Physical Health Assessment Thorax and Lungs Lecturer/ Hanaa Eisa

Learning out come Identify the anatomic landmarks of the thorax. Describe the characteristics of the most common respiratory chief complaints. Perform inspection, palpation, percussion, and auscultation on a healthy adult and on a patient with pulmonary pathology.

Learning out come Explain the pathophysiology for abnormal findings. Document respiratory assessment findings. Describe the changes that occur in the lungs with the aging process.

Anatomy anterior thorax Sternum Clavicles Nipples Suprasternal notch Angle of Louis Costal angle

Anatomy of posterior thorax Vertebra prominence Spine

Anatomy of the lungs Right lung — three lobes Left lung — two lobes Apex Base Mid clavicular line (MCL) Mid axillary line (MAL)

Location of Lobes of Lungs with in The Thoracic Cavity

Anatomy of the lungs cont’d Pleura Parietal Visceral Mediastinum or interpleural space Bronchi Right Left

Anatomy of the lungs cont’d Alveoli Diaphragm External intercostals muscles Accessory muscles

Thoracic anatomic topography Anterior axillary line Midspinal (vertebral) line Midsternal line Posterior axillary line Scapular line

Physiology Ventilation External respiration Internal respiration Control of breathing

Health history Age Patient profile Children and young adults: cystic fibrosis Adults and older adults: chronic bronchitis, emphysema, pneumonia, lung cancer Gender Race African ,American

Common chief complaints Dyspnea Cough Sputum Chest pain

Characteristics of chief complaint Quantity Quality Associated manifestations Aggravating factors Alleviating factors Timing Setting

Past health history Medical Respiratory specific Nonrespiratory specific Surgical Medications Communicable diseases Allergies Special needs Childhood illnesses

Family health history Allergies? Asthma? Cystic Fibrosis? Emphysema? Cancer? Bronchiectasis? TB?

Social history Alcohol, drug, or tobacco use Travel history Work and home environment Stress Economic status

Health maintenance activities Sleep Diet Exercise Use of safety devices Health check-ups

Assessment of the thorax and lungs Equipment Stethoscope Centimeter ruler and measuring tape Washable marker Watch with second hand

Inspection Shape of thorax Diameter -Transverse diameter –Anteroposterior Symmetry of chest wall Presence of superficial veins Costal angle Angle of the ribs Intercostals spaces Muscles of respiration

Respirations Pattern Depth Rate Normal in adult 12 – 20 c/m Tachypnea > 20 c/m Bradypnea < 12 c/m Apnea: no respiration for 10 or more seconds Pattern Depth

Respirations Patient position Upright Supine Orthopnea Mode of breathing

Sputum Color Odor Amount Consistency

Assessing patients with respiratory assistive devices Oxygen therapy Mode of delivery Percentage of oxygen Flow rate Humidification Pulse oximeter

Assessing patients with respiratory assistive devices Incentive spirometer Frequency of use; volume achieved; number of repetitions Endotracheal tube Size Nasal or oral insertion

Assessing patients with respiratory assistive devices Length of tube as it exits mouth or nose Cuff inflated or deflated Tracheostomy tube Size Cuffed or cuff less How tube is secured to neck

Assessing patients with respiratory assistive devices Mechanical ventilation Type of ventilator Mode Peep Rate Tidal volume Alarms

Palpation Anterior Posterior Lateral Pulsations Masses

Palpation Thoracic tenderness Crepitus Thoracic expansion Tactile or vocal fremitus

Percussion Anterior Posterior Lateral Diaphragmatic excursion

Auscultation fields Anterior Posterior Lateral

Auscultation—breath sounds Pitch Intensity Quality Duration Location

Normal breath sounds Bronchial Bronchovesicular Vesicular

Adventitious breath sounds Crackle or Rate Fine Coarse Wheeze Sonorous (Rhonchi) Sibilant Pleural friction rub Stridor

Voice sounds Bronchophony Egophony Whispered pectoriloquy

Normal findings AP to transverse diameter is 1:2 Elliptical-shaped thorax Shoulders and scapula at same height bilaterally

Normal findings No masses or superficial veins Costal angle < 90 degrees during exhalation and at rest Ribs articulate at a 45-degree angle with the sternum Absence of intercostals retractions

Normal findings No accessory muscle use Respiratory rate 12–20 breaths per minute Eupnea Respiratory pattern is regular . Respiratory depth is nonexaggerated and effortless

Normal findings Symmetrical rise and fall of thorax Respirations are quiet, unless a few centimeters from patient’s nose or mouth Able to breath comfortably in supine, prone, or upright position Usually breathe through nose

Normal findings Small amount of sputum may be present Sputum should be odorless and light yellow to clear in color No pulsations, masses, thoracic tenderness, crepitus present Thoracic expansion is 3 to 5 cm Trachea is midline

Normal findings Resonant sound on percussion over lung tissue Dull sounds over diaphragm and cardiac Rib sounds are flat Hyperresonance present if adult is thin

Normal findings Diaphragmatic excursion is 3 to 5 cm Bronchial breath sounds over trachea Bronchovesicular breath sounds over scapular area Vesicular breath sounds over peripheral lung

Anatomic changes Increased work of breathing Limited chest wall expansion Muscle atrophy Alveolar gas exchange Decreased surface area for diffusion

Age-related changes Regulation of ventilation Decreased sensitivity to changes in carbon dioxide and oxygen Lung defense mechanisms Decreased ciliary action Diminished cough reflex Increased susceptibility for infection

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