular and bronchovesicular Adventitious breath sounds
the flat- disk diaphragm of the breath sounds (e.g., crackles, wheeze, friction
stethoscope. • Use the rub) Absence of breath sounds
systematic zigzag procedure
used in percussion. • Ask the
client to take slow, deep breaths
through the mouth. Listen at
each point to the breath sounds
during a complete inspiration
and expiration. • Compare
findings at each point with the
corresponding point on the
opposite side of the thorax.
ANTERIOR THORAX
8. Inspect breathing patterns Quiet, rhythmic, and effortless Abnormal breathing patterns and
(e.g., respiratory rate and respirations sounds
rhythm).
9. Inspect the costal angle (angle Costal angle is less than 90°, Costal angle is widened
formed by the intersection of the and the ribs insert into the spine (associated with chronic
costal margins) and the angle at at approximately a 45° angle obstructive pulmonary disease)
which the ribs enter the spine.
10. Palpate the anterior thorax
(see posterior thorax palpation).

11. Palpate the anterior thorax

for respiratory excursion. - Place Full symmetric excursion; Asymmetric and/or decreased
the palms of both your hands on thumbs normally separate 3 to 5 respiratory excursion
the lower thorax, with your cm (1.2 to 2 in.)
fingers laterally along the lower
rib cage and your thumbs along
the costal margins. • Ask the
client to take a deep breath
while you observe the
movement of your hands
12. Palpate tactile fremitus in Same as posterior vocal Same as posterior vocal
the same manner as for the fremitus; fremitus fremitus; fremitus
posterior thorax and using the
sequence as shown. If the
breasts are large and cannot be
retracted adequately for
palpation, this part of the
examination is usually omitted.
13. Percuss the anterior thorax Percussion notes resonate down Asymmetry in percussion notes
systematically. to the sixth rib Areas of dullness or flatness
• Begin above the clavicles in Flat over areas of heavy muscle over lung tissue
the supraclavicular space, and and bone
proceed downward to the Dull on areas over the heart and
diaphragm. the
• Compare the lung on one side Liver Tympanic over the
to the lung on the other side. • underlying stomach
Displace female breasts to
facilitate percussion of the lungs
14. Auscultate the trachea Bronchial and tubular breath Adventitious breath sounds
sounds
15. Auscultate the anterior Bronchovesicular and vesicular Adventitious Breath sounds
thorax. Use the sequence used in breath Sounds
percussion beginning over the
bronchi between the sternum
and the clavicles.

16. Document findings in the

client record
BREAST AND LYMPHATIC SYSTEM

NORMAL FINDINGS ABNORMAL FINDINGS

FMALE BREAST Breasts can be a variety of sizes A recent increase in the size of
Inspect size and symmetry. and are somewhat round and one breast may indicate
Have the client disrobe and sit pendulous. One breast may inflammation or an abnormal
with arms hanging freely. normally be larger than the growth.
Explain what you are observing other.
to help ease client anxiety.
Inspect color and texture. Be Color varies depending on the Redness is associated with
sure to note client’s overall skin client’s skin tone. Texture is breast inflam- mation.
tone when inspecting the breast smooth, with no edema.
skin. Note any lesions.
Linear stretch marks may be A pigskin-like or orange-peel
seen during and after pregnancy (peau d’orange) appearance
or with significant weight gain results from edema, which is
or loss. seen in metastatic breast disease.
The edema is caused by blocked
lymphatic drainage.
Inspect superficial venous Veins radiate either horizontally A prominent venous pattern may
pattern. and toward occur as
Observe visibility and pattern of the axilla (transverse) or a result of increased circulation
breast veins. vertically with a due to a
lateral flare (longitudinal). Veins malignancy. An asymmetric
are more venous pattern
prominent during pregnancy. may be due to malignancy.

Inspect the areolas. Note the Areolas vary from dark pink to Peau d’orange skin, associated
color, size, dark brown, with carci-
shape, and texture of the areolas depending on the client’s skin noma, may be first seen in the
of both tones. They areola. Red, scaly, crusty areas
breasts. are round and may vary in size. are may appear in Paget’s
Small Montgomery tubercles are disease
present.

Inspect the nipples. Note the Nipples are nearly equal A recently retracted nipple that
size and bilaterally in size was previ-
direction of the nipples of both and are in the same location on ously everted suggests
breasts. each breast. malignancy.
Also note any dryness, lesions, Nipples are usually everted, but Any type of
bleeding, or they may be spontaneous discharge should be
discharge. inverted or flat. referred
Supernumerary nipples may for cytologic study and further
appear along the embryonic evaluation.
“milk line.”
No discharge should be present.

Palpate texture and elasticity Palpation reveals smooth, firm, Thickening of the tissues may
elastic tissue. occur with an
underlying malignant tumor.
Palpate for tenderness and A generalized increase in Painful, tender breasts may be
temperature. nodularity and indicative of
fibrocystic breasts, especially
tenderness may be a normal right before
finding associ- menstruation (Mayo Clinic,
ated with the menstrual cycle or 2010b).
hormonal

medications. Breasts should be a

normal
body temperature.

Palpate for masses. Note No masses should be palpated. Malignant tumors are most often
location, size in However, found
centimeters, shape, mobility, a firm inframammary transverse in the upper outer quadrant of
consistency, and ridge may the breast.
tenderness. Also note the normally be palpated at the They are usually unilateral, with
condition of the lower base of irregular,
skin over the mass. the breasts. poorly delineated borders. They
are hard and
nontender and fixed to
underlying tissues.

Palpate the nipples. Wear gloves The nipple may become erect Discharge may be seen in
to com- and the areola endocrine disorders and with
press the nipple gently with your may pucker in response to certain medications (i.e.,
thumb and index finger. Note stimulation. A antihypertensives, tricyclic
any discharge. milky discharge is usually antidepressants, and estrogen).
If spontaneous discharge occurs normal only during Discharge from one breast may
from the pregnancy and lactation. indicate benign intraductal
nipples, a specimen must be However, some papilloma, fibrocystic
applied to a women may normally have a disease, or cancer of the breast.
slide and the smear sent to the clear discharge. Sometimes
laboratory there is only a watery, pink
for cytologic evaluation. discharge from the nipple. This
should be referred to a primary
care provider (Medline Plus,
2009).

Palpate mastectomy or Scar is whitish with no redness Redness and inflammation of

lumpectomy site. or swelling. the scar area
No lesions, lumps, or tenderness may indicate infection. Any
If the client has had a noted. lesions, lumps,
mastectomy or lumpectomy, it is or tenderness should be referred
still important to perform a for further
thorough examination. Palpate evaluation.
the scar and any remain-
ing breast or axillary tissue for
redness, lesions, lumps,
swelling, or tenderness
AXILLAE No rash or infection noted. Redness and inflammation may
Inspect and palpate the axillae. be seen with infection of the
Ask the sweat gland. Dark, velvety
client to sit up. Inspect the pigmentation of the axillae
axillary skin for (acanthosis nigri-
rashes or infection. cans) may indicate an
underlying malignancy.

Hold the client’s elbow with one No palpable nodes or one to two Enlarged (greater than 1 cm)
hand, and use the three finger small (less lymph nodes
pads of your other hand than 1 cm), discrete, nontender, may indicate infection of the
to palpate firmly the axillary movable hand or arm.
lymph nodes. nodes in the central area. Large nodes that are hard and
fixed to the
skin may indicate an underlying
malignancy.

MALE BREAST No swelling, nodules, or Soft, fatty enlargement of breast

Inspect and palpate the breasts, ulceration should be tissue is
areolas, detected. seen in obesity. Gynecomastia, a
nipples, and axillae. Note any smooth,
swelling, firm, movable disc of glandular
nodules, or ulceration. Palpate tissue,
the flat disc of may be seen in one breast in
undeveloped breast tissue under males during
the nipple. puberty, usually temporary.
However, it may also be seen in
hormonal
imbalances, drug abuse,
cirrhosis, leukemia,
and thyrotoxicosis. Irregularly
shaped, hard
nodules occur in breast cancer.

HEART AND NECK VESSELS

NORMAL FINDINGS ABNORMAL FINDINGS

NECK VESSELS The jugular venous pulse is not Fully distended jugular veins
Observe the jugular venous normally with the cli ENTS TORSO
pulse. Inspect the jugular venous visible with the client sitting ELEVATED MORE THAN 45
pulse by stand ing on the right upright. This DEGREES indicate increased
side of the client. The client position fully distends the vein, central venous pressure that may
should be in a supine position and pulsations may or may not be the result of right ventricular
with the TORSO ELEVATED be discernible. failure, pulmonary hypertension,
30-45 DEGREES -AKE SURE pulmonary emboli, or cardiac
the head and torso are on the tamponade.
same plane. Ask the client to
turn the head slightly to the left.
Shine a tangential light source
onto the neck to increase
visualization of pulsations as
well as shadows. Next, inspect
the suprasternal notch or the
area around the clavicles for
pulsations of the internal jugular
veins.
Evaluate jugular venous The jugular vein should not be dISTENTION BULGING OR
pressure (Fig. 21-8). Evaluate distended, BULGING OR PROTRUSION AT 45, 60 OR
jugular venous pressure by PROTRUDING AT 45 90 DEGREES MAY
watching for distention of the DEGREES OR greater. INDICATE RIGHT SIDED
jugular vein. It is normal for the HEART FAILURE
jugular veins to be vis ible when $OCUMENT AT WHICH
the client is supine. To evaluate POSITIONS YOU OBSERVE
jugular vein distention, position DISTENTION
the client in a supine position
with the head of the BED Clients with obstructive
ELEVATED 30,45,60AND 90 pulmonary disease may have
DEGREES At each increase of elevated venous pressure only
the elevation, have the client’s during expiration.
head turned slightly away from
the side being evaluated. Using An inspiratory increase in
tangential lighting, observe for venous pressure, called
distention, protrusion, or Kussmaul’s sign, may occur in
bulging. clients with severe constrictive
pericarditis.
Auscultate the carotid arteries if Pulse Amplitude Scale: Pulse inequality may indicate
the client IS MIDDLE AGED arterial con striction or
OR OLDER OR IF YOU 0 = Absent occlusion in one carotid.
SUSPECT cardiovascular 1+ = WEAK
disease. Place the bell of the 2+ = Normal wEAK PULSES MAY
stethoscope over the carotid 3+ = Increased INDICATE HYPOVOLEMIA
artery and ask the client to hold 4+ = Bounding shock, or decreased cardiac
his or her breath for a moment output.
so that breath sounds do not
CONCEAL ANY VASCULAR A bounding, firm pulse may
SOUNDS indicate hyper volemia or
increased cardiac output.

Variations in strength from beat

to beat or with respiration are
abnormal and may INDICATE
A VARIETY OF PROBLEMS
Palpate the carotid arteries. Arteries are elastic and no thrills lOSS
Palpate each are noted. OF
carotid artery alternately by ELASTICITY
placing the pads MAY
of the index and middle fingers INDICATE
medial to ARTERIOSCLERO
the sternocleidomastoid muscle sis. Thrills may indicate a
on the neck. Palpate the carotid narrowing of the
arteries. Palpate each artery.
carotid artery alternately by
placing the pads
of the index and middle fingers
medial to
the sternocleidomastoid muscle
on the neck
HEART (PRECORDIUM) The apical impulse may or may Pulsations, which may also be
Inspect pulsations. 7ITH THE not be vis ible. If apparent, it called heaves or lifts, other than
CLIENT IN supine position would be in the mitral AREA the apical pulsation are
with the head of the bed LEFT MID CLAVICULAR considered abnormal and should
ELEVATED BETWEEN 30 LINE FOURTH OR FIFTH be evalu ated. A heave or lift
AND 45 DEGREES STAND on INTERCOSTAL SPACE 4HE may occur as the result of an
the client’s right side and look APICAL IMPULSE IS A result enlarged ventricle from an
for the apical impulse and any of the left ventricle moving overload of WORK
abnormal pulsations. outward during systole.
Palpate the apical impulse. The duration is brief, lasting The apical impulse may be
Remain on the client’s right side through the FIRST TWO impossible to pal pate in clients
and ask the client to remain THIRDS OF SYSTOLE AND with pulmonary emphysema.
supine. Use one or two finger OFTEN LESS. obese clients or
pads to palpate the apical clients with large breasts, the
impulse in the mitral AREA apical impulse may not be
FOURTH OR FIFTH palpable.
INTERCOSTAL SPACE AT
THE MID CLAVICULAR
LINE
Palpate for abnormal pulsations. No pulsations or vibrations are A thrill or a pulsation is usually
Use palpated in associated
your palmar surfaces to palpate the areas of the apex, left sternal with a grade IV or higher
the apex, border, or murmur.
left sternal border, and base. base.
Auscultate heart rate and rATE SHOULD BE n BEATS "RADYCARDIA (LESS THAN
rhythm. pLACE PER MINUTE WITH regular 60BEATS/MIN) OR
THE rhythm. TACHYCARDIA (MORE
DIAPHRAGM THAN 100 BEATS/MIN) MAY
OF result in decreased cardiac
THE output.
stethoscope at the apex and
listen closely to
the rate and rhythm of the apical
impulse.
Auscultate for murmurs. A Normally no murmurs are heard. Pathologic midsystolic,
murmur is a swishing sound However, innocent and pansystolic, and DIASTOLIC
caused by turbulent blood flow physiologic midsystolic mur MURMURS
through the heart valves or great murs may be present in a
vessels. Auscultate for murmurs healthy heart.
across the entire heart area. Use
the diaphragm and the bell of
the stethoscope in all areas of
auscultation because murmurs
have a variety of pitches. Also
auscultate with the client in
different positions as described
in the next section because some
murmurs occur or subside
according to the client’s
position.
Auscultate with the client S1 and S2 heart sounds are An S3 or S4 heart sound or a
assuming other positions. Ask normally present. murmur of mitral stenosis that
the client to assume a left lateral was not detected with the client
position. Use the bell of the in the supine position may be
stethoscope and listen at the revealed when the client
apex of the heart. assumes the left lateral position.

PERIPHERAL VASCULAR SYSTEM

ARMS Skin is warm to the touch A cool extremity may be a sign

Palpate the client’s fingers, bilaterally from fingertips to of arte- rial insufficiency. Cold
hands, and arms, and note the upper arms. fingers and hands, for example,
temperature. are common findings with
Raynaud’s.
Palpate to assess capillary refill Capillary beds refill (and, Capillary refill time exceeding 2
time. Compress the nailbed until therefore, color returns) in 2 seconds may indicate
it blanches. Release the pressure seconds or less. vasoconstriction, decreased
and calculate the time it takes cardiac output, shock, arterial
for color to return. This test occlusion, or hypothermia.
indicates peripheral perfusion
and reflects cardiac output.
Palpate the ulnar pulses. Apply The ulnar pulses may not be Obliteration of the pulse may
pressure with your first three detectable. result from compression by
fingertips to the medial aspects external sources, as in
of the inner wrists. The ulnar compartment syndrome. Lack of
pulses are not routinely assessed resilience or inelasticity of the
because they are located deeper artery wall may indicate
than the radial pulses and are arteriosclerosis.
difficult to detect. Palpate the
ulnar arteries if you suspect
arterial insufficiency
You can also palpate the Brachial pulses have equal Brachial pulses are increased,
brachial pulses if you suspect strength diminished, or
arterial insufficiency. Do this by bilaterally. absent.
placing the first three fingertips
of each hand at the client’s right
and left medial antecubital
creases. Alternatively, palpate
the brachial pulse in the groove
between the biceps and triceps
Perform the Allen test. The Pink coloration returns to the With arterial insufficiency or
Allen test evalu- ates patency of palms within occlusion of the ulnar artery,
the radial or ulnar arteries. It is 3–5 seconds if the ulnar artery is pallor persists. With arterial
implemented when patency is patent. insufficiency or occlusion of the
questionable or before such Pink coloration returns within radial artery, pallor persists.
procedures as a radial artery 3–5 seconds
puncture. The test begins by if the radial artery is patent.
assessing ulnar patency. Have
the client rest the hand palm side
up on the examination table and
make a fist. Then use your
thumbs to occlude the radial and
ulnar arteries
LEGS Hair covers the skin on the legs Loss of hair on the legs suggests
Inspect distribution of hair. and arterial
appears on the dorsal surface of insufficiency. Often thin, shiny
the toes. skin is noted
as well.
Inspect for lesions or ulcers. Legs are free of lesions or Ulcers with smooth, even
ulcerations. margins that occur at pressure
areas, such as the toes and
lateral ankle, result from arterial
insufficiency. Ulcers with
irregular edges, bleeding, and
possible bacterial infection that
occur on the medial ankle result
from venous insufficiency
Inspect for edema. Inspect the Identical size and shape Bilateral edema may be detected
legs for unilateral or bilateral bilaterally; no by the
edema. Note veins, tendons, and swelling or atrophy. absence of visible veins,
bony prominences. If the legs tendons, or bony
appear asymmetric, use a prominences.
centimeter tape to measure in
four different areas:
circumference at mid-thigh,
largest circumference at the calf,
smallest circumference above
the ankle, and across the
forefoot. Compare both
extremities at the same locations
Palpate the femoral pulses. Ask Femoral pulses strong and equal Weak or absent femoral pulses
the client to bend the knee and bilaterally. indicate partial or complete
move it out to the side. Press arterial occlusion.
deeply and slowly below and
medial to the inguinal ligament.
Use two hands if necessary.
Release pressure until you feel
the pulse. Repeat palpation on
the opposite leg. Compare
amplitude bilaterally
Palpate the popliteal pulses. Ask It is not unusual for the popliteal Although normal popliteal
the client to raise (flex) the knee pulse to be difficult or arteries may be nonpalpable, an
partially. Place your thumbs on impossible to detect, and yet for absent pulse may also be the
the knee while positioning your circulation to be normal. result of an occluded artery.
fin- gers deep in the bend of the Further circulatory assessment
knee. Apply pres- sure to locate such as temperature changes,
the pulse. It is usually detected skin-color differences, edema,
lateral to the medial tendon hair distribution variations, and
dependent rubor (dusky redness)
distal to the popliteal artery
assists in determining the
significance of an absent pulse.
Cyanosis may be present yet
more subtle in darker-skinned
clients (Mann, 2013).
Determine ankle-brachial index Generally, the ankle pressure in Early recognition of
(ABI), also known as ankle- a healthy person is the same or cardiovascular disease even in
brachial pressure index (ABPI). slightly higher than the brachial asymptomatic people can be
Even though this advanced skill pressure, resulting in an ABI of deter- mined using ABI
is most often performed in a approximately 1, or no arterial measurements (Taylor-Piliae et
cardiovascular center, it is insufficiency. al., 2011).
important to know how the test
is performed and the People who smoke, are
implications. If the client has physically inactive, have a body
symptoms of arterial occlusion, mass index >30 or are hyperten-
the ABPI should be used to sive are more likely to have an
compare upper- and lower- limb abnormal ABI, suggesting PAD
systolic blood pressure. The (Taylor-Piliae et al., 2011).
ABI is the ratio of the ankle
systolic blood pressure to the Suspect medial calcification
arm (brachial) systolic blood sclerosis any time you calculate
pressure (see Box 22-3, p. 468). an ABPI of 1.3 or greater or
The ABI is considered an measure ankle pressure at more
accurate objective assessment than 300 mm Hg. This condition
for determining the degree of is associated with diabetes
peripheral arterial disease. It mellitus, chronic renal failure,
detects decreased systolic and hyperparathyroidism.
pressure distal to the area of Medial calcific sclerosis
stenosis or arterial narrowing produces falsely elevated ankle
and allows the nurse to quantify pressure by making the vessels
this measurement. noncompressible.

Measure ABI. In addition to abnormal ABI

Use the following steps to findings, reduced or absent
measure ABI: • Have the client pedal pulses, a cool leg
rest in a supine position for at unilaterally, lack of hair, and
least 5 minutes. • Apply the shiny skin on the leg sug- gests
blood pressure (BP) cuff to first peripheral arterial occlusive
one arm and then the other to disease.
determine the brachial pressure
using the Doppler. First palpate Nexøe et al. (2012) caution
the pulse and use the Doppler to about false ABI test results,
hear the pulse. The “whooshing” which may occur in general
sound indicates the brachial practice settings rather than
pulse. Pressures in both arms are when per- formed in specialized
assessed because asymp- vascular centers.
tomatic stenosis in the
subclavian artery can produce an Inaccurate readings may also
abnormally low reading and occur in people with diabetes
should not be used in the because of artery calcification
calculations. Record the higher (Scanlon et al., 2012).
reading.
Abnormal ABI findings,
indicating PVD, are associated
significantly with poorer
walking endurance (McDermott
et al., 2010).