ASSESSMENT-OF-THE-THORAX-AND-LUNGS-Copy (1).pptx

Psychosocial Assessment and Holistic Appraisal of Oncology Patients

1. ASSESSMENT OF THE THORAX AND LUNGS

2. ANATOMY REVIEW ANTERIOR THORACIC CAGE

3. POSTERIOR THORACIC CAGE

4. CHESTWALL LANDMARKS

5. LUNGS are two cone-shaped, elastic structures suspended within the thoracic cavity apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm . not completely symmetric

6. Right lung- three lobes, shorter due to the liver Left lung- two lobes, narrower due to the heart

7. CHEST SHAPE AND SIZE Oval, elliptical anteroposterior diameter is half its transverse diameter

8. THE PROCEDURE

9. PREPARATION Assemble the equipment. Stethoscope-clean steth and warm with both hands prior to use on the client Skin marker/pencil Centimeter ruler Clean gloves

10. INQUIRE IF THE CLIENT HAS ANY HISTORY OF THE FOLLOWING: Family history of illness including cancer Rationale: A history of respiratory disease (emphysema, asthma) increases the risk for the development or a recurrence of the disease. The risk for lung cancer is thought to be partially based on genetics. Exposure to viral or bacterial respiratory infections in the home increases the risk for development of respiratory problems.

11. Allergies Rationale: Many allergic responses are manifested with respiratory symptoms such as dyspnea , cough, or hoarseness. Clients may need education on controlling the amount of allergens in their environment.

12. Tuberculosis Rationale: TB is a respiratory disease and is communicable. It is important to know the client’s adherence to treatment as this could be a basis for the treatment plan.

13. Lifestyle habits such as smoking and occupational hazards Smoking is linked to a number of respiratory conditions, including lung cancer Second-hand smoke puts clients at risk for COPD (including emphysema and chronic bronchitis) or lung cancer later in life

14. Occupational hazards: Exposure to coal dust, insecticides, paint, pollution, asbestos fibers, and the like. inhaling dust contaminated with Histoplasma capsulatum may cause histoplasmosis , a systemic fungal disease.

15. Any medications being taken Rationale: beta-adrenergic antagonists (beta blockers) “ olols ” and angiotensin-converting enzyme (ACE) inhibitors such as enalapril or lisinopril are associated with the side effect of persistent cough If the client is using oxygen or other respiratory therapy at home, it is important to evaluate knowledge of proper use and precautions as well as the client’s ability to afford the therapy herbal therapies or alternative therapies have side effects or adverse interactions to a certain respiratory disease

16. Current problem such as swelling, cough. wheezing, pain SWELLING maybe associated with cardiopulmonary disease

17. COUGH Continuous coughs-acute infections Coughs early in the morning- chronic bronchial inflammation or smoking Coughs late in the evening- result of exposure to irritants during the day Coughs at night- postnasal drip or sinusitis.

18. Nonproductive coughs-associated with upper respiratory irritations and early congestive heart failure (CHF). White or mucoid sputum- seen in common colds, viral infections, or bronchitis. Yellow or green sputum- bacterial infections. Hemoptysis (blood in the sputum)- more serious respiratory conditions.

19. Rust-colored sputum- tuberculosis or pneumococcal pneumonia. Pink, frothy sputum- pulmonary edema. Increase in the amount of sputum- increase in exposure to irritants, chronic bronchitis, and pulmonary abscess excessive, tenacious secretions may need instruction on controlled coughing and measures to reduce viscosity of secretions

20. WHEEZES indicates narrowing of the airways due to spasm or obstruction associated with CHF, asthma (reactive airway disease), or excessive secretions.

21. PAIN Pain-sensitive nerve endings are located in the parietal pleura, thoracic muscles, and tracheobronchial tree, but not in the lungs. Thus chest pain associated with a pulmonary origin may be a late sign of pulmonary disease.

22. Posterior Chest 1) Inspect the color , shape and contour and symmetry of the thorax from posterior and lateral views. Compare the anteroposterior diameter to the transverse diameter.

23. PARAMETER NORMAL ABNORMAL Color even and consistent with the color of the face Uneven color Shape/contour Oval, elliptical Downward equal slope at the rib cage Barrel chest Pigeon chest Funnel chest Symmetry symmetrical Assymetric diameter Transverse diameter is greater than anteroposterior diameter Anteroposterior to transverse diameter in ratio of 1:2 increased anteroposterior to transverse diameter

24. Barrel Chest- wider AP diameter, common in persons with kyphosis and and chronic , lung disease Pectus Carinatum (Pigeon chest)- protruding ribs and sternum due to overgrowth of cartilage Pectus Excavatum (Funnel chest)- depressed sternum due to abnormal growth of the ribs and sternum; congenital

25. 2) Inspect the spinal alignment for deformities. Have the client stand. From a lateral position, observe the three normal curvatures: cervical, thoracic, and lumbar To assess for lateral deviation of spine (scoliosis), observe the standing client from the rear. Have the client bend forward at the waist and observe from behind.

26. NORMAL FINDINGS Spine vertically aligned Spinal column is straight, right and left shoulders and hips are at same height

27. ABNORMAL FINDINGS Exaggerated spinal curvatures (kyphosis, lordosis ) Spinal column deviates to one side, often accentuated when bending over (scoliosis) Shoulders or hips not even.

28. KYPHOSIS- over curvature of the spine LORDOSIS- inward curvature SCOLIOSIS- S or C shaped spine

29. 3) Palpate the posterior thorax For clients who have no respiratory complaints, rapidly assess the temperature and integrity of all chest skin. For clients who do have respiratory complaints, palpate all chest areas for bulges, tenderness, or abnormal movements. Avoid deep palpation for painful areas, especially if a fractured rib is suspected.

30. NORMAL FINDINGS Skin intact; uniform temperature Chest wall intact no tenderness no masses

31. ABNORMAL FINDINGS Presence of skin lesions With areas of hypothermia With lumps , bulges, depressions, tenderness, movable structures

32. 4) Palpate the posterior chest for respiratory excursion. Place the palms of both your hands over the lower thorax with your thumbs adjacent to the spine and your fingers laterally. Ask the client to take a deep breath while you observe the movement of your hands and any lag in movement.

33. NORMAL FINDINGS Full and symmetric chest expansion (when the client takes a deep breath, your thumbs should move apart an equal distance and at the same time; normally the thumbs separate 3 to 5 cm [1 ½ to 2 inches during inspiration]

34. ABNORMAL FINGDINGS Asymmetric and/ or decreased chest expansion

35. 5) Palpate the chest for vocal (tactile) fremitus, the faintly perceptible vibration felt through the chest wall when the client speaks. Place the palmar surfaces of your fingertips or the ulnar aspect of your hand or closed fist on the posterior chest, 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

36. Compare the fremitus on both lungs and between the apex and the base of each lung, either: using one hand and moving it from one side of the client to the corresponding area on the other side or using two hands that are placed simultaneously on the corresponding areas of each side of the chest.

37. NORMAL FINDINGS Bilateral symmetry of vocal fremitus Fremitus is heard clearly at the apex of the lungs Low-pitched voices of males are readily palpated than higher pitched voices of females

38. ABNORMAL FINDINGS Decreased or absent fremitus ( associated with pneumothorax) Increased fremitus (associated with consolidated lung tissue, as in pneumonia

39. 6) Percuss the thorax Percussion of the thorax is performed to determine whether underlying lung tissue is filled with air, liquid, or solid material and to determine the positions and boundaries of certain organs. Because percussion penetrates to a depth of 5 to 7 cm (2 to 3 in), it detects superficial rather than deep lesions.

40. NORMAL FINDINGS Percussion notes resonate, except over scapula Lowest point of resonance is at the diaphragm Note: Percussion on a rib normally elicits dullness

41. ABNORMAL FINDINGS Asymmetry in percussion Area of dullness or flatness over lung tissue (associated with consolidation of lung tissue or mass ) Hyperresonance - too much air (emphysema, pneumothorax) Dullness- abnormal density, tumor, pneumonia, atelectasis

42. 7) Percuss for diaphragmatic excursion (movement of the diaphragm during maximal inspiration and expiration ) ▪Ask the client to take a deep breath and hold it while you percuss downward along the scapular line until dullness is produced at the level of the diaphragm. Mark this point with a marking pencil, and repeat the procedure on the other side of the chest. ▪Ask the client to take a few normal breathes and then expel the last breathe completely and hold it while you percuss upward from the mark point to assess and mark the diaphragmatic excursion during deep expiration on each side. ▪Measure the distance between the two marks.

43. NORMAL FINDINGS Excursion is 3 to 5 cm (11/2 to 2 inches. Bilaterally in women and 5 to 6 cm (2 to 3 in) in men ABNORMAL FINDINGS Restricted excursion (associated with lung disorder)

44. 8) Auscultate the chest using the flat disc diaphragm of the stethoscope (best for transmitting the high-pitched breathe sounds). ▪Use the 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 of the chest.

45. NORMAL FINDINGS Vesicular and bronchovesicular breath sounds ABNORMAL FINDINGS Adventitious breath sounds Absence of normal breath sounds

46. NORMAL BREATH SOUNDS

47. ADVENTITIOUS BREATH SOUNDS

48. Anterior Thorax PROCEDURE 9 ) Inspect breathing patterns NORMAL FINDINGS Quiet, rhythmic/regular, and effortless respirations ABNORMALFONDINGS Irregular, labored, with use of accessory muscles

49. 10) Inspect the costal angle(angle formed by the intersection of the costal margins) and the angle at which the ribs enter the spine . NORMAL FINDINGS No retractions, Costal angle is less than 90°, and the ribs insert into the spine at approximately a 45° angle ABNORMAL RETRACTIONS With retractions, Costal angle is widened (associated with COPD)

50. 11) Palpate the anterior chest for bulges, tenderness or abnormal movements 12)Palpate the anterior chest for respiratory excursion .

51. Normal Findings: Full symmetric excursion; thumbs normally separate 3 to 5 cm (1.2 to 2 in.) Abnormal Findings: Asymmetric and/or decreased respiratory excursion

52. 13)Palpate tactile fremitus in the same manner as of the posterior chest. ▪If the breast are large and cannot be retracted adequately for palpation, this part of examination is usually omitted.

53. Normal Findings: Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue Abnormal Findings: Same as posterior fremitus

54. 14) Percuss the anterior chest symmetrically . ▪Begin above the clavicles in the supraclavicular space, and proceed downward to the diaphragm ▪Compare one side of the lung to the other ▪Displace female breast for proper examination.

55. Normal Findings: Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach. Abnormal Findings: Asymmetry in percussion notes Areas of dullness or flatness over lung tissue

56. 15) Auscultate the trachea . NORMAL FINDINGS Bronchial and tubular sounds ABNORMAL FINDINGS Adventitious breath sounds Bruits

57. 16. Auscultate the anterior chest. Use the sequence used in percussion, beginning over the bronchi and the sternum and the clavicles

58. NORMAL FINDINGS Bronchovesicular and vesicular breath sounds ABNORMAL FINDINGS Adventitious sounds

59. 17. Document findings in the client record using forms or checklist supplemented by narrative notes if supplemented.