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Thoracic & lung assessment

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Structure & FunctionTHORACIC CAGE

Sternum and Clavicle

12 Ribs and thoracic vertebrae

Muscles

Cartilage

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Vertical lines references

1

9

8

11

10 3

2

4

6

5

3

7

21

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Lateral imaginary landmarks

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Posterior landmarks

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Thoracic cavityLungs

Pleural membranes

Trachea and bronchi

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Collecting subjective data

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The nursing health history

History of present health concernCOLDSPA

QuestionDifficulty breathing?

Chest pain?

Cough? Wheezing?

Past Health History

Family History

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Collecting objective data

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Physical assessment

General

InspectionInspect for nasal flaring and pursed lip breathing

Observe for color of face, lips, and chest

Inspect color and shape of nails

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Respiratory patterns

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Respiratory patterns

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InspectionAnterior/Posterior/Lateral ChestInspect respiratory rate, rhythm, depth, and

symmetry of chest movements.

Shape and symmetry (configuration)

Movement with breathing:

Women - more thoracic respiratory movements;

Men and infants - more abdominal respiratory movements.

■ Condition of chest skin

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Inspect configurationNormal : Scapulae are symmetric &

non-protruding.

1:2 ratio (anteroposterior to tranverse diameter)

Abnormal : Scoliosis,

Kyphosis,

Barrel chest,

Pectus excavatum,

Pectus carinatum

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1

43

2

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Observe for use of accessory musclesInspect the clients positioning

Note for posture & ability to support weight while breathing comfortably

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Palpationis useful in assessing

1. Tracheal position,

2. Tenderness and crepitus,

3. Chest excursion,

4. Tactile fremitus

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1. Tracheal Position

Place your thumb and index finger on either side of the trachea, and note position and distance between trachea and sternocleidomastoid muscle.

Normal: Trachea should be midline.

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2. Chest Tenderness and Crepitus

Use light palpation to assess for tenderness and crepitus.

Normal: Non-tender, no deformities or crepitus.

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3. Chest Excursion

Anteriorly, place hands vertically on the chest with fingers spread on the costal margin and thumbs together at the costal angle (like a butterfly).

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Posteriorly, place hands vertically on the chest with fingers spread and the thumbs together at the spine at the eighth to tenth rib (like a butterfly).

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4. Tactile Fremitus

■ Place the balls of your hands with your fingers hyperextended or the ulnar surface of your hand on the patient’s chest.

■ Have patient say “99” as you palpate vibrations.

NORMAL: Equal bilaterally and diminished midthorax.

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PERcussionAnterior/Posterior/Lateral Chest

Use indirect or mediate percussion

Percuss over intercostal spaces.

Note for the following sounds:

1. Resonance

2. Hyperresonance

3. Dull

4. Flat

4. Tympany

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Thorax percusion sound

Resonance to second intercostal space on left;

Slight dullness over third through fifth intercostal space over heart.

Resonance to fourth intercostal space on right

Dullness from approximately fifth to just above costal margin over liver.

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Percusion sequence

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Percuss for diaphragmatic excursion

Ask client to EXHALE forcefully and hold breath, percuss the ICS downward beginning at the scapular line (T7) of the right posterior wall until tone changes from resonance to dullness. Mark this level and allow client breathe.

Ask the client to INHALE deeply & hold. Percuss the ICS from the first mark downward until resonance changes to dullness. Then mark the level and allow client to breathe.

Measure the distance between the two marks.

NORMAL : 3–6 cm diaphragmatic excursion.

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Auscultation

Auscultate for Breath Sounds

Use the diaphragm of the stethoscope

Listen to one full respiratory cycle at each site.

NORMAL: With no adventitious sounds, lungs are clear to auscultation. No crackles, wheezes, or rubs.

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Auscultation sequence

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Adventitious breath sounds

1. Crackles or rales - sounds resulting from air bubbling through moisture in the alveoli or from collapsed alveoli popping open

2. Wheezing - caused by the narrowing of an airway by spasm, inflammation, mucus secretions,or a solid tumor

3. Rhonchi – lowerpitched, sonorous wheezes, may even have a snoring or rattle-like quality.

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4. Stridor - is a harsh, high-pitched, continuous honking sound resulting from an upper airway obstruction, a partial obstruction, or a spasm of the trachea or larynx.

5. Grunting - is a larger airway sound heard predominantly on expiration. It results from retention of air in the lungs, which prevents alveolar collapse.

6. Friction rubs - results from the rubbing together of the parietal and visceral layers of an inflamed pleura, which produces a high-pitched grating or squeaking sound.

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Auscultate Voice Sounds

■Bronchophony: Have patient say “1, 2, 3”; ■Egophony: Have patient say “ee”■Whispered pectoriloquy: Have patient whisper “1, 2, 3”;

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Lung Cancer

Leading cause of cancer deaths in men and women:

163,510 deaths from lung cancer in 2005 (90,490 men; 73,020 women).

60 percent diagnosed with lung cancer die within first year.

75 percent die within 2 years.

5-year survival rate is 15 percent.

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Risk Factors for Lung Cancer

Smoking

Asbestos

Radon

Occupational exposure to cancer-causing agents:

Marijuana

Radiation therapy.

Recurring lung inflammation.

Mineral exposure

Family history

Genetic abnormality

Diet

Air pollution: Slight increase in risk.

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Warning Signs of Lung Cancer

■ Persistent cough

■ Changes in respiratory pattern

■ Unexplained dyspnea

■ Blood-streaked sputum

■ Hemoptysis

■ Rust-colored or purulent sputum

■ Chest, shoulder, or arm pain

■ Recurring pleural effusion, pneumonia, or bronchitis