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PHYSICAL ASSESSMENT

THE THORAX ANDLUNGS

Assessing The Thorax and Lungs

Anatomy of the Chest

Anatomy of the Chest Chest bones

Sternum Manubrium Xiphoid process Clavicles 12 Pairs of ribs 12 Thoracic

vertebrae Scalpula

Chest Landmarks Anatomical

mapping

right anterior axillary line

Right midclavicular line

Midsternal line

Chest Landmarks Anatomical

mapping

posterior axillary line

midaxillary line

Anterior axillary line

Chest Landmarks

Anatomical mapping

Vertebral line

Scapular line

Anatomy of the Lungs Lungs

Right has 3 lobes Left has 2 lobes Oblique fissure divides

upper & lower lobes Trachea

Anterior to esophagus Branches into right & left

bronchi Right wider, shorter,

more vertical (aspiration)

Bronchioles Alveoli

Anatomy of the Lungs

Mapping of the lungsAnterior

chest primarily upper lobes

Anterior Chest Landmarks

Anatomy of the Lungs

Mapping of the lungs Posterior

chestprimarily lower lobes

Posterior Chest Landmarks

Lateral Chest Landmarks

Chest Shape and Size

The adult chest The thorax is oval Anteroposterior diameter is half its

transverse diameter Elliptical Diameter is smaller at the top than at the

base

Deformities of the Chest

Pectus Carinatum Pigeon chest May be caused

by rickets Protruding

sternum Narrow

transverse diameter

Deformities of the ChestPectus

Excavatum Funnel Chest

Congenital defect

Depressed sternum

Narrow anteroposterior diameter


Barrel Chest Ratio of anteroposterior diameter to

transverse diameter is 1:1 seen in clients with kyphosis and

emphysema


Kyphosis Excessive

convex curvature of the thoracic spine


Lordosis


Scoliosis Lateral

deviation of the spine

Normal Breath Sounds Types of breath sounds

Vesicular Low pitch gently sighing Heard over lung fields 5:2 ratio inspiration:expiration

Bronchovesicular Medium pitch Blowing sounds Heard over main bronchus 1:1 ratio inspiration:expiration

Bronchial (tracheal/tubular) High pitch, loud Harsh sounds Heard over trachea 1:1 ratio, maybe 1:2

Adventitious Breath Sounds Crackles

Fine short interrupted crackling sounds

Gurgles Continuous, low-

pitched, coarse, gurgling, louder sounds

Friction rub Superficial, grating or

creaking sounds Wheeze

Continuous, high pitched, squeaky musical sounds

Normal and Abnormal Breath Sounds

Assessing the Thorax and Lungs

1. Introduce self, verify the clients identity and explain the procedure

2. Perform hand hygiene3. Provide for client privacy4. Inquire if the client has any history of

the following: Family history of illness including cancer,

allergies and tuberculosis Lifestyle habits such as smoking Occupational hazards Medications being taken Current problems

Assessing the Posterior Thorax

5. Inspect the shape and symmetry of the thorax form posterior to lateral views

6. Inspect the spinal alignment for deformities

Exaggerated spinal curvatures


7. Palpate the posterior thorax8. Palpate the posterior chest for

respiratory excursion

Full and symmetric chest expansion

Thumbs should move apart an equal distance and at the same time

Normally the thumb separates 3 to 5 cm during deep inspiration


9. Palpate the chest for vocal (tactile) fremitus

Bilateral symmetry of vocal fremitus

Decreased or absent, or increased fremitus


Palpating the chest for vocal fremitus using ulnar aspect of the hand

Palpating the chest for vocal fremitus using the palmar surfaces of the fingertips


10. Percuss the thorax.

Percussion Technique

Determine air, fluid or solid materials in the lungs

Determine the positions and boundaries of certain organs

Penetrates to a depth of 5-7cm (2-3 in)


Percussion pattern of the Posterior thorax

Percussion notes resonant, except over scapula

Asymmetry in percussion,areas of dullness or flatness over lung tissue


11. Percuss for diaphragmatic excursion

Excursion is 3 to 5 cm (1 to 2 in. bilaterally in women, 5 to 6 cm (2 to 3 in) in men

Diaphragm is usually slightly higher on the right side


12. Auscultate the chest using flat-disc diaphragm of the stethoscope

Areas and sequence in aucultating the posterior thorax

Normal Breath sounds

Adventitious breath sounds

Absence of breath sounds

Assessing the Anterior Thorax

13. Inspect breathing patterns.14. Inspect the costal angle and the angle and at

which the ribs enter the spine

Costal angle is less than 90 degrees

The ribs insert into the spine at approximately 45 degrees

Costal Angle is widened


15. Palpate the anterior chest.

16. Palpate for respiratory excursion

Fingers are placed laterally along the lower rib cage, and thumbs along the costal margins

Full symmetric excursion

Thumbs normally separates 3 to 5cm (1 to 2 in)


17. Palpate tactile fremitus in the same manner as for the posterior chest

Areas and sequence for palpating tactile fremitus on the anterior chest

Fremitus is normally decreased over the heart and breast tissue


18. Percuss the anterior chest systemetically

Percussion pattern of anterior thorax

Resonance down to the sixth rib at the level of the diaphragm

Flat over the areas of heavy muscles and bone

Dull on the areas over the heart and the liver

Tympanic over the underlying stomach


19. Auscultate the trachea.20. Auscultate the anterior chest.21. Document findings in the client

record.

Lifespan Considerations

I. Infants Thorax is rounded, cylindrical,

anteroposterior equal to transverse diameter

Tends to breath using the diphragm

II. Children 1:2 ratio at 6 years old Breath abdominally than thoracically Should be assessed for scoliosis by

age of 12

Lifespan Considerations

III. Elders Kyphosis and osteoporosis alter the size of

cavity Anteroposterior diameter of the chest widens Inspiratory muscles becomes less powerful Expiration may require use of accessory

muscles Elastic tissue of the alveoli loses its

strechability Cilia in the iarwy decerese in number

Breathing is so characteristic of life; studying, sleeping, talking, eating and exercising all involve breathing

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