UNIVERSITY OF CEBU – BANILAD

COLLEGE OF NURSING

ASSESSMENT OF THE THORAX & LUNGS

OBJECTIVES:
Review on the anatomy & physiology of the thorax and lungs
Identify the thoracic landmarks
Know the different approaches in the physical assessment of the thorax
Know the ways on how to collect subjective data: History Taking
Collection of Objective Data: Physical Assessment
Document respiratory assessment findings

ANATOMY AND PHYSIOLOGY

Thoracic Cage:
Provides support and protection for many important organs including those of the lower respiratory
system.
THORACIC LANDMARKS
Anterior:
Clavicles
Suprasternal notch
Angle of Louis
Sternum
Costal angle
Posterior:
Superior angle
Acromion
Spine
Medial border
Lateral border
Inferior angle
Axillary line:
Mid axillary line - It is the imaginary vertical line from the middle of the axilla.
Anterior axillary line - An imaginary vertical line along the anterior axillary fold (crease of armpit).
Midclavicular line - An imaginary vertical line from the middle of the clavicle (collarbone).

GENERAL APPROACHES
Greet the patient and explain the assessment techniques that you will be using.
Room should be warm to prevent the patient from chilling and shivering.
Use a quite room that will be free from interruptions
Ensure that the light provides sufficient brightness
Instruct patient to remove clothes and change to a gown
Place the patient in an upright sitting position
Exposed the entire area to be assessed. Provide a drape to cover the breast of women when
posterior thorax is assessed.
When palpating, percussing and auscultating the anterior thorax of an obese female patient, ask
them to displace breast tissue.
Visualize the underlying respiratory structures during assessment process.
Always compare the right and left sides of the anterior and posterior thorax, as well as the right
and left lateral thorax.
Use a systematic approach every time assessment is performed.

COLLECTING SUBJECTIVE DATA

Importance:
◼ Provides clues about underlying respiratory disorders
◼ Data helps the nurse in the formulation of nursing diagnoses as well as clues on possible risk for
the development of lung disorder
◼ Important because certain respiratory problems greatly impact a person’s ability to perform
activities of daily living.

COLLECTING OBJECTIVE DATA

INSPECTION
A. Shape of the Thorax:
◼ Stand in front of the patient
◼ Estimate visually the transverse diameter of the thorax
◼ Move to either side of the patient.
◼ Estimate the anteroposterior (AP) diameter of the thorax
◼ Compare the estimates of these visualizations
NORMAL :
Ratio of the AP diameter to the transverse diameter is app. 1:2 to 5:7. A normal adult is wider from side
to side than from front to back.
Normal thorax is slightly elliptical in shape.
For infants a barrel chest is normal.

ABNORMAL FINDINGS:
PECTUS EXCAVATUM OR CONCAVE CHEST WALL
Depressed sternum or breast bone.
Space in the chest cavity for lungs to expand is diminished causing difficulty of breathing, shortness of
breathe and decreased endurance during exercise.
Cardiac compression reduces stroke volume and cardiac output causing fatigue and elevated heart rate.

PECTUS CARINATUM or Protruding Sternum

Difficulty in exhaling the air in the lungs which restricts gas exchange and causes short and fast breathing
and reduced exercise tolerance.

Pott’s disease or caries of the spine

Chest falls forward and its anteroposterior diameter is increased.
The abdominal contents are crowded up into the chest and pushthe sternum and lower ribs forward.
Associated with this deformityis oftentimes a lateral deviation of the parts above the site of the disease.
When the scapulae project like wings it is called "alar" or "pterygoid chest".

B. Symmetry of Chest Wall:

◼ Stand in front of the patient
◼ Inspect the right and left anterior thoraxes
◼ Note the shoulder height .
◼ Move behind the patient
◼ Inspect the right and left posterior thoraxes.
◼ Note the position of the scapula.

NORMAL: The shoulders should be of the same height , so with the scapula. No masses.
ABNORMAL FINDINGS:
Scoliosis
Kyphosis
Lordosis
Lateral curvature
Excessive convexity

C. Presence of Superficial Vein:

• Stand in front of the patient
• Inspect the anterior thorax for the presence of dilated superficial veins.
NORMAL : Dilated superficial veins are not seen.

D. Costal Angle:
Stand in front of the patient.
Visually locate the costal margins
Estimate the angle formed by the costal margins during exhalation and at rest.
In a heavy or obese patient, place your fingertips on the lower anterior borders of the thoracic
skeleton.
Gently move your fingertips to the xiphoid process
NORMAL : Costal angle is less than 90 deg. During exhalation and rest.

E. Angle of the Ribs:

• Stand in front of the patient
• Visually locate the midsternal area
• Estimate the angle at which the ribs articulate with the sternum
• In a heavy or obese patient, place your fingertips on the mdsternal area.
• Move your finger along the rib laterally to the anterior axilliary line. Visualize the line that is
created by your hand as it traces the ribs.
NORMAL: The ribs articulate at a 45 deg.angle with the sternum.

F. Intercostal Spaces:
⚫ Stand in front of the patient
⚫ Inspect the ICS throughout the respiratory cycle
⚫ Note any bulging of the ICS and any retractions.
NORMAL : Absence of retractions and bulging of the ICS.
G. Muscles of Respiration:
Stand in front of the patient
Observe the patient’s breathing for a few respiratory cycles, paying close attention to the thorax
and the neck.
Note all of the muscles that are being used by the patient.
NORMAL : No accessory muscles used in normal breathing.

H. Respirations:
Inspection of the respiration process includes 7 components:

RATE OF RESPIRATION:
NORMAL :
12 – 20 breaths per minute in a resting adult.
EUPNEA - normal breathing
ABNORMAL FINDINGS:
Tachypnea - respiratory rate greater than 20
Bradypnea - respiratory rate lower than 12
Apnea - lack of spontaneous respirations for 10 or more seconds

PATTERN OF RESPIRATION:
NORMAL :
Normal respiration are regular and even in rythym.
ABNORMAL FINDINGS:
CHEYNE- STOKES - occur in crescendo and decrescendo patterns
BIOT RESPIRATION OR ATAXIC RESPIRATION - irregularly irregular respiratory pattern
APNEUSTIC RESPIRATION - characterized by prolonged gasping during inspiration followed by a
very short, inefficient expiration. These pauses can last 30 – 60 seconds.
AGONAL RESPIRATIONS - irregularly irregular respirations. They are of varying depths and pattern.

DEPTH OF RESPIRATION:
NORMAL : Nonexaggerated and effortless
ABNORMAL FINDINGS:
HYPERPNEA - the breath that is greater in volume
KUSSMAUL’S RESPIRATION - characterized by extreme depth and rate of respirations.

SYMMETRY OF RESPIRATION:
NORMAL: The thorax rises and fall in unison of the respiratory cycle.
There’s no paraxodical movement.

AUDIBLITY OF RESPIRATION:
NORMAL : A patient’s respiration are normally heard by the unaided ear a few centimeters from the
patient’s nose and mouth.

PATIENT POSITION IN RESPIRATION:

NORMAL : The healthy adult breathes comfortably in a supine, prone or upright position.
ABNORMAL FINDING:
ORTHOPNEA - is a difficulty breathing in positions other than upright.

MODE OF BREATHING:
NORMAL : Normal findings vary among individuals but, generally, most patients inhale and exhale
through the nose.

I. Sputum:
◼ Ask the patient to expectorate a sputum sample.
◼ Note the color, odor, amount and consistency of the sputum.
NORMAL: Color is light yellow or clear.
Odorless
Thick or thin depending on the hydration status of the patient.
ABNORMAL FINDINGS:
Sputum Color PATHOLOGY
Mucoid - Tracheobronchitis, asthma, coryza
Yellow or green - Bacterial infection
Rust or blood- - Pneumonia, pulmonary tinged infarction, TB, lung cancer
Black - Black lung disease
Pink - Pulmonary edema
 PALPATION OF THE THORAX

A. GENERAL PALPATION
A. ANTERIOR
◼ Stand in front of the patient
◼ Place the fingerpads of the dominant hand on the apex of the right lung (above the clavicle)
◼ Using light palpation, assess the integument of the thorax in that area.
◼ Move the fingerpads down to the clavicle
◼ Proceed the palpation, moving down to each rib and ICS
◼ Repeat the procedure on the left anterior thorax
B. POSTERIOR
◼ Stand behind the patient.
◼ Place the fingerpads of the dominant hand on the apex of the right lung (approximately on the
level of T1.
◼ Using light palpation, assess the integument of the thorax on that area.
◼ Move the fingerpads down to the first thoracic vertebra and palpate.
◼ Move down to each thoracic vertebra and ICS of the right posterior thorax.
◼ Repeat the procedure on the left posterior thorax.
C. LATERAL
◼ Stand on the patient’s right side
◼ Have the patient lift the arms overhead
◼ Place the fingerpads of the dominant hand beneath the right axilliary fold.
◼ Usng light palpation, assess the integument of the thorax in that area.
◼ Move the fingerpads down to the first rib beneath the axilliary fold.
◼ Proceed with the palpation, moving down to each rib and ICS of the right lateral thorax.
◼ Repeat for the left lateral thorax.

B. PULSATIONS
C. MASSES
D. THORACIC TENDERNESS
E. CREPITUS

THORACIC EXPANSION

ASSESS THE EXTENT OF CHEST EXPANSION AND THE SYMMETRY OF CHEST WALL
EXPANSION.
A. ANTERIOR THORACIC EXPANSION
PROCEDURE:
⚫ Stand directly in front of the patient . Place the thumbs of both hands on the costal margin and
pointing towards the xiphoid process.
⚫ Lay your outstreched palms on the anterolateral thorax.
⚫ Instruct the patient to take a deep breath.
⚫ Observe the movement of the thumbs, both in direction and in distance.
⚫ Ask the patient to exhale.
⚫ Observe the movement of the thumbs as they return to the midline.
NORMAL: 3 – 5 cm.

B. POSTERIOR THORACIC EXPANSION

PROCEDURE:
⚫ Stand directly behind the patient. Place the thumb of both hands at the level of the 10 th spinal
vertebra. Gather a small amount of skin between the thumbs as directed for anterior expansion.
⚫ Place your outstretched palms on the posterolateral thorax.
⚫ Instruct the patient ot take a deep breathe.
⚫ Observe the movement pf the thumbs, both n direction and n distance.
⚫ Ask the patient to exhale
⚫ Observe the movement of the thumbs as they return to the midline.

TACTILE OR VOCAL FREMITUS

Is the palpable vibration of the chest wall that is produced by the spoken word.
The technique is useful in assessing the underlying lung tissue and pleura.
PALMAR BASES OF THE FINGERS
ULNAR ASPECT OF THE HANDS
ULNAR ASPECT OF A CLOSED FIST
PROCEDURE:
• Firmly place the ulnar aspect of an open hand (or palmar base of the fingers or ulnar aspect of a
closed fist) on the patient’s right anterior apex.
• Instruct the patient to say the word “99”
• Feel any vibration on the ulnar aspect of the hand as the patient phonates.
 • Move your hand to the same location on the left anterior thorax.
• Repeat steps 2 and 3

PERCUSSION

GENERAL PERCUSSION
A. Anterior
⚫ Patient is in upright position
⚫ Percuss 2-3 strikes in the lung apex
⚫ Repeat in the left lung apex
⚫ Note the percussion sound
B. POSTERIOR
⚫ Patient in upright sitting position
⚫ Have the patient bend down his head and fold the arms around his waist
⚫ Percuss the right lung apex located at the top of the shoulder.
⚫ Repeat on the left lung.
⚫ Note the sound produces
C. LATERAL
Patient is in upright sitting position
Start to percuss the ICS directly below the axilla
Note the sound produced.

DIAPHRAGMATIC EXCURSION
Provides information on the patient’s depth of ventilation.
This is accomplished by measuring the distance the diaphragm moves during inspiration and expiration.
Procedure:
⚫ Position the patient for thoracic percussion
⚫ With the patient breathing normally, percuss the right lung from the apex (resonance ) to below
the diaphragm (dull).
⚫ Instruct the patient to inhale deeply and hold the breath
⚫ With the patient holding the breathe, percuss the right lung in the scapular line from below the
scapula to the location where resonance changed into dullness.
⚫ Mark this location.
⚫ Do this again with the patient with patient holding the exhaled breath.
⚫ Measures the distance with 2 marks
NORMAL: Measured distance is normally 3-5 cm. The level of the diaphragm on inspiration is T12 and
T10 on expiration. The right side is slightly higher than the left.

AUSCULTATION

The aim is to identify the presence of normal breath sounds, abnormal lung sounds, adventitious (added)
lung sound and adventitious pleural sound.
Auscultation of the Thorax
3 distinct types of normal breath sounds:
⚫ BRONCHIAL (TUBULAR) I<E
⚫ BRONCHOVESICULAR I=E
⚫ VESICULAR I>E

BRONCHIAL LUNG SOUNDS

Bronchial or tracheal sounds are heard on the chest at sites which are close to large airways.
They are relatively louder in expiration than inspiration
They have a tubular or blowing quality similar to air being blown through a tube.
Heard on the back between the scapulae and at the lung apices especially on the right
They may also be heard in the axillae
• It has a "tubular" quality - it has been compared to the sound of air blowing through a
cardboard tube.

VESICULAR LUNG SOUNDS

This is the sound heard over the chest at a distance from large airways.
It is a "soft" sound that has been compared to the sound of wind blowing through the leaves of a tree.
This is the most common sound heard in the absence of lung disease.

BRONCHOVESICULAR SOUNDS
Location: Over the major bronchi – posterior
Between the scapula
Around the upper sternum in the first and second intercostal spaces – anterior
 ADVENTITIOUS

FINE CRACKLES (rales)

These are “discontinuous” i.e. intermittent, “explosive” sounds
Laennec described them as sounding like the crackling noise made when salt is heated on a frying pan.
They are caused by airway opening.

COARSE CRACKLES
These are intermittent "bubbling" sound.
Laennec compared these sounds to the sound of water being poured from a bottle.
They are caused by airway opening and secretions in airways.

WHEEZES (ronchi)
⚫ These are high pitched, whistling or sibilant sounds.
⚫ Musical and continuous
⚫ They are caused by airway narrowing, secretions

PREPARATION OF THE CLIENT

• Have the client remove all clothing from the waist up and put on an examination gown or drape
• The gown should be open down the back to limit exposure
• Explain the exposure of the entire chest which is necessary during some parts of the examination
• Explain the procedure before initiating the examination to further ease the client
• Place the client in an upright position with arms relaxed at the sides
• Provide explanations during the examination as various examination techniques are performed
• Encourage client to ask questions and to inform the examiner of any discomfort or fatigue during
the examination
• The room temperature should be comfortable to the patient

EQUIPMENT
Examination gown and drape
Gloves
Stethoscope
Light source
Mask
Skin Marker
Metric ruler

KEY POINTS
• Provide privacy for the client
• Keep your hand warm to promote the client’s comfort during the examination
• Remain nonjudgmental regarding the client’s habits and lifestyle and at the same time educate
and inform about risks such as lung cancer, COPD or related habits

Prepared by:
Jegs C. Pornia RN, MN, LPT