HA (Thorax)

• action of rib cage in inhalation

  during this, the diaphragm presses the abdominal organs downward and forward; lumalaki
• action of rib cage in exhalation

  during this, the diaphragm rises and recoils to the resting position; lumillit
• inspect configuration (PT)

  observe the position of scapulae and the shape and configuration of the chest wall
• Inspect configuration (PT) = normal

  Scapulae are symmetric and nonprotruding. Shoulders and scapulae are at equal horizontal positions. Spinous processes appear straight, and thorax appears symmetric, with ribs sloping downward at approximately a 45-degree angle in relation to the spine.
• Inspect configuration (PT) = deviation


  Scoliosis: Spinous processes that deviate laterally in the thoracic area

  barrel chest: Ribs appearing horizontal at an angle greater than 45 degrees with the spinal column; result of emphysema due to hyperinflation of the lungs
• Observe use of accessory muscles.

  client breathes and note use of muscles.
• Observe use of accessory muscles (PT) - NORMAL

  The diaphragm is the major muscle at work. This is evidenced by expansion of the lower chest during inspiration.
• Observe use of accessory muscles (PT) = DEVIATION


  Tripod position: leans forward and uses arms to support weight and lift chest to increase breathing capacity
• Inspect the client’s positioning (PT) = NORMAL


  client’s posture and ability to support weight while breathing comfortably
• Inspect the client’s positioning (PT) = NORMAL


  should be sitting up and relaxed, breathing easily with arms at sides or in lap.
• Inspect the client’s positioning (PT) = DEVIATION


  symptom of fractured ribs: Pain over the ribs, especially at the costal chondral junctions

  inflamed pleurae: Pain over the intercostalspaces
• Palpate for tenderness and sensation. (PT) 


  Use your fingers to palpate for tenderness, warmth, pain, or other sensations; Move systematically downward and out to cover the lateral portions of the lungs at the bases.
• Palpate for crepitus (PT) 


  subcutaneous emphysema; crackling sensation that occurs when air passes through fluid or exudate. Use your fingers and follow the sequence when palpating.
• Palpate for crepitus (PT) = NORMAL

  no palpable crepitus
• Palpate for crepitus (PT) = DEVIATION


  can be palpated if air escapes from the lung or other airways into the subcutaneous tissue as occurs after an open thoracic injury, around a chest tube, or tracheostomy.
• Palpate surface characteristics (PT)

  palpate any lesions that you noticed during inspection. Feel for any unusual masses.
• Palpate surface characteristics (PT) = NORMAL


  Skin and subcutaneous tissue are free of lesions and masses.
• Palpate surface characteristics (PT) = DEVIATION

  unusual palpable mass.
• Palpate for fremitus (PT) 


  use the ball or ulnar edge of one hand to assess for fremitus (vibrations of air in the bronchial tubes transmitted to the chest wall). ; ask the client to say “ninety-nine.” Assess all areas for symmetry and intensity of vibration.
• Palpate for fremitus (PT) = NORMAL


  symmetric and easily identified in the upper regions of the lungs; If fremitus is not palpable on either side, the client may need to speak louder
• Palpate for fremitus (PT) = DEVIATION


  Unequal fremitus is usually the result of consolidation (which increases fremitus); decrease fremitus is obstruction
• PALPATION (PT)

  8 TIMES
• Assess chest expansion. (Diaphragmatic Excursion) (PT)

  hands on the posterior chest wall with your thumbs at the level of T9 or T10 and pressing together a small skin fold. As the client takes a deep breath, observe the movement of your thumbs
• Assess chest expansion. (Diaphragmatic Excursion) (PT) = NORMAL


  When the client takes a deep breath, the examiner’s thumbs should move 5 to 10 cm apart symmetrically.
• Assess chest expansion. (Diaphragmatic Excursion) (PT) = DEVIATION


  Unequal chest expansion, Decreased chest excursion at the base of the lungs is characteristic of COPD. ; BUTTERFLY
• PERCUSSION (PT)

  22 TIMES
• Percuss for tone (PT) = NORMAL


  Resonance: over normal lung tissue.

  flat: over the scapula
• Percuss for tone (PT) = DEVIATION


  Hyperresonance: cases of trapped air such as in emphysema or pneumothorax.
• Normal percussion tones (PT)

  Resonance - over healthy lung

  Flat - over scapula

  Dullness - visceral and liver
• Percuss for diaphragmatic excursion. (PT)

  Ask the client to exhale forcefully and hold the breath. Beginning at the scapular line (T7); Percuss the intercostal spaces from the mark downward until resonance changes to dullness. Mark the level and allow the client to breathe. Measure the distance between the two marks.
• Percuss for diaphragmatic excursion. (PT) = NORMAL


  equal bilaterally and measure 3–5 cm in adults ; In well-conditioned clients, excursion can measure up to 7 or 8 cM
• Percuss for diaphragmatic excursion. (PT) = DEVIATION

  Dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space ; The diaphragm remains in a low position on inspiration and expiration
• AUSCULTATION (PT)

  20 TIMES
• Auscultate for breath sounds. (PT)

  place the diaphragm of the stethoscope firmly and directly on the posterior chest wall at the apex of the lung at C7. Ask the client to breathe deeply through the mouth for each area of auscultation (each placement of the stethoscope) in the auscultation sequence so that you can best hear inspiratory and expiratory sounds
• Auscultate for breath sounds (PT) = NORMAL


  Three types of normal breath sounds may be auscultated— bronchial, bronchovesicular, and vesicular
• Auscultate for breath sounds (PT) = DEVIATION


  Diminished or absent breath sounds ; Increased (louder) breath sounds often occur when consolidation or compression results in a denser lung area.
• Auscultate for adventitious sounds. (PT)


  are sounds added or superimposed over normal breath sounds and heard during auscultation.
• Auscultate for adventitious sounds. (PT) = NORMAL


  No adventitious sounds, such as crackles (discrete and discontinuous sounds) or wheezes (musical and continuous), are auscultated.
• Auscultate for adventitious sounds. (PT) = DEVIATION


  Adventitious lung sounds, such as crackles (formerly called rales) and wheezes (formerly called rhonchi) are evident.
• NORMAL BREATH SOUNDS (bronchial)

  • high pitch
  • harsh/hollow quality
  • loud amplitude
  • short during inhalation & long during expiration
  • at trachea and thorax