Assessment of the

Lungs & Thorax

 By the end of this session, learners will be able to;
• Review A&P Respiratory System.
• Collect pertinent historical data related to thorax
complaints.
• Apply diagnostic reasoning process to clients with
thorax complaints.
• Demonstrates advanced pulmonary and breast
Objectives: assessment.
• Discuss classic positive and negative findings for
clients with thorax complaints.
• Apply geriatric and cultural considerations when
assessing clients with thorax complaints.
• Document findings.
Anatomy &
Physiology
Thoracic Cage

• Sternum
• 12 pairs of ribs
• 12 thoracic vertebrae
Includes: • Diaphragm at the floor
• Septum that separates
it from abdominal
cavity
Anatomy of
Chest

Bickley & Szilagyi, 2017

Imaginary lines and landmarks
 1. Vertebral prominence
2. Spinous processes
Posterior 3. Inferior border of scapulae
Thoracic 4. Twelfth rib

Landmark
s
Anterior view of lobes
Posterior view of lobes
Right lateral view of
lobes
Left lateral view of
lobes
Thoracic
Diameter
AP to Lateral diameter

Till age 6 - 1:1 (equal)

1:2 in normal adult

Barrel chest - 1:1 in adult

• presence of chronic
pulmonary disease
 • Any risk factors for
Health
Present health status
respiratory disease
• URI

History
• Smoking
• Allergies
• Pack years ppd X #
years • Recent screening or diagnostic
• Exposure to smoke assessments, last CXR
• History of attempts to • Medications
quit, methods, results
• Use of aerosols or inhalants
• Sedentary lifestyle, for any purpose
immobilization • Exercise tolerance
• Age
• How soon do vital signs return
• Environmental to NL after exercise
exposure
• Dust, chemicals,
asbestos, air pollution
• Obesity
• Family history
Health History of Presenting Illness
Cough
Sputum
• amount
History • Type
• color
• Onset
• presence of
• Duration blood (hemoptysis)
• Pattern • odor
• activities, time of day, • consistency
weather
• pattern of production
• Severity
• effect on ADLs
• Wheezing
• Associated symptoms
• Treatment and effectiveness
 History of Presenting Illness

Health Shortness Of Breath

• Onset - sudden or gradual
Past Health History
• Respiratory infections or

History • Frequency- intermittent or persistent

• Pattern- when/where condition
diseases (URI)
• Trauma
occurs • Surgery
• relationship to exercise • Chronic conditions of other
• time of day systems
• eating
• Severity- effect on activity
• COPD
• Response to treatment
Other terms for SOB
• Orthopnea
• "2 pillow"
• paroxysmal nocturnal dyspnea
- PND
Health Family Health History
• Tuberculosis
Other considerations
• Employment
History • Lung Cancer • Exposure
• Allergies • Hobbies
• Asthma
 • Sitting: …. Examining
posterior thorax and lungs
• Supine: …. Examining anterior
thorax and lungs

Positions for • Examine;

• Anterior/Posterior
Chest…
• Inspection
examinations • Palpation
• Percussion
• Auscultation
Physical Examination/ Thoracic Assessment

Privacy
Warm
Well lit
EQUIPMENT

• Examination gown and drape

• Gloves
• Stethoscope
• Light source
• Mask
• Skin marker
• Metric ruler
Inspection of chest
General:
• Inspect for nasal flaring and pursed lip breathing.
• Observe color of face, lips, and chest.
• Inspect color and shape of nails.
• Observe use of accessory muscles.
• Inspect the client’s positioning.
 SYMPTOMS
• S…Shape of the chest
• SY...Symmetry of the chest
• M…Movements of Chest
• P…Positions of trachea, Pigmentations, scars
Chest • T…Types of Respiration
• O…Other Pulsation and Apex beat
• M…Mid-costal (intercostal) spaces
Inspection • S…Supra-clavicular fossa
 • Thoracic contour
1. Shape…
• Normal…. 1:2 AP to Lateral diameter
• Abnormal… Pigeon chest, barrel chest, funnel
chest,
Thoracic 2.
Symmetry:
• Bulging…plural effusion,
pneumothorax, kyphosis, fractures,
tumors
Inspection • Retraction… collapse or fibrosis lungs,
thoracoplastyfossa:
3. Supra-clavicular surgery
 Shallow fossa… Emphysema
 Deep fossa… collapse or fibrosis lungs
Shape of chest: Thoracic
Deformities
Inspection Respiratory Pattern 2.Depth: shallow, deep
Deep and fast
• Rate
• Agitation
• Rhythm
Deep and slow
• Depth • Severe metabolic acidosis
• Effort 3. Respiratory movement

• Respiratory movement • Abdominal breathing: male adult

& child
• Thoracic breathing: female adult
1. Respiratory rate: 14-20 4. Effort/Quality
b/min
• unlabored
• Tachypnea: >24 b/min • labored- dyspnea, orthopnea
• Bradypnea: <12 b/min • shallow
• Shallow and fast
Palpation

• Check through following points

• Position of trachea
• Anterior-posterior expansion
• Vocal fremitus
• Tenderness& crepitating
• Palpable crepitation and rhonchi
 • Position of trachea
• Normal…….Middle of the chest
• Pull…collapse of lungs, fibrosis,
• Push… Pneumothorax, pleural effusion, upper
Palpation mediastinal tumor
• Palpable crepitation or rhonchi
• Tenderness
• Local inflammation, fractured rib,
Palpation
Thoracic expansion

Posteriorly- level of T9 or T10

Thumbs should separate 5 - 10 cm

Feel during quiet I & E

Should be symmetrical

• If not - ?
• atelectasis (lung collapse)
• Massive hydrothorax,
pneumonia, pleural thickening,
Tactile Fremitus
• Vocal fremitus (tactile fremitus)
• Palpable vibrations of chest wall over
lung fields from speech or sounds
• Use palmar or ulnar surface
• Palpate vocal sounds by
• Asking the patient to say “99” or
“1, 1, 1.”
• Systematically palpate side to side in
same area
• Normal, increased or decreased
 Tactile Fremitus Increased-
conditions that increase
density of thoracic tissue
• consolidation of
pneumonia
• Some lung
tumor

Tactile Fremitus Decreased -

obstruction of transmission of
vibrations-
What does increase or • Pleural effusion

decrease tactile fremitus • Pleural thickening (fibrosis)

• Pneumothorax

mean ? • Bronchial obstruction

• COPD/emphysema
 Percussion
Check underlying area for:
Air
Fluid

Solid
Percussion sounds
• Flat
• Dull - @ heart, liver
• Resonant
• Hyper resonant - COPD,
hyperinflation
• Tympany
 Percussion
• Dullness: when fluid or solid tissue
replaces air-containing lung.
•Examples include lobar pneumonia, in
which the alveoli are filled with fluid and
blood cells; and pleural accumulations of
serous fluid (pleural effusion), blood
(hemothorax), pus (empyema), fibrous tissue,
or tumor.
• Generalized hyper-resonance is common
over the hyper-inflated lungs of COPD or
asthma.
• Unilateral hyper-resonance suggests a
large pneumothorax or an air-filled bulla
Diaphragmatic
excursion
Done when;
• Breathing is shallow
• Suspected limiting diaphragmatic
movement
• Percuss to mark level of diaphragm at
• Full exhalation,
• Full inhalation
• Excursion should be equal bilaterally and
measure 3 to 5 cm in adults.
• In well-conditioned clients, excursion can
measure up to 7 or 8 cm.
Diaphragmati
c Excursion

Bickley & Szilagyi, 2017

Auscultation

Note:
• Pitch
• Intensity
• Quality
• Duration
Order of
Auscultation
 BREATH SOUNDS

• Normal

Auscultatio • Absent

n • Reduced

• Bronchial
Adventitious
sound
• Crackles (moist)
• Rhonchi (wheezes)
• Pleural friction rub
Sounds

• Wheeze

• Crackles

• Rub

• Stridor
 Auscultation: Breath Sounds
• Bronchial
• Bronchovesicular
• Vesicular
 • Reveals if lungs are full of air, fluid or solid
• Instruct pt to say “99” each time you place
stethoscope
N= Muffled or unclear transmission

Assessment Abnormal dt any type of consolidation

of Voice • Bronchophony - clear transmission of “99”

• Egophony - normally hear a muffled long E

Sounds sound.
• Whispered pectoriloquy – Ask to patient say
“99” or “1,2,3”. The whispered voice is
normally heard faintly and indistinctly.
• Voice sounds absent - dt air in lungs from
disease - emphysema, asthma or pneumothorax
Vocal resonance

• Bronchophony

• Whispering pectoriloquy

• Egophony
 Physical Findings in Selected Chest
Disorders

CONDITION PURCUSSION TRACHEA BREATH ADVENTITIOUS TACTILE

NOTE SOUNDS SOUNDS FREMITUS AND
TRANSMITTED
VOICE SOUNDS

Normal Resonant Midline Vesicular None Normal

Left-Sided Resonant Midline Vesicular Late inspiratory crackles Normal

Heart Failure (normal) in the dependent portions
of the lungs; possibly
wheezes
Chronic Resonant Midline Vesicular Possible scattered coarse Normal
Bronchitis (normal) crackles in early
inspiration and
expiration; possible
wheezes or
rhonchi
 Conti
…
Condition Purcussion Trachea Breath Sounds Adventitious Tactile Fremitus and
Note Sounds Transmitted Voice
Sounds
Lobar Dull over the Midline Bronchial over the Late inspiratory Increased over the involved area,
Pneumonia airless area involved area crackles over the with egophony, bronchophony, and
(Consolidation) involved area whispered pectoriloquy

Partial Lobar Dull over the May be shifted Usually absent when None Usually absent when the bronchial
Obstruction airless area toward involved bron- chial plug plug persists.
(Atelectasis) side persists.

Pleural Dull to flat over Shifted toward Decreased to absent, None, except a Decreased to absent, but may be
Effusion the fluid the unaffected but bronchial breath possible pleural rub increased toward the top of a large
side in a large sounds may be heard effusion
effusion near top of large
effusion.
 Conti
…
CONDITION PURCUSSION TRACHEA BREATH ADVENTITIOUS TACTILE
NOTE SOUNDS FREMITUS AND
SOUNDS TRANSMITTED
VOICE SOUNDS

Pneumothorax Hyper resonant or Shifted toward Decreased to None, except a Decreased to absent
tympanitic over the unaffected absent possible pleural rub over the pleural air
the pleural air side if tension over the pleural
air
pneumothorax

Chronic Diffusely Midline Decreased to None, or the crackles, Decreased

Obstructive hyper resonant absent, wheezes, and rhonchi of
Pulmonary with delayed associated chronic bronchitis
Disease (COPD) expiration

Asthma Resonant to Midline Often obscured Wheezes, possibly crackles Decreased

diffusely hyper by wheezes
resonant
Documentation
of Findings
Group Activity
 References
• Alila Medical Media. (2019). Overview of the Respiratory System,
Animation. In YouTube. https://www.youtube.com/watch?v=03qvN5pjCTU
• Bickley, L. S. (2017). Bates’ Guide to Physical Examination and History
Taking, 12e. Meded.lwwhealthlibrary.com.
https://meded.lwwhealthlibrary.com/book.aspx?bookid=1876
• Weber, J. R., Weber, J., Kelley, J. H., & Kelley, J. (2013). Health Assessment in
Nursing. In Google Books. Wolters Kluwer Health/Lippincott Williams &
Wilkins.
https://books.google.com/books/about/Health_Assessment_in_Nursing.ht
ml?id=868XlAEACAAJ
• http://www.thesimtech.org/audio
Thank
you