thoracic & lung assessment

PrePared By:

dr. MohaMMed Mohsen

Thoracic and Lung AssessmentEquipment: 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 AssessmentRisk 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

I- inspection1- 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 shapeA. 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- pulsation1- 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 spaceIn case of systemic hypertension

5- any abnormality

1. Inspect: Anterior, posterior, & Lateral thorax for

1. Inspect: (Continue)

Anterior, posterior, & Lateral thorax for

1. Inspect: (Continue)

Anterior, posterior, & Lateral thorax for

II- chest palpation1- chest palpation

2- Tracheal examination

3- Tenderness

4- tactile vocal fremitus

5- Pulsation

6- Palpable sound

7- any abnormality

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

2. Palpation: (Continue) Palpate thorax for thoracic expansion by:


1. Test respiratory expansion

Place hands on posterior thorax at level of 10th

Vertebra.*Gently press skinbetween thumbs &have client takedeep breath.*Observe thumbmovement

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:


2. Anteriorly, pressskin together atlower sternum &have patient takedeep 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:


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

Technique of percussion

A lung affected by COPD displaces upper border of liver downward

3. Percussion: (Continue)


2. Percuss over posterior, Diaphragmaticexcursions

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

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:


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:


2. Large-stem bronchi

Bronchovesicular breath sounds heard over -mainstem bronchi-below clavicles-Between scapular

Expiration =inspiration

Bronchovesicular breath sounds heard over periphery



3. Lung periphery

vesicular breath sounds heard over lung periphery

Expiration < inspiration

↓ breath sounds with:-obstruction-pleural thickening-Pleural effusion-pneumothorax



4. Adventitious sounds

( crackles,rhonchi, wheezes)

If an abnormalsound is heard, askclient to cough.Note if adventitioussound is stillpresent or if itcleared with cough

Lungs clear to auscultation on inspiration & expiration

Crackles are auscultated during inspiration:in late inspiration-pneumonia-congestive heart failurein early inspiration-bronchitis-asthma-emphysema



4. Adventitious sounds

Abnormal sounds-crackles,-rhonchi, -wheezes

Lungs clear to auscultation on inspiration & expiration

Crackles are soft, high or lower pitchedRhonchi (snoring, low-pitched sounds) heard in inspiration & expirationWheezes (high-pitched musical sounds) heard on inspiration or expiration in acute asthma & chronic emphysema

4. Auscultation: Auscultate for altered voice sounds over lung periphery:


1. Bronchophony Client says “99”while examinerauscultates

2. Whispered pectoriloquy

Client Whispers “one, two, three” whileExaminer auscultates

Sounds muffled

Sounds muffled

Sounds loud & clear over consolidation from -pneumonia-atelectasis-tumorSounds loud & clear over consolidation

4. Auscultation: (Continue) Auscultate for altered voice sounds over lung periphery:


3. Egophony Client says “ee”while examinerauscultates

Sounds like muffled “ee”

Sounds like “ay” over areas consolidation or compression

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 Variations1. 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

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

allergyPediatric: Ineffective airway clearance related to bronchospasm and increased pulmonary

secretions

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thoracic & lung assessment