thoracic & lung assessment

2. PrePared By:
dr. MohaMMed Mohsen

6. Thoracic and Lung Assessment
Equipment: 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

7. Thoracic and Lung Assessment
Risk 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

8. Thoracic & Lung Assessment
Objective data: collected through:
Inspection
Palpation
Percussion
Auscultation

9. Anterior
Posterior

13. I- inspection
1- 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 )

14. Abnormal shape
A.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.

15. 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 )

16. 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”

17. 4- pulsation
1- Apex
2- Epigastric
3- Left parasternal pulsation
4- 2
nd
left space
5- 2
nd
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

18. 3- Left parasternal pulsation
Pulsated on 3
rd,
4
th
& 5
th
left intercostal space just lateral to the
sternum due to right ventricular conduction.
4- 2
nd
left space
Equal pulmonary hypertension
5- 2
nd
right space
In case of systemic hypertension
5- any abnormality

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

20. 1.Inspect: (Continue)
Anterior, posterior, & Lateral thorax for

23. 1.Inspect: (Continue)
Anterior, posterior, & Lateral thorax for

25. II- chest palpation
1- chest palpation
2- Tracheal examination
3- Tenderness
4- tactile vocal fremitus
5- Pulsation
6- Palpable sound
7- any abnormality

27. 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

28. 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

30. 2. Palpation: (Continue)
Palpate thorax for thoracic expansion by:
Procedure Normal Deviations from
normal
1. Test respiratory
expansion
Place hands on
posterior thorax at
level of 10
th
Vertebra.
*Gently press skin
between thumbs &
have client take
deep breath.
*Observe thumb
movement
Symmetrical
expansion
Thumbs move
apart equal distance
in both directions)
Asymmetrical
expansion
Thumbs
movement apart
is unequal

31. Assess lung expansion

32. 2. Palpation: (Continue)
Palpate thorax for thoracic expansion by:
Procedure Normal Deviations from
normal
2. Anteriorly, press
skin together at
lower sternum &
have patient take
deep breath.
*observe thumb
movement
Symmetrical
expansion
Thumbs move
apart equal distance
in both directions)
Asymmetrical
expansion
Thumbs
movement apart
is unequal

33. 3. Percussion:
Use mediate percussion over shoulder apices &
intercostal spaces
Compare for symmetry of percussion notes, while
moving from apex to base of lungs

34. 3. Percussion:
Procedure Normal Deviations from normal
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

35. Intercostal Landmarks for percussion of thorax

36. Thoracic landmarks of underlying lungs

38. Technique of percussion

39. A lung affected by
COPD displaces
upper border of
liver downward

40. 3. Percussion: (Continue)
Procedure Normal Deviations from normal
2. Percuss over
posterior,
Diaphragmatic
excursions
bilaterally
Diaphragm
descends 3-6 cm
from T
10
(with full
expiration held)
To T
12
(with full
expiration held)
Diaphragm descends
less than 3 cm owing to
atelectasis of lower
lobes
-emphysematous
-ascites
-tumor

42. Pleural effusion, atelectasis,
diaphragmatic paralysis

43. 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

44. 4. Auscultation:
Auscultate breath sounds over:
Procedure Normal Deviations from
normal
1. Trachea Bronchial (loud, tubular)
breath sounds heard over
trachea
Expiration > inspiration
Short silence between
inspiration & expiration
Bronchial
sounds heard
over lung
periphery

45. 4. Auscultation: (Continue)
Auscultate breath sounds over:
Procedure Normal Deviations from
normal
2. Large-stem
bronchi
Bronchovesicular
breath sounds heard
over
-mainstem bronchi
-below clavicles
-Between scapular
Expiration =inspiration
Bronchovesicular
breath sounds
heard over
periphery

46. 4. Auscultation: (Continue)
Auscultate breath sounds over:
Procedure Normal Deviations from
normal
3. Lung
periphery
vesicular breath
sounds heard over lung
periphery
Expiration < inspiration
¯ breath sounds
with:
-obstruction
-pleural
thickening
-Pleural effusion
-pneumothorax

49. 4. Auscultation: (Continue)
Auscultate breath sounds over:
Procedure Normal Deviations from
normal
4. Adventitious
sounds
( crackles,rhonchi,
wheezes)
If an abnormal
sound is heard, ask
client to cough.
Note if adventitious
sound is still
present or if it
cleared with cough
Lungs clear to
auscultation on
inspiration &
expiration
Crackles are
auscultated during
inspiration:
in late inspiration
-pneumonia
-congestive heart
failure
in early inspiration
-bronchitis
-asthma
-emphysema

50. 4. Auscultation: (Continue)
Auscultate breath sounds over:
Procedure Normal Deviations from normal
4. Adventitious
sounds
Abnormal sounds
-crackles,
-rhonchi,
-wheezes
Lungs clear to
auscultation on
inspiration &
expiration
Crackles are soft, high
or lower pitched
Rhonchi (snoring,
low-pitched sounds)
heard in inspiration &
expiration
Wheezes (high-
pitched musical
sounds) heard on
inspiration or expiration
in acute asthma &
chronic emphysema

54. 4. Auscultation:
Auscultate for altered voice sounds over lung
periphery:
Procedure Normal Deviations from normal
1. Bronchophony
Client says “99”
while examiner
auscultates
2. Whispered
pectoriloquy
Client Whispers “one,
two, three” while
Examiner auscultates
Sounds
muffled
Sounds
muffled
Sounds loud & clear
over consolidation from
-pneumonia
-atelectasis
-tumor
Sounds loud & clear
over consolidation

55. 4. Auscultation: (Continue)
Auscultate for altered voice sounds over lung
periphery:
Procedure Normal Deviations from normal
3. Egophony
Client says “ee”
while examiner
auscultates
Sounds like
muffled “ee”
Sounds like “ay” over
areas consolidation or
compression

57. 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)

58. Pediatric Variations
1. 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

60. 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

61. Possible Collaborative Problems
Examples:
Respiratory insufficiency or failure
Pneumonia
Pulmonary edema
Airway obstruction/ atelectasis
Laryngeal edema
Pleural effusion
Respiratory acidosis
Respiratory alkalosis

62. 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
allergy
Pediatric:
 Ineffective airway clearance related to
bronchospasm and increased pulmonary
secretions