Thorax and Lungs

Health History Tobacco use (amount, duration, Pack year

index) http://www.coquitline.org/

– 2nd hand smoke exposure Occupation/Exposure to pulmonary irritants

– Chemicals, vapors, dust, allergens, animals, smoke, asbestos, arsenic, coal dust, radiation)

PMH/FH of respiratory illness/disease/cancer or allergies– Pneumonia, TB, COPD, asthma, lung cancer– Pneumonia or influenza vaccine received?

Risk factors for TB: – HIV, substance abuse, low income or homeless,

resident of nursing home, shelter or prison, immigrant from country with high TB rate

Health History Do you have any shortness of breath?

(Dyspnea)– Occurs @ rest, with exercise, lying flat?

Have you heard any wheezing? Do you have a cough?

– Dry, productive, barking, etc..– http://www.youtube.com/watch?v=mXAxnZ4JJ6A

– Amount, color,& consistency of sputum. Presence of odor.

– Hemoptysis- coughing up blood (varies from blood streaked phlegm to frank blood)

Do you have chest pain with breathing? Have you recently had any pain in calves or

been on any long car or plane rides?

Sample Charting

Sample Electronic Charting

Respiratory SymptomsDifficulty breathingDyspnea with exertionDyspnea at restUnable to lie flatDifficulty coughingDifficulty clearing secretions

Inspection Observe symmetry, rate, rhythm, depth

and effort of breathing– Symmetry: Chest wall movement equal bilaterally– Rate: Adult 12-20 resp/min is normal

• Bradypnea: Slow (<12 per minute)• Tachypnea: Rapid (>20 per minute)

– Rhythm: Regular vs. irregular• Cheyne-Stokes, Kussmaul’s respirations, Biot’s

– Depth• Hypoventilation–rate slow, depth• Hyperventilation–rate rapid, depth deep

Respirations 16/min, symmetrical,relaxed and even

Inspection– Effort

• Unlabored vs. labored– Presence of retractions

» Suprasternal: above clavicle & sternum» Intercostal: between ribs» Subcostal: below lower costal margin» Substernal: Below Xiphoid process

– Presence of nasal flaring (inhalation) or grunting (exhalation)» Infants/children

– Use of accessory muscles» Neck/shoulders (ie Sternocleidomastoid & trapezius)» Abdominal (exhalation)

Respirations nonlabored.

http://www.youtube.com/watch?v=Hv68EQ3tCBIhttp://www.youtube.com/watch?v=J2R8MOoQtd8

Inspection

Body position– Relaxed vs. Upright/Tripod position

Color of skin, lips, nail beds– Even skin tone vs. cyanotic

Presence of clubbing

Patient relaxed. Skin and mucous membrane pink. Nail beds pink without clubbing in upper and lower extremities.

Inspect/Palpate Trachea Position

InspectShould be midline

PalpateFor tracheal shift

• Place finger in sternal notch and slip to each side.

Trachea midline.

Inspection

Wounds, scars, drains, tubes, dressings– Documentation must include location, size, amount of

drainage and discharge if present, and signs of inflammation.

– Additional terms to describe location:• Supraclavicular- Above the clavicles• Infraclavicular- Below clavicles• Interscapular- Between scapula• Infrascapular- Below scapula• Midaxillary line- Along line of armpit• Midclavicular- Along line in middle of clavicle

No wounds, scars, drains, tubes, or dressings. Or- No lesions.

Inspection

Shape of Chest :– Symmetrical vs. asymmetrical– Deformities

• Pectus carniatum, Pectus excavatum, Spinal deformitiies

– Normal AP diameter vs.. increased AP diameter

• Oval vs. barrel chest

• Ribs slope downward vs. more horizontal

• Barrel chest appears as if patient in continuous inspiratory position

Chest symmetrical without deformities. AP < transverse diameter

Kyphosis

Scoliosis

Palpation Assess for masses, tenderness, or crepitus– Subcutaneous emphysema-

air escapes form lungs into subcutaneous tissue

Assess chest expansion– Posteriorly place thumbs at

level of 10th rib & place palms on posterolateral chest.

– Approx 2 inches apart before inspiration. Feel thoracic expansion during quiet & deep inspiration. Look for symmetry.

Chest expansion symmetrical. No masses or tenderness.

http://www.youtube.com/watch?v=ygD93IKorEw

Palpation Tactile Fremitus

– Palpable vibrations transmitted through bronchopulmonary tree to chest when patient speaks

– Have patient repeat 99 or 1, 1, 1 while palpate with ulnar surface or ball of hand

• Decreased or absent when vibration impeded by obstructed bronchus, tumor, or separation of pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), or air (pneumothorax)

• Increased with gross compression or consolidation (lobular pneumonia) without bronchus obstruction

Tactile fremitus equal bilaterally.

Palpation

Percussion

Tapping of an chest to set chest wall and underlying tissues into motion

Helps to establish if underlying tissue air-filled, fluid-filled, or solid

Normal sound is resonance

Resonant to percussion over all lung fields.

Percussion

http://www.youtube.com/watch?v=PlUejZE6c_w

Auscultation Use diaphragm of stethoscope andhave patient breath out of their mouth.

– Peds- use smaller pediatric diaphragm or adult bell

Place stethoscope firmly on skin. Avoid movement because it may produce confusing sounds (i.e. clothing)

Auscultate at least one complete respiration Move from one side to the other Observe for hyperventilation, allow to rest if

needed Peds- transmission of sounds enhanced,

harder to localize sounds

Auscultation- Anterior Chest

Auscultation- Lateral Chest

Auscultation- Posterior Chest

Anatomy Review

Air: Mouth/Nose respiratory portion of larynx trachea right & left bronchus smaller bronchi smaller bronchioles alveolar duct individual alveoli

Auscultation Breath Sounds

– Bronchial (Tracheal)• Heard over trachea• Exp > insp• Loud, High pitch• Hollow quality

– Bronchovesicular• Heard over major bronchi• Insp = exp• Medium, Medium pitch• Blowing sound

– Peds in periphery

– Vesicular • Heard over lung

parenchyma/periphery• Insp > exp• Soft, Low pitch• Breezy quality

– Diminished

Auscultation

Adventitious Breath Sounds– Wheezes (Sibilant

wheeze)• High pitched, musical

sound heard during inhalation or exhalation

• Mild, moderate, severe

– Rhonchi (Sonorous wheeze)

• Low pitch snoring sound during inspiration or exhalation, but louder on exhalation

• May clear with coughing

Asthma

Auscultation

Bronchitis

Emphysema

Auscultation– Crackles/Rales

• Popping sounds heard on inhalation

• Fine– High pitched fine, short,

interrupted crackling sounds heard during end of inspiration

• Medium– Lower, more moist sounds

heard during middle of inspiration

• Course– Loud, bubbly sounds

heard during inspiration

http://www.med.ucla.edu/wilkes/intro.html

Auscultation

Pneumonia

Atelectasis

Auscultation

– Pleural friction rub• Dry, low pitched rubbing or grating sound on inhalation

and exhalation• Heard loudest over lower lateral anterior surface• Occurs with pleurisy or pleuritis

http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html

Auscultation– Stridor

• High pitched, harsh sound heard on inspiration when trachea or larynx is obstructed

– Croup, foreign body, large airway tumor– http://www.youtube.com/watch?

v=QkaX83H31QY&feature=PlayList&p=0C59700763AFDD1E&playnext=1&index=8– http://www.youtube.com/watch?v=Z1_uKqmPyLA&feature=related

Auscultation

Breath sounds vesicular without adventitious sounds.

Or- Lungs sounds CTA in all lung fields without wheezes, rales, rhonchi, or rubs

Auscultation Voice Sounds

– Bronchophony• “99” or “1-2-3”

– Normal- Muffled– Abnormal- Clear

– Whispered Pectoriloquy• Whisper “1,2,3”

– Normal- faint and indistinct– Abnormal- clear and distinct

– Egophony• “eeeeeeee”

– Normal– Abnormal “aaaaaa”

Bringing it all togetherhttp://www.youtube.com/watch?v=ygD93IKorEw

http://www.youtube.com/watch?v=nUJQvFXmTxQ&feature=related

Case StudyJuan Pablo comes to the Urgent Care Clinic for complaint of a cough that started about a week ago. He is accompanied by

his friends who work at the local chicken processing plant with him. He is from Mexico and has lived in the United States now for 2 years. He speaks English hesitantly. His family still lives in Mexico. He is 38 years old and states that he has been

in good health. He smokes one pack of cigarettes daily and occasionally drinks alcohol. Polly Curtis is a student nurse

assigned to do a health assessment and physical exam with the registered nurse. Polly is 25 years old and is in her second

year of nursing school. 

Sample Charting

Sample Electronic Charting

Normal Parameters Met Breath sounds clear through all lung fields. Respirations unlabored, symmetrical,

regular rhythm and depth. No shortness of breath Cough effective Skin color within pt’s norm Sputum clear or white

Sample Electronic Charting

Sputum AmountScantSmallModerateLargeCopiousSwallowed

Sputum ColorYellowTanGreenPinkBrownBloody

Sample Electronic Charting

Sputum ConsistencyThinMucoidThickMucus plugFrothySmallTenaciousClots

Sample Electronic Charting

EffortLaboredShallowStridorAgonalAccessory muscle

useGasping laboredGrunting

Mechanical ventilated

Moderate laboredSlightly laboredNasal flaringPursed lipSplinting

Sample Electronic Charting

Retraction TypeSubsternalIntercostalSupraclavicularSubclavicularAbdominal

DepthDeepShallow

Mediastinal Shift?YesNo

Sample Electronic Charting

PatternIrregularBradypneaTachypneaGaspingGruntingKussmaulCheyne-stokes

Irregular or periodicParadoxicalAgonaApnea

Respiratory Pattern Comment: _______

Sample Electronic Charting

AuscultationClear throughoutAbsentDiminishedInspiratory wheezeExpiratory wheezeRalesRhonchiRub

Lung Characteristics Audible Decreased Diffuse Increased Slightly decreased Tight

Difference between anterior and posterior breath sounds: _______

Lung sound comments:___________

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