Assessment of Thorax and Lungs Christine M. Wilson Viterbo University

Objectives Landmarks Structures Function Developmental/transcultural Subjective data Objective data

Anterior Landmarks Clavicle Suprasternal notch Sternum Sternal angle Intercostal spaces Xiphod process Costal angle

Posterior Landmarks Vertebra prominens (C7) Spinous processes Scapula

Reference Lines Anterior Chest Midsternal Midclavicular

Reference Lines Posterior Wall Vertebral Line Scapular Line

Reference Lines Axillary Area Anterior Axillary Posterior Axillary Midaxillary Anterior Axillary Posterior Axillary

Position in Chest Lobes of the lung Trachea Bronchial Tree

Functions of Respiration Major Functions Supply oxygen to body for energy production Remove carbon dioxide as a waste from energy production Maintain pH balance of arterial blood Maintain heat exchange

Developmental Considerations Fetal Life At 5 weeks primitive lung buds emerge By 16 weeks there are the same # of conducting airways as in the adult. At 32 weeks surfactant sufficient to sustain life At birth 70 million primitive alveoli kick in

Developmental Considerations The Aging Adult Lungs more rigid; harder to inflate Less surface available for gas exchange Common increase in AP diameter Kyphosis: Front to back curvature spine May fatigue more easily

Transcultural Considerations Largest chests (descending order): whites, blacks, Asians, Native Americans Fetal lung maturity reached earlier in black population Incidence of TB is higher in Asian Americans

Subjective Data Cough Shortness of breath Chest pain with breathing History of respiratory infections Smoking history Environmental exposure Self care behavior

Objective Data-Posterior Chest Inspect Shape and configuration A/P diameter should be less than transverse by 1:2 Position Skin color and condition

Posterior Chest Symmetric chest expansion Place hands at T9-T10 Equal movement of thumbs with inhaling

Posterior Chest Tactile fremitus Palpate chest wall Place ulnar edge on skin; client repeats 99 Symmetry is expected Decreases if sound transmission is obstructed Palpate chest wall

Posterior Chest Percussion Begin at apices Find predominant note over lung fields Begin at apices Use same pathway side to side

Lung Percussion Sounds Resonance: non-musical; healthy lung Hyper-resonance: slightly musical; too much air, i.e. emphysema/pneumothorax Dull: muffled; organ or abnormal density, i.e. pneumonia Flat: soft thud; i.e. muscle mass, bone

Posterior Chest Diaphragmatic Excursion Find lower lung border in expiration and inspiration Measure: Should measure 3-5cm, equal distance bilaterally.

Posterior Chest Auscultation Use diaphragm of stethoscope; place firmly One full breath at each position Use same pathway side to side comparison

Breath Sounds Bronchial Bronchovesicular Vesicular Loud, harsh sounds over trachea Bronchovesicular Moderate, mixed sounds over bronchi Vesicular Soft, rustling sounds over periphery

Decreased or Absent Obstruction Emphysema Silent chest Secretions, mucus plug, foreign body Emphysema Loss of elasticity; air already in lungs Silent chest No air is moving in or out of lungs; ominous sign

Increased Sounds Bronchial sounds heard over wrong area Solid tissue conducts sounds to surface better Found in pneumonia with consolidation or fluid in intra-pleural space

Adventitious Sounds Crackles (Rales): Fine Fine, discontinuous high-pitched, short crackling sound on inspiration which are not cleared by coughing. (Roll a strand of hair at ear) Found in pneumonia and heart failure

Adventitious Sounds Crackles: Coarse Loud, low-pitched bubbling or gurgling sounds Start in inspiration, may be in expiration Decrease with coughing, but comes back Found in pulmonary edema and terminally ill with suppressed cough reflex

Adventitious Sounds Wheeze: High pitch High-pitched, musical squeaking sound that predominates with expiration Indicates narrowed passageway Obstruction from acute asthma or chronic emphysema

Adventitious Sounds Wheeze Low-pitch Single note which is more prominent on expiration Air flow obstruction bronchitis or tumor

Adventitious Sounds Stridor High-pitched, crowing sound with inspiration Louder in neck Upper airway obstruction Croup, acute epiglottis, or foreign body inhalation

Objective Data-Anterior Chest Inspect Shape and configuration Facial expression Level of consciousness Color and condition Respiration rate/quality

Anterior Chest Symmetric chest expansion Place hands at costal margins Equal movement of thumbs with inhaling

Anterior Chest Tactile fremitus Apices to MCL Side to side Symmetry expected Palpate chest wall

Objective Data-Anterior Chest Percussion Dullness over breast tissue, liver, cardiac borders Tympany over gastric Auscultation Displace breast and listen over chest wall

Visualize lungs beneath skin