2Assessment thorax & lungs Learning Objectives:Describe the normal shape and size of the thorax.List the deformities in the chest.Describe the normal breath sounds.Differentiate between adventitious breath sounds.Determine the normal and abnormal findings in ass. of thorax &lunges.
3Assessment thorax & lungs Chest shape and size:The thorax is oval. Its anteroposterior diameter is half its transverse diameter. Its diameter is smaller at the top than at the base.Deformities of the chest:Pigeon chest: a permanent deformity, may be caused by rickets.Characteristics:Narrow transverse diameter.Increased anteroposterior diameter.Protruding sternum.
4Assessment thorax & lungs A funnel chest, a congenital defect, is the opposite of pigeon chest.Characteristics:Narrow anteroposterior diameter.Depressed sternum.Depressed sternum make abnormal pressure on the heart may result in altered function.
5Assessment thorax & lungs A barrel chest: the ratio of the anteroposterior diameter and transverse diameter is 1:1 e.g., in clients with kyphosis and emphysema.Scoliosis: is a lateral deviation of the spine.
8Factors may be affecting on patient’s respiratory function. Pregnancy.Age.Circulatory problems( anemia).Trauma.Environment .Path physiology ( COPD ).Allergy.
9Normal Breathing Sounds typesDescriptionLocationCharacteristicsVesicularSoft intensityLow pitched. Sounds created by air moving through small airwaysOver peripheral lung, best heard at the base of the lungs.The inspiratory phase is 2.5 times longer than expiratory phase.Broncho-vesicularModerate intensityModerate pitched “blowing” sounds created by air moving through larger airway.Between the scapulae & the lateral to the sternum at the first and second intercostal space.Equal inspiratory and expiratory phase.Bronchial (tubular)High pitched. Loud “harsh” sounds created by air moving through the trachea.Anteriorly over the trachea not normally heard over the lungs tissue.Have a short inspiratory phase and long expiratory phase.
11Abnormal Breathing Sounds TypesDescriptionCauseLocationCrackles (rales)Fine, short, interrupted.Sound can be stimulate by rolling a lock of hair near the ear.Air passing through fluid or mucus in any air passage.Heard in the bases of lower lung lobes.Gurgles (rhonchi)Continuous, low pitched, gurgling, harsh, louder sounds with moaning (complaining).Air passing throw a narrow air passage due to secretion, tumors, swelling.Heard over most lung areas but predominate over the trachea and bronchi.Friction rubSuperficial grating (harsh) or creaking.Rubbing together of inflamed pleural surfaces.Heard over the areas of greatest thoracic expansion.Wheeze(expiration)High pitched, squeaky (noisy) musical sounds.Air passing throw constricted bronchus.Heard over all lung field.
15Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalInspect the shape and symmetry of posterior and lateral views. Compare the anteroposterior diameter to the transverse diameter.Anteroposterior to the transverse diameter in ratio of 1:2Chest symmetricBarrel chest, increased anteroposterior diameter to the transverse diameter.Chest a symmetric
16Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalInspect the spinal alignment for deformities. Have the client stand from a lateral position, observe the three normal curvatures: cervical, thoracic, and lumbar.Spine vertically alignedExaggerated spinal curvatures (kyphosis, lordosis).
17Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalTo assess for lateral deviation of spine (scoliosis), observe the standing clients from the rear (back). The client bend forward at the waist and observe from behindSpinal column is straight, right and left shoulders and hips are at the same heightSpinal column deviates to one side, often accentuated when bending (twisting) over. Shoulders or hips not even (constant)
19Assessment thorax & lungs Ass. of posterior chestNormal findingsDeviations from normalPalpate the posterior thorax:Assess the temperature and integrity of all chest skin.Skin intact, uniform T.Skin lesions, areas of hyperthermia.
20Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalIf the clients have R. complaints:Palpate all chest areas for bulges, tenderness, or abnormal movements. Avoid deep palpation for painful areas, especially if a fractured rib is suspected.Chest wall intact, no tenderness, no masses.Lumps, bulges, depressions, areas of tenderness, movable structures (e.g., rib).
21Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalPalpate the posterior chest for respiratory excursion (thoracic expansion). Place the palms of both your hands over the lower thorax with your thumbs adjacent (next) to the spine and your fingers stretched laterally. Ask the client to take a deep breath while you observe the movement of your hands and any lag in movement.Full and symmetric chest expansion (i.e., when the clients takes a deep breath, your thumbs should move apart an equal distance and at the same time, normally the thumbs separate 3 to 5 cm.A symmetric and/or decreased chest expansion.
23Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalPalpate the chest for tactile fremitus, vibration felt through the chest wall when the clients speaks.Bilateral symmetry of tactile fremitus.Fremitus is heard most clearly at the apex of the lungsDecreased or absent fremitus.Increased fremitus as in pneumonia.
24Assessment thorax & lungs Ass. Of posterior chestNormal findingsPlace the palmar surfaces of your fingertips, starting near the apex of the lungs.*Ask the client to repeat such words as “blue moon” or “one, two,……*Repeat the two steps, moving your hands sequentially to the base of the lungs.Low pitched voices of males are more readily palpated than higher pitched voices of males
25Areas and sequence of palpating tactile fremitus Assessing tactile fremitus
26Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalCompare the fremitus on both lungs and between the apex and the base of each lung.
28Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalObjective of percussion:*To determine whether underlying lung tissue is filled with air, liquid, or solid material.*To determine the positions & boundaries of certain organs to a depth of 5 : 7 cm., it detects superficial rather than deep lesionsPercussion notes resonanceA symmetryAreas of dullness over the lung (associated with consolidation of lung tissue or a mass).
31Assessment thorax & lungs Ass. Of posterior chestpercuss the intercostal spaces in a systematic sequence.compare one side of the lung with the other.Percuss the lateral thorax starting at the axilla and working down to the eight rib.
32Assessment thorax & lungs Ass. of posterior chestNormal findingsDeviations from normalPercuss for diaphragmatic excursion (movements of the diaphragm during maximal inspiration and expiration).Ask the clients to take a deep breath and hold it while you percuss downward along the scapular line until dullness is produced at the level of diaphragm. Repeat the procedure on the other side of the chest.*Excursion is 3:5 cm. bilaterally in women and 5:6cm. In men.*Diaphragm is usually slightly higher on the right sideRestricted excursion associated with lung disorders
34AuscultationIs the process of listening to sounds produced within the body.Done by:Unaided ear.Stethoscope.Types of auscultation:Direct auscultation.Indirect auscultation.
35Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalAuscultate the chest using the flat disc diaphragm of the stethoscope.Use the systematic zigzag procedure used in percussion.Ask the client to take slow, deep breaths through the mouth. Listen at each point to the breath sounds during a complete inspiration and expiration.Vesicular and bronchovesicular breath sounds.Crackles, gurgles, wheeze, friction rub.Absence of breath sounds.
36Assessment thorax & lungs Ass. Of posterior chestNormal findingsDeviations from normalCompare findings at each point with the corresponding point on the opposite side of the chest.
37Assessment thorax & lungs Ass. Of anterior thoraxNormal findingsDeviations from normalAnterior thorax:Inspect breathing patterns.Inspect the costal angle.Palpate the anterior chest (as in posterior chest)Quiet, rhythmic, and effortless respirations.Costal angle is less than 90 degree, and the ribs insert into the spine at approximately a 45 angle.Abnormal breathing patterns and sounds.Costal angle is widened associated with COPD
38Assessment thorax & lungs Ass. of anterior thoraxNormal findingsDeviations from normalPalpate the anterior chest excursion (outing).Palpate the tactile fremitusFull symmetric excursion, thumbs normally separate 3 : 5 cm.Same as posterior vocal fremitusA symmetric and/or decreased respiratory excursion.
39Assessment thorax & lungs Ass. of anterior thoraxNormal findingsDeviations from normalPercuss the anterior chest systematically.Begin above the clavicles in the supraclavicular space, and proceed downward to the diaphragmCompare one side of the lung to the other.Percussion notes:Resonance.Flatness.Dullness.Tympanic.A symmetry in percussion notesAreas of dullness or flatness over lung tissue
40Assessment thorax & lungs Ass. Of anterior thoraxNormal findingsDeviations from normalAuscultate the trachea.Auscultate the anterior chest (beginning over the bronchi between the sternum and the clavicles . Document findings.Bronchial and tubular breath sounds.Bronchovesicular breath sounds.Adventitious breath sounds.