lungs and thorax assessment

• Thorax


  The portion of the body extending from the base of the neck superiorly to the level of the diaphragm inferiorly
• Components of the thoracic cavity

  • Mediastinum
  • Lungs

  
• Thoracic cage


  Constructed of the sternum, 12 pairs of ribs, 12 thoracic vertebrae, muscles, and cartilage
• Sternum


  Divided into three parts: the manubrium, the body, and the xiphoid process
• Suprasternal notch


  A U-shaped indentation located on the superior border of the manubrium
• Ribs


  12 pairs, numbered superiorly to inferiorly, the uppermost pair being number one
• Mediastinum


  A central area in the thoracic cavity that contains the trachea, esophagus, heart, and great vessels
• Trachea and bronchi


  Represent "dead space" in the respiratory system, where air is transported but no gas exchange takes place
• Trachea and bronchi


  • They function primarily as a passageway for both inspired and expired air
  • They are lined with mucous membranes containing cilia that help sweep dust, foreign bodies, and bacteria toward the mouth for removal
• Air flow through the respiratory system

  1. Inspired air travels through the trachea into the main bronchi

  2. The bronchi repeatedly bifurcate into smaller passageways known as bronchioles

  3. The bronchioles terminate at the alveolar ducts

  4. Air is channeled into the alveolar sacs, which contain the alveoli

  
• Trachea


  A flexible structure that lies anterior to the esophagus, begins at the level of the cricoid cartilage in the neck, and is approximately 10 to 12 cm long in an adult
• Bronchi


  The right main bronchus is shorter and more vertical than the left main bronchus, making aspirated objects more likely to enter the right lung than the left
• Lungs


  Two cone-shaped, elastic structures suspended within the thoracic cavity

  
• Pleural membranes


  • The thoracic cavity is lined by a thin, double-layered serous membrane referred to as the pleura
  • Parietal pleura line the chest cavity
  • Visceral pleura covers the external surfaces of the lungs
  • The pleural space lies between the two pleural layers
• Vertical reference lines


  Used to describe the location of findings vertically and around the circumference of the chest wall
• Anterior chest lines


  Midsternal line, right and left mid-clavicular lines
• Posterior thorax lines


  Vertebral (or spinal) line, right and left scapular lines
• Purpose of respiration


  Maintain an adequate oxygen level in the blood to support cellular life and provide rapid compensation for metabolic acid-base defects
• External respiration (ventilation)


  The mechanical act of breathing, accomplished by expansion of the chest both vertically and horizontally
• Inspiration


  A slight negative pressure is created in the lungs in relation to the atmospheric pressure, resulting in an inflow of air into the lungs
• Expiration


  1. Mostly passive in nature, occurring with relaxation of the intercostal muscles and the diaphragm

  2. As the diaphragm relaxes, it assumes a domed shape, decreasing the size of the chest cavity and creating a positive pressure to force air out of the lungs
• Breathing patterns


  Change according to cellular demands, often without awareness on the part of the individual
• Hypercapnia

  An increase of carbon dioxide in the blood
• Hypoxemia


  Decrease in oxygen
• Subjective data to collect in nursing health history

  • Difficulty of breathing
  • Chest pain
  • Cough
  • Gastrointestinal symptoms
• Past health history questions

  • Prior respiratory problems
  • Thoracic surgery, biopsy, or trauma
  • Allergies
  • Medications for breathing problems
  • Pulmonary studies
  • Recent travel
• Family history questions


  • Lung disease
  • Smoking exposure
  • Other pulmonary illnesses/disorders
• Lifestyle and health practice questions

  • Dietary intake
  • Smoking history
  • Environmental exposures
  • Difficulty with daily activities
  • Stress
  • Use of herbal/alternative therapies
• Preparing the client for physical examination

  • Have the client remove clothing from the waist up and put on an examination gown or drape
  • Explain the procedures before initiating the examination
  • Encourage the client to ask questions and inform the examiner of any discomfort or fatigue
• Equipment for physical examination

  • Examination gown and drape
  • Gloves
  • Stethoscope
  • Light source
  • Mask
  • Skin marker
  • Metric ruler
• Key points during physical examination

  • Provide privacy for the client
  • Keep hands warm to promote client comfort
  • Remain nonjudgmental regarding client habits and lifestyle
• Inspection findings


  • Nasal flaring
  • Pursed lip breathing
  • Skin color
  • Nail color and shape
• Posterior thorax inspection findings

  • Scapular position and symmetry
  • Kyphosis
  • Scoliosis
  • Use of accessory muscles
  • Client positioning
• Palpation findings

  • Tenderness and sensation
  • Crepitus
• Client in tripod position


  • Leans forward and uses arms to support weight and lift chest to increase breathing capacity
• Palpation

  1. Palpate for tenderness and sensation

  2. Start toward the midline at the level of the left scapula and move hand left to right, comparing findings bilaterally

  3. Move systematically downward and out to cover the lateral portions of the lungs at the bases

  
• Palpate for crepitus

  Crepitus, also called subcutaneous emphysema, is a crackling sensation that occurs when air passes through fluid or exudate
• Palpate surface characteristics

  1. Put on gloves and use fingers to palpate any lesions noticed during inspection

  2. Feel for any unusual masses
• Palpate for fremitus

  1. 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)

  2. As you move your hand to each area, ask the client to say "ninety-nine"

  3. Assess all areas for symmetry and intensity of vibration
• Assess chest expansion

  1. Place your hands on the posterior chest wall with your thumbs at the level of T9 or T10 and pressing together a small skin fold

  2. As the client takes a deep breath, observe the movement of your thumbs