HEALTH ASSESSMENT - THORAX AND LUNGS

• Purpose of nursing physical assessment of the lungs and thorax

  Assessing the thorax and lungs is frequently critical to assessing the client's oxygenation status. Changes in the respiratory system can occur slowly or quickly.
• Anatomic descriptors of the chest

  • Suprasternal (above the clavicles)
  • Infraclavicular (below the clavicles)
  • Interscapular (between the scapulae)
  • Infrascapular (below the scapulae)
  • Bases of the lungs (the lowermost portions)
  • Upper, middle, and lower lung fields
• Core muscles involved in expiration

  Internal intercostals and the diaphragm. The internal intercostals contract to pull ribs down, while the diaphragm relaxes to reduce the thoracic cavity.
• Accessory muscles of expiration

  Abdominals and the quadratus lumborum. The abdominals contract to compress the abdomen, and the quadratus lumborum contracts to pull ribs down.
• Core muscles involved in inspiration

  External intercostals and the diaphragm. The external intercostals contract to elevate ribs, while the diaphragm contracts to expand the thoracic cavity.
• Accessory muscles of inspiration

  Sternocleidomastoid and the pectoralis minor. The sternocleidomastoid contracts to elevate the sternum, and the pectoralis minor contracts to pull ribs outwards.
• Purpose of respiration


  To maintain an adequate oxygen level in the blood to support cellular life. It also assists in eliminating carbon dioxide. Changes in the respiratory pattern can cause acid-base imbalances.
• How external respiration is accomplished

  Expansion of the chest, both vertically and horizontally. Vertical expansion is accomplished through the contraction of the diaphragm, while horizontal expansion occurs as intercostal muscles lift the sternum and elevate the ribs, resulting in an increase in anteroposterior diameter.
• Pairs of ribs


  There are 12 pairs of ribs. Ribs 1-7 are true ribs, attached directly to the sternum by costal cartilages. Ribs 8-10 are false ribs, attached to the sternum by a common cartilage. Ribs 11-12 are floating ribs, not attached to the sternum at all.
• Anterior ribs and intercostal spaces


  The arrangement of ribs and spaces on the front side of the ribcage. The ribs are numbered from 1 to 12, with the spaces in between them being the intercostal spaces.
• Posterior ribs and intercostal spaces

  The arrangement of ribs and spaces on the back side of the ribcage. Similar to the anterior side, the ribs are numbered from 1 to 12, with the spaces in between them being the intercostal spaces.
• Lung lobes and their fissures

  The lung lobes are the different sections of the lungs. There are three lobes on the right lung: the right upper lobe (RUL), right middle lobe (RML), and right lower lobe (RLL). On the left lung, there are two lobes: the left upper lobe (LUL) and left lower lobe (LLL). Fissures divide these lobes; the right lung has horizontal and oblique fissures, while the left lung has an oblique fissure.
• Vertical lines in reference to the thorax

  Imaginary lines that divide the thorax to help the examiner describe a location around the circumference of the chest wall.
• Anterior vertical lines


  Imaginary lines on the front side of the thorax, including the midsternal line, right midclavicular line, and left midclavicular line.
• Posterior vertical lines


  Imaginary lines on the back side of the thorax, including the vertebral line, right scapular line, and left scapular line.
• Characteristics of a healthy adult thorax

  The thorax is oval-shaped, with its anteroposterior diameter being half its transverse diameter. In older adults, kyphosis and osteoporosis may alter its size as the ribs move downward and forward.
• Deformities of the chest

  • Pigeon Chest (Pectus Carinatum) - protruding sternum, narrow transverse diameter, and increased anteroposterior diameter
  • Barrel Chest - seen in clients with thoracic kyphosis and emphysema, has a ratio of the anteroposterior to transverse diameter being 1 to 1
  • Funnel Chest (Pectus Excavatum) - depressed sternum, narrowing the anteroposterior diameter
• Thoracic kyphosis


  Excessive convex curvature of the thoracic spine
• Scoliosis


  Lateral deviation of the spine
• Normal breath sounds


  • Vesicular
  • Bronchovesicular
  • Bronchial (tubular)
• Adventitious breath sounds


  • Crackles (rales)
  • Gurgles (rhonchi)
  • Friction rub
  • Wheeze
• Equipment needed for assessing the posterior thorax and lungs

  • Examination gown
  • Drape
  • Working gloves
  • Stethoscope
  • Drop light (or any other light source)
  • Face mask
  • Skin marker
  • Metric ruler
• Collection of Subjective Data

  • Present Health History: Dyspnea, Chest Pain, Cough, Gastrointestinal Symptoms
  • Past Health History: History of Respiratory Disease, Thoracic Surgery/Trauma, Allergies, Medications, Previous Diagnostic/Lab Results
  • Family Health History: Lung disease, Smokers
  • Lifestyle: Diet, Smoke, Exposure to environmental hazards, Activity, exercise, rest and sleep pattern, Use of other complementary therapies
• Assessment of Spinal Alignment

  • Normal: Cervical, Thoracic, and Lumbar curvatures are observed
  • Abnormal (Scoliosis): Deviation of the spine is observed when the client bends forward at the waist and is observed from behind
• Thoracic Expansion (Respiratory Excursion)


  Normal: Full and Symmetric Thorax Expansion (3 to 5 cm/1.2-2 inches) during deep inspiration

  Abnormal: Asymmetric and/or decreased thorax expansion; Unequal chest expansion; Decreased chest excursion at the base of the lungs (COPD)
• Tactile Fremitus


  Normal: Bilateral symmetry of vocal fremitus; Felt most clearly at the apex of the lungs; Low-pitched voices of males are more readily palpated than higher pitched voices of females

  Abnormal: Decreased or absent fremitus (associated with pneumothorax); Increased fremitus (associated with consolidated lung tissue, as in pneumonia)
• Percussion


  Technique used in physical examination to assess the underlying structures of the body by producing sounds
• Purpose of percussion


  To assess the density, size, and consistency of underlying organs and tissues
• Normal findings during percussion

  • Resonance, with percussion notes resonating except over the scapula. The lowest point of resonance is at the diaphragm level (8th to 10th rib posteriorly).
• Abnormal findings during percussion


  • Asymmetry in percussion notes, areas of dullness or flatness over lung tissue (associated with consolidation of lung tissue or a mass)
• Characteristics used to describe percussion notes

  • Relative intensity
  • Relative pitch
  • Relative duration
  • Example of location
• Examples of percussion notes and their characteristics

  • Flat (soft, high, short) - Thigh

  Dull (medium, medium, medium) - Liver

  Resonant (loud, low, long) - Healthy lung

  Hyperresonant (very loud, lower, longer) - Usually none

  Tympanitic (loud, high, longer) - Gastric air bubble or puffed-out cheek
• Auscultation of voice sounds


  Technique used to listen to voice sounds during a physical examination
• Bronchophony


  Involves asking the client to repeat the phrase "ninety-nine" while auscultating the chest wall. Voice transmission is soft, muffled, and indistinct. The sound of the voice may be heard, but the actual phrase cannot be distinguished.
• Egophony


  Involves asking the client to repeat the letter "E" while listening over the chest wall. Voice transmission will be soft and muffled, but the letter "E" should be distinguishable.
• Whispered pectoriloquy


  Involves asking the client to whisper the phrase "one-two-three" while auscultating the chest wall. Transmission of sound is very faint and muffled. It may be inaudible.
• Focus of assessment for the anterior lung and thorax

  Assessment of the anterior lung and thorax
• Normal and abnormal findings in respiratory rate

  • Normal breathing rate: 12-20 breaths per minute

  Abnormal findings include tachypnea (>24 breaths per minute), bradypnea (<10 breaths per minute), hyperventilation (rapid, deep breaths), and others
• Costal angle


  Assessed for its width. A normal finding is a costal angle of less than 90 degrees, while an abnormal finding is a widened costal angle, often associated with chronic obstructive pulmonary disease (COPD).
• Palpation of the anterior chest


  Full and symmetric chest expansion is assessed. Normal findings include thumbs separating 3 to 5 cm (1.2 to 2 inches) during inspiration. Abnormal findings include asymmetric or decreased thorax expansion, unequal chest expansion, and decreased chest excursion at the base of the lungs, characteristic of COPD.