1. Assessment of Thorax and Lungs
Christine M. Wilson
Viterbo University

2. Objectives Landmarks Structures Function Developmental/transcultural
Subjective data
Objective data

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

4. Posterior Landmarks
Vertebra prominens (C7)
Spinous processes
Scapula

5. Reference Lines
Anterior Chest
Midsternal
Midclavicular

6. Reference Lines
Posterior Wall
Vertebral Line
Scapular Line

7. Reference Lines Axillary Area Anterior Axillary Posterior Axillary
Midaxillary
Anterior Axillary
Posterior Axillary

8. Position in Chest
Lobes of the lung
Trachea
Bronchial Tree

9. 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

10. 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

11. 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

12. 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

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

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

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

16. 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

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

18. 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

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

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

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

22. 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

23. 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

24. 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

25. 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

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

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

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

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

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

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

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

33. Visualize lungs beneath skin