NURS 1030 Update!

1. Open Labs Sundays between 1400 and 1600; Wednesdays

between 1200 and 1400
2. Practice your assessment skills using the checklists

Student Office Hours: Mondays/Wednesdays/Thursdays 1300 – 1400

NURS 1030: Introduction to Health Assessment

Respiratory – Nose, Mouth, Throat

Thorax & Lungs
(Chapters 17 & 19)
Readings:
Jarvis, C. (2019). Physical examination & health assessment (3rd
Canadian. ed.). Elsevier

Jarvis:
✓Chapter 17
✓Chapter 19
 Objectives
At the end of this session, students should be able to:

• Describe the significant features of the nose, mouth, throat,

thorax, and lungs (respiratory system)
• Review the structures and landmarks
• Perform a focused health assessment
• Identify relevant developmental considerations
• Incorporate health promotion concepts when performing an
assessment
NURS 1030: Introduction to Health Assessment

Nose, Mouth, Throat, Sinuses

(Chapters 17)
Anatomy and Physiology Review:
Nose
Sinuses
 Structure and Function

Mouth:
• Hard
and
soft
palates
• Uvula
• Tongue
• Gingiva

Slide 16-8
 Nose, Sinuses, Mouth, and Throat:
Health History Taking
Assessment of risk factors: Subjective data collected:
• Personal history • Discharge
• Family history • Frequent colds
• Nosebleed
• Psychosocial history • Sinus pain
(e.g. Smoking in • Trauma
different forms) • Allergies
• Environmental • Altered smell
exposure • Bleeding gum
• Medication and • Toothache, sugar
supplements consumption
• Hoarseness of voice,
dysphagia
• Sleep apnea
• Smoking and tobacco use,
alcohol
 Inspection and Palpation of Nose
1. Symmetry
2. Deformity
3. Tenderness – may indicate
fracture
4. Inflammation
5. Nasal cavity (Otoscope)
6. Nasal flaring
7. Patency (each nostril)
8. Sense of smell
Palpation of Frontal and Maxillary Sinuses
 Inspection of Mouth and Throat
Inspect lips for color, moisture, and lesions
• Lips are pink and moist with no lesions
• What colour may indicate a problem?

Inspect the buccal mucosa, soft and hard

palates, and the tongue
• Buccal mucosa is pinkish-red and moist
• Soft and hard palates are pink with no
lesions
• Tongue is smooth and midline

Inspect the teeth and gums (gingiva)

• Gingiva is pink and moist without
inflammation
Inspection of Mouth and Throat

Note the position of the uvula:

• Instruct the client to say “ah”

• Note the rise of the uvula
• Uvula rises symmetrically with “ah”
• This test also assesses the function of the
vagus nerve (IX& X)

Gag Reflex: Nerve Injury?

 Nose, Mouth, and Throat

Harper College Nursing:

https://www.youtube.com/watch?
v=7jOmHZA_bPY

NursingYou 2.0:
https://www.youtube.com/watch?
v=C0-VGCujzi0
 Health Promotion Topics

• Oral Health – Qatar?

• HP = Hygiene Practices?
• Smoking & tobacco
consumption
 Nose, Sinuses, Mouth, and Throat

LIFE SPAN CONSIDERATION CULTURAL CONSIDERATIONS

• Pregnancy: Rhinitis, sinus infection,
epistaxis, hyperemic gums • Incidence of dental caries varies
• Children: ability to smell since birth, with sociodemographic group
salivation begins at 3 months, tactile
sensation of lip and tongue since birth • Nasopharyngeal cancer is high
Teething begins in utero, teeth erupt
between 5-27 month
among Asians
• Older adult: gustatory rhinitis; decrease
sense of smell and taste; resorption in
gum and mandible bone
 Question

A 70 year-old woman complains of dry mouth. The

most frequent cause of this problem is:

a. The aging process

b. Related to medications she may be taking
c. The use of dentures
d. Related to diminished sense of smell
 Question

In a medical record, the tonsils are graded as 3+.

The tonsils would be:

a. Visible
b. Halfway between the tonsillar pillar and uvula
c. Touching the uvula
d. Touching each other
NURS 1030: Introduction to Health Assessment

Respiratory – Thorax and Lungs

(Chapters 19)
 Anatomy and Physiology Overview
• Upper and lower tracts
– Upper airway --------, ---------, and ---------
air
– Lower airway, where ------------ and ---------
----- occur
• The thorax
• One of the most dynamic regions of the
body Why?
• Thoracic cage consist of what bones?
• Thoracic cavity contains what organs?
• Thoracic nerves in the chest (T1 to T12)
• Phrenic nerve innervate what?
• Intercostal nerves innervate what?
 Anatomy and Physiology Overview (cont.)
• Each lung has a pulmonary artery that
supplies lungs with ----------blood for
gas exchange

• Two pulmonary veins return --------

blood from lungs to the left side of the
heart for circulation to the rest of the
body.
 Anatomy and Physiology Overview (cont.)

• Anterior thoracic landmarks

– Involve the ribs and their
associated interspaces
– Suprasternal (jugular) notch
– Sternal angle
– Intercostal space (ICS)
– Costal angle
Anatomy and Physiology Overview (cont.)
Anatomy and Physiology Overview (cont.)

• Posterior thoracic
landmarks
• Vertebral processes
• Spinous process of T1
• Lower tip of the scapula
• 11th floating rib
• 12th floating rib
Anatomy and Physiology Overview (cont.)

• Reference lines
– Anterior
• Midsternal
• Midclavicular
• Anterior axillary
lines
Anatomy and Physiology Overview (cont.)

• Reference lines
– Posterior
• Vertebral line
• Scapular line
 Anatomy and Physiology Overview (cont.)

• Reference Lines
– Lateral
• Anterior axillary lines
• Midaxilary line
• Posterior axillary line
 Anatomy and Physiology Overview (cont.)
• Lobes of the lungs
– The left lung has two lobes
– Left Upper Lobe LUL
– Left Lower Lobe LLL
– The right lung has three lobes
– Right Upper Lobe RUL
– Right Middle Lobe RML
– Right Lower Lobe RLL
• Fissures
– Horizontal (minor) fissure: divides RUL &
RML
– Right Oblique fissure: divides RML & RLL
– Left Oblique Fissure: divides LUL & LLL+
Let’s Outline the Thoracic Cage

Anterior landmark:

Apex - about 2 to 4 cm above the

inner third of the clavicle.

Base - extends till 6th rib MCL and

the 8th rib at the mid-axillary line.

Posterior landmark:
Apex - near C7
Base - near T10
One side is not like the other!
 Anatomy and Physiology Overview (cont.)
• Lower respiratory tract
• Trachea bifurcates to left and right main bronchi
• Right main bronchus is shorter, wider, and more
vertical
• Narrowed bronchioles create which sound?
• Excessive mucous in the airways produce which
sound?
• Breath sounds are coarser, louder and easier to
auscultate in ----------
• Breath Sound is softer, finer and difficult to
auscultate in -------------
 Anatomy and Physiology Overview (cont.)

• Lower respiratory tract

(cont.)

• Alveoli: the primary

units in the lungs that
absorb oxygen and
excrete carbon
dioxide.
• Pulmonary
arterioles
• Pulmonary veins
 Anatomy and Physiology Overview (cont.)

Pleurae: is a double layer membrane consist of

• Visceral Pleura: encases lungs

• Parietal Pleura: lines thoracic wall,

mediastinum, diaphragm

Mediastinum: contains organs and tissue

between right and left lung the heart (aorta,
thymus gland, part of the trachea, esophagus,
lymph nodes, and important nerves)
 Mechanism of Breathing
• When breathing is triggered, the ------------
contracts and flattens, pulling the lungs down.
• The thorax and lungs elongate, increasing the -
--------diameter.
• The external intercostal muscles open the ribs
and lift the sternum, and the-------------
diameter of the thorax increases.
• With increased thoracic size, pressure in the
lungs ---------than pressure in the atmosphere.
• As a result, approximately ----------mL of air
enters the lungs with each breath in adults
 Mechanics of Respiration
Inspiration: Starts with
contraction of the
diaphragm

Expiration: Is primarily a
passive process

Tidal volume: Amount of

air inhaled during a normal
relaxed breath (approx.
500 mL).
 Terms to Know & Matching Game

A. Eupnea 1. Absence of respiration

B. Dyspnea 2. Difficulty breathing
C. Orthopnea 3. Breathing rate <10 breaths/min
D. Bradypnea 4. Normal breathing
E. Tachypnea 5. Breathing rate > 24 breaths/min
F. Apnea 6. Difficulty breathing when lying
flat
 Lifespan Considerations - Pregnancy

• Lower ribs flare up and out (5-7

cm increase in circumference)
as the fetus and uterus grow
• Costal angle increases
• Uterus pushes diaphragm up by
4cm
• Tidal volume increases
 Respiratory Pattern in Infants
• Chest is round • Respirations in
in the newborn infants should be
counted for 1
• Chest wall is minute, why?
made of
• Respiratory rates
cartilage are fastest in
mostly newborns, how
• Continuous many breaths per
development minute?
of respiratory
system
 Lifespan Considerations: Older Adults

▪ Decreased inspiratory volume

▪ Increased residual volume
▪ Alveoli less elastic and more rigid,
lungs become ‘stiff’
▪ Decreased function of the cilia leads
to the pooling of secretion in the
lungs
▪ Weaker chest muscles also decrease
the ability to cough up secretions
 Common Lab/Diagnostic test

• CBC
• ABGs
• Sao2
• Chest X-ray
 Health Assessment: General Survey
General Survey:
• Physical appearance
• Body structure
• Behaviour
• Mobility
Inspect skin color:
• Document the absence of cyanosis or
pallor
Note position:
• Normally, posture is relaxed and upright
with the arms at the sides
• Clients in respiratory distress may assume
a tripod position
 General Survey

Assess for any signs of respiratory

distress:

• Normally, facial expression is

relaxed
• Clients in respiratory distress may
have an anxious expression
• Pursed lip breathing can be seen in Pursed lip breathing:
1. Provide positive pressure in the
patients with COPD when exhaling bronchial tree to prevent
airway collapse
2. Allow for more air out and
then more air in.
 Health Assessment: Health History Taking
• Begins with the health history
• Respiratory conditions
• Allergies
• TB
• Vaccine
• Medication
• Family history
• Lifestyle
• Occupational history
 Health Assessment: Physical Examination
• Promoting patient comfort
• Ensure comfortable room temperature
• Draping
• Provide the rationale for the need to
expose the chest
• Expose only the area of the chest
you will be examining

• Equipment needed
• Stethoscope and alcohol swab
• Small ruler and marking pen to mark
diaphragmatic excursion
 Physical Examination: Inspection
Respiratory Pattern:
• Assess respiratory rate (12 to 20
breaths/min in adults)
• Observe for any nasal flaring, lip
pursing, or wheezes
• A wheeze is an unexpected or
adventitious breath sound
produced by air passing through
narrowed bronchioles
 Physical Examination: Inspection
Posterior Chest:
Check shape and configuration of the
thoracic cage:
• Chest expansion is symmetrical
• Most common antero-posterior
(front to back) to transverse
(side to side) ratio is 1:2
• Some people who have chronic
obstructive pulmonary disease
— develop a “barrel chest” in
the later stages of the disease.
Comparison: Normal chest versus barrel chest
 Physical Examination: Palpation

Symmetrical Expansion:

1. Confirm chest expansion by placing

warmed hands on the posterior chest

1. Slide your hands medially to pinch up a

small fold of skin between your thumbs

2. Ask the client to inhale deeply – your

thumbs should move apart symmetrically
https://www.youtube.com/watch?v=Ixm97rb3
gxI
 Physical Examination: Palpation

Assessing Tactile Fremitus:

• Ask the client to repeat the word

“ninety-nine”

• Use the palmar base or ulnar surface

• Start over the lung apices, and

palpate from one side to another

• Normally, tactile fremitus is symmetrical

https://www.youtube.com/watch?v=9B3
4XR8UDUg
 Physical Examination: Palpation
Posterior Chest:

• Using the finger pads, start

above the scapula over the lung
apex and progress from side to
side to compare findings
bilaterally, ending at the base
of the lung and moving laterally
to the mid-axillary line
• Thorax is non-tender without
any lesions, lumps, masses, or
crepitus.
 Physical Examination: Percussion
• Healthy lung tissue sounds
resonant

• Percussion is usually combined

with other tests (e.g. chest x-
ray) to confirm the diagnosis

• Percussion sounds may

become dull secondary to the
increased tissue mass in
people with large chests

• https://www.youtube.com/wa
tch?v=taLx1I6AFj4
Expected Percussion Notes
 Physical Examination: Auscultation

 Most important physical examination for

assessing air flow through the respiratory
passages and alveoli

 Larger airways – sounds are louder and

coarser
 Smaller airways – sounds are softer and
finer

 Auscultate from the top down – listen to

one full breath in each location, moving
from side to side to compare symmetry
 Physical Examination: Auscultation

Breath sounds:
• Bronchial breath sounds –
over trachea and larynx
• Bronchovesicular breath
sounds
• Anteriorly – over
sternocostal margins
• Posteriorly – Between
scapulae
• Vesicular breath sounds –
over most of the lung fields
Adventitious Breath Description Mechanism Associated Conditions
Sound
‘Popping’ or ‘Crackling’ Deflated small airways and fibrosis, heart failure, pulmonary edema,
Inspiration or Expiration alveoli will pop open during asthma, COPD, atelectasis
inspiration
Crackles Fine: Soft, short, high-pitched
Small air bubbles flow
Coarse: Louder, slightly longer through secretions in
low-pitched narrowed airways

Wheeze High or low-pitched Air moving thru NARROWED Asthma, bronchitis, emphysema
‘musical’ quality airways
Primarily expiratory
Constriction, swelling, or partial
obstruction
Low-pitched snoring or gurgling Airflow passes around or Pneumonia
Rhonchi that may clear with cough through secretions or narrowed
passages
Loud, course, low-pitched Inflamed pleural surfaces lose Pleurisy
grating or creaking sound their usual lubrication and rub
Pleural friction rub similar to a squeaky door together during breathing

Stridor Loud, high-pitched crowing or Laryngeal or tracheal Croup, epiglottitis

honking sound louder in upper inflammation
airway
 Physical Examination: Inspection
Anterior Chest:

• Note shape and configuration

• Note patient’s facial expression
• Assess level of consciousness
• Note skin colour and condition
• Assess the quality of respirations
 Physical Examination: Palpation

Symmetrical Expansion:

1. Confirm chest expansion by placing

warmed hands on the posterior chest

2. Slide your hands medially to pinch up a

small fold of skin between your thumbs

3. Ask the client to inhale deeply – your

thumbs should move apart symmetrically
 Physical Examination: Palpation

Assessing Tactile Fremitus:

• Ask the client to repeat the word

“ninety-nine”

• Use the palmar base or ulnar surface

• Start over the lung apices, and

palpate from one side to another

• Normally, tactile fremitus is symmetrical

 Physical Examination: Palpation
Anterior Chest:

Note any:
• Tenderness
• Superficial lumps or masses
• Skin mobility and turgor
• Skin temperature and moisture
 Physical Examination: Percussion
• Healthy lung tissue sounds
resonant

• Percussion is usually combined

with other tests (e.g. chest x-
ray) to confirm the diagnosis

• Percussion sounds may

become dull secondary to the
increased tissue mass in
people with large chests
 Physical Examination: Auscultation

Breath sounds:
• Bronchial breath sounds –
over trachea and larynx
• Bronchovesicular breath
sounds
• Anteriorly – over
sternocostal margins
• Posteriorly – Between
scapulae
• Vesicular breath sounds –
over most of the lung fields
 Respiratory System
Harper College Nursing:
https://www.youtube.com/watch?
v=9u13G9j81FY

NursingYou 2.0:
https://www.youtube.com/watch?
v=j5D9hkppDGY
 Health Promotion
• Risk assessment and
health promotion:
• Smoking cessation
• Prevention of occupational
exposure
• Prevention of asthma
• Immunizations
 Health Promotion: Smoking Cessation
• Use a non-judgemental approach

• Adopt the five “A’s”:

• Ask about smoking at each visit
• Advise clients regularly to stop
smoking, using a clear
personalized message
• Assess client readiness to quit
• Assist client to set stop dates and
provide educational materials for
self-help
• Arrange for follow-up visits to
monitor and support client
progress
 Question

Select the best description of the left lung:

a. Narrower than the right lung with three lobes

b. Narrower than the right lung with two lobes
c. Wider than the right lung with two lobes
d. Shorter than the right lung with three lobes
 Question

The assessment of the lateral chest wall is:

a. Important when assessing the left middle lobe

b. Only performed when assessing adults
c. Referred to as the forgotten lobe
d. Only performed on the right lateral chest wall
 Question
Select the best description of bronchovesicular
breath sounds.

a. High-pitched, of longer duration on inspiration

b. Moderate pitch, inspiration and expiration are
equal
c. Low-pitched, inspiration greater than expiration
d. Rustling sound, like the wind in the trees
Reference:
Jarvis, C. (2019). Physical examination & health assessment (3rd
Canadian. ed.). Elsevier. (Including On- line access) and student
laboratory manual, and pocket guide.

Stephen, T. C., & Jensen, S. (2013). Canadian Jensen's nursing health

assessment: A best practice approach. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
The Institution of Excellence in Technical and
Vocational Education and Training

www.udst.edu.qa