Thorax and Lungs

Nursing 330

Governors State University

Shirley Comer

Posterior Chest

Inspect- observe shape and configuration– Spinous process in straight line

Scoliosis= s shaped curve Kyphosis= outward curvature

– Thorax symmetrical– Ribs slope downward– Scapulae placed symmetrically

Chest Diameter

Anteroposterior diameter less than transverse diameter

– Barrel Chest- diameter equal to transverse diameter /c horizontal ribs and costal angles greater then 90 degrees.

Occurs in chronic emphysema r/t lung hyperinflation

Neck and Trapezius muscles- normal development– Hypertrophy /c COPD

Chest diameter image

Observe

Body position– Tripod position /c COPD so ancillary muscles can

aid breathing– Orthopnea- inability to lie flat r/t SOB- rib cage

cannot expand fully while lying-Some pt may report using several pillows in bed or sleeping sitting up

Skin color and condition Resp rate and character

Palpate the Posterior Chest

Symmetric chest expansion- place hands at T9-chest should expand evenly during inspiration. – Unequal may be present in:

Atelectasis Pnuemonia Trauma/fractured ribs Pnuemothorax

Chest expansion image

Tactile Fremitus

Is a palpable vibration– Use palms– Pt repeats phrase “99 or blue moon”

Palpate over apices to bases Vibrations should be equal bilaterally Decreased fremitus = pleural effusion, thickened chest wall,

Pnuemothorax, emphysema Increased fremitus= consolidation of lung tissue, pneumonia,

tumor, fibrosis Crepitus = crackling sensation over skin surface = SQ

emphysema

Tactile Fremitus image

Palpate

Palpate the entire chest wall– Note

Tenderness Change in skin temp Moisture Lumps Masses Skin lesions

Percuss

Percuss from apices to bases Percuss at 5cm intervals Avoid the ribs, clavicle and scapulae

– Resonance is heard over healthy lung tissue Heavily muscled or obese pt may sound duller

– Dullness is heard over bone or abnormal lung = pneumonia, pleural effusion Atelectasis or tumor

– Lungs are hyper inflated /c COPD=hyper resonance

Percussion/Auscultation pattern

Diaphragmatic Excursion

Percuss the position of the diaphragm during inspiration and expiration and mark.

Measure the difference should be equal Normal is 3 to 5 cm but may be as high as 8 in

athletes Excursion will be decreased in COPD, pleural

effusion and Atelectasis

Diaphragmatic Excursion

Auscultate the Posterior chest

Normal breath sounds– Bronchial aka tracheal or tubular-

heard close to larger airways (trachea, main bronchi)

– Bronchovesicular- heard over medium sized airways

– Vesicular- heard over lung periphery

Decreased/ Diminished Breath Sounds

Occur when– Bronchial tree is obstructed by secretions, mucous

plug or foreign body– Emphysema r/t loss of elasticity in lung and

decreased force of inspired air– Sound transmission is obstructed- pleurisy, pleural

thickening, Pnuemothorax, pleural effusion– Absent breathing

Adventitious Sounds

Crackles AKA fine rales– Short popping sounds at the end of inspiration– Caused by fluid collapsing the alveoli during

expiration– Common /c pneumonia, CHF, Atelectasis

Coarse Rales– Similar to crackles but more bubbling sounds earlier

in inspiration– Caused by more fluid than crackles

Adventitious Sounds cont

Rhonchi– Snoring sound heard during expiration– Caused by secretion in bronchial tree

Wheezes– Musical whistling sounds heard mainly on expiration

but can be through our cycle– Present in asthma, emphysema, bronchitis or

bronchospasm

Anterior Chest

Observe shape and configuration of chest Costal angle less than 90 degrees Position of ribs Observe

– Facial expression- COPD may have tense or tired faces– LOC- Cerebral hypoxia = drowsiness, irritability confusion– Skin color and condition– Quality of respirations-noisy, use of ancillary muscles

Auscultate the Anterior chest

Listen for 1 full respiratory cycle over the entire anterior chest.

Will hear vesicular lung sounds over most of anterior chest.

Pt should take deep breath in and out through mouth.

Vocal Fremitus

Egophony– Pt says “E”

Bronchophony– Pt says “99 or blue moon”

Whispered Pectoriloquy– Pt says “1-2-3”

Age Specific Considerations

Infants and Children– Resp rate will be irreg during feeding or sleeping in

neonate.– Broncho vesicular sounds heard over entire lung

field r/t thin chest wall– Crackles heard in upper fields /c cystic fibrosis.– Stidor is a high pitched inspiratory sound heard

audibly /c croup epiglottis or foreign body aspiration

Age Specific Continued

Pregnant women– Thoracic cage widens– Apical pulse displaced laterally– Orthopnea may be present– Change in resp character

Elderly– Kyphosis-Barrel chest– Marked bony prominences r/t decreased subcutaneous fat.– May fatigue during exam or hyperventilate– More likely to have disease present-pneumonia,` Atelectasis

ect

Practice Exam Question

Your client has a 20 year history of cigarette smoking and a productive cough. What adventitious breath sound are you most likely to hear during your assessment?– A. Stridor– B. Rhonchi– C. Coarse Rales– D. Vesicular

Rationale

B is the correct answer. A productive cough and history of cigarette smoking indicate the possible presence of secretions in the bronchial tree.

A is a condition seen in children C is caused by fluid D is not an adventitious breath sound