Thoracic Assessment

Unit 6
Thoracic Assessment Overview

Anatomy & Physiology

History

IPPA

Developmental Considerations

Nursing Diagnoses

Teaching Opportunities

Oro/naso pharynx and respiratory tree

respiratory system extends from nares to diaphragm

Anatomy & Physiology

Thoracic cavity

two distinct pleural cavities

separated by mediastinum

Pleural cavities lined by serous membranes

o

parietal pleura

visceral pleura
o

parietal pleura lines chest wall and diaphragm

visceral pleura lines the lungs

potential space between, small amount of lubricating fluid

Lungs

R has 3 lobes

L has 2 lobes

Topography

2nd rib articulates with sternum at the Angle of Louis

Suprasternal notch

Costal Angle

Midsternal line

Midclavicular line

Anterior Axillary line

Note:
Intercostal space - named for rib above
Lung Borders

anterior thorax
o

posterior thorax
o

apices extend 2-4 cm ABOVE clavicle

apices extend to T1

lower borders
o

T 10 on exhalation

T12 on deep inspiration

Physiology of respiration

Specifically ventilation ("breathing")

inspiration/expiration
o

inspiration- air from atmosphere lungs

expiration - outflow, passive

accomplished by movement of

diaphragm

muscles - intercostal and neck

change in intrathoracic pressure

Inspiration accomplished by movement of

o

diaphragm

muscles

change in intrathoracic pressure

diaphragm moves down, flattens

intercostal and neck muscles expand

diameter and length of thoracic cavity

pressure in lungs below atmospheric

air rushes in

Breathing
Exhalation
o

nearly opposite

passive event

diaphragm relaxes

chest wall and lungs recoil (elastic)

air is expelled

Pulmonary pressures
Intrapulmonic (within lungs)
Intrapleural (around lungs)
o

Boyles law - volume of gas varies inversely with

P

intrapleural pressure ALWAYS NEGATIVE

(unless chest cavity open)

essential - creates suction

holds visceral and parietal pleural tog.

Health History

Any risk factors for respiratory disease

smoking
o

pack years ppd X # years

exposure to smoke

history of attempts to quit, methods, results

sedentary lifestyle, immobilization

age

environmental exposure
o

Dust, chemicals, asbestos, air pollution

obesity

family history

Present health status

URI

Allergies

Recent screening or diagnostic assessments, last CXR

Medications
o

Rx or OTC

Use of aerosols or inhalants for any purpose

Exercise tolerance
How soon do vital signs return to NL after exercise

HPI - Cough

Type
o

dry, moist, wet, productive, hoarse, hacking, barking, whooping

Onset

Duration

Pattern
o

activities, time of day, weather

Severity
o

effect on ADLs

Wheezing

Associated symptoms

Treatment and effectiveness

HPI - sputum

amount

color

presence of blood (hemoptysis)

odor

consistency

pattern of production

Onset - sudden or gradual

Frequency- intermittent or persistent

Pattern- when/where condition occurs

HPI - SOB

relationship to exercise

time of day

eating

Wheezing

Severity- effect on activity

COPD

Response to treatment

Other terms for SOB

orthopnea
o

"2 pillow"

paroxysmal nocturnal dyspnea - PND

Past Health History

Respiratory infections or diseases (URI)

Trauma

Surgery

Chronic conditions of other systems

Family Health History

Tuberculosis

Emphysema

Lung Cancer

Allergies

Asthma

Other considerations

Employment

place

exposure

Current or past residence/travel

Hobbies

Thoracic Assessment

Privacy

Warm

Well lit

Assessment

Inspection

Skin
o

color and nutritional state

lips - color

nail beds - color and shape

posture

Thoracic contour

shape, symmetry

developmental:
Pigeon chest
Funnel chest
Spinal Deformities
Kyphosis

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

Ribs and interspaces

o

retraction of interspaces indicative of obstruction

bulging during exhalation result of air outflow obstruction:

tumor, aneurysm, cardiac enlargement

slope of ribs, costal angle

Respiratory Pattern
o

Rate

Rhythm

Depth

Effort

Respiratory movement

Rate
o

adult NL: 12 - 20 resting

tachypnea = > 20

bradypnea= <10

Rhythm

Depth: shallow, deep

Hyperventilation
deep and rapid
20 anxiety
drug OD
CNS disease
acid/base imbalance

Hypoventilation
20 post op pain
CNS drugs
neuro impairment
obstruction
o

Effort/Quality

unlabored

labored- dyspnea, orthopnea

shallow

grunting

Respiratory movement

thoracic or abdominal

Men & children - abdominal breathers

Women- thoracic

Normal rate, rhythm, quality termed eupnea

rhythmic

effortless

quiet

symmetrical

Also inspect for

o

cyanosis of
skin
MM
lips, earlobes, nail beds
soles, palms

flaring of nares

use of accessory muscles

supraclavicular retraction

cough

Palpation
assess for lesions
thoracic expansion
tactile fremitus
tracheal position
Thoracic Expansion

Posteriorly- level of 10th rib

Thumbs should separate 3 - 5 cm

Feel during quiet I & E

Palpate during deep inspiration

Should be symmetrical

If not - ? Fx ribs

atelectasis (lung collapse)

Tactile Fremitus

palpable vibrations of chest wall over lung fields from speech or

sounds

Use palmar or ulnar surface

Palpate vocal sounds

Systematically palpate side to side in same area

Normal, increased or decreased

Locations for feeling fremitus

What does increased or decreased tactile fremitus mean ?

Percussion
check underlying area for

air

fluid

Tactile Fremitus Increased- conditions that increase

density of thoracic tissue
o

consolidation of pneumonia

some lung tumor

Tactile Fremitus Decreased - obstruction of

transmission of vibrationso

pleural effusion

pleural thickening (fibrosis)

pnemothorax

bronchial obstruction

COPD/emphysema

solid

Percussion sounds flat

dull - @ heart, liver
resonant - NL
hyperresonant - COPD, hyperinflation
tympany
Why would sounds be dull ?

Diaphragmatic excursion
o

done when breathing is shallow

when suspect something is limiting diaphragmatic movement

percuss to mark level of diaphragm at full exhalation, then full

inhalation

should be 3 -6 cm difference

Auscultation

How is respiratory sx working?

What lung areas are not working?

Are secretions, fluid, an obstruction blocking air passages?

Hold stethoscope firmly but not tightly over ICS

Use diaphragm or bell ??

Ask pt to breathe normal/deeply with mouth open (Tell pt to tell you if

dizzy, lightheaded)

Listen for entire cycle inhale/exhale

Tune out heart sounds

Systematic

Dont confuse sounds over chest hair with breath sounds

Auscultate

Normal breath sounds

Adventitious breath sounds

Voice sounds (vocal resonance) (if abnormalities are suspected)

Normal breath sounds

Note

Pitch

Intensity

Quality

Duration

Vesicular

heard over most of lung

I>E
low pitch
soft intensity sigh

Bronchovesicular-over bronchi

I=E

moderate pitch and intensity, breezy

Bronchial/Tracheal

I<E

high pitched, loud, blowing

Documenting NL breath sounds:

Vesicular breath sounds audible all lung fields bilaterally.
Adventitious Breath Sounds

Abnormal sounds imposed on top of normal

Crackles
o

due to air passing thru moisture in airway

usually heard R and L lung bases

best heard during inspiration

fine (in small airways, alveoli)

medium (in bronchioles)

coarse (larger airway, "gurgle", thick secretions,

coughing may affect)

Rhonchi and wheezes

continuous sounds produced by movement of air thru

narrowed areas in larger airways (tracheobronchial tree)

narrowed 20
fluid, secretions
COPD
mass
o Predominate in exhalation
o wheeze
high pitched
suggests COPD or bronchitis
o

rhonchi
lower pitched
whistle, rumble, snore
suggests secretions in large airways

Clearing of crackles, wheezes or rhonchi by coughing

suggests that they are caused by secretions

Pleural Friction Rubs

Caused by inflamed visceral and parietal pleura rubbing together
o

Creaking, grating, leather-like quality

Can be heard over lungs (pleurisy)

also heart (pericardial friction rub) (usually heard over
anterolateral chest)

Very painful

not cleared by coughing

Documenting variation from NL breath sounds:

Fine crackles R and L lung bases bilaterally.

Voice sounds

Vocal Resonance
o

Advanced technique

Tactile fremitus but auscultated

Client says or whispers "99",

NL sounds muffled

Abnormal if increased 20 consolidation (pneumonia)

(air-filled lung has become airless)

THINK! If vocal resonance is increased

Tactile fremitus will be ?
Percussion sound will be ?
Breath sounds - may hear...?

Difference between tactile fremitus and vocal resonance

Tactile fremitus- sound vibration of spoken or whispered voice through lung
fields on palpation
Vocal resonance- sound vibration of spoken or whispered voice through lung
fields on auscultation
Corroborate findings with
faculty
colleagues
CXR
ABGs
continued assessment
Developmental Differences

First thing assessed in neonate is breathing

Respiratory rate highest in neonate, decreases throughout childhood

Chest circumference in child same as head circumference until age 2

Strictly abdominal breathing until age 7

Breath sounds louder due to thin chest wall

Elderlyo

thorax may become more rounded 2 0 kyphosis (osteoporosis)

Increased muscle tone

emphysema/ spine changes may increase AP: lateral diameter
(barrel chest)
breath sounds more difficult

lung tissue and chest wall less compliant/elastic

Decreased muscle tone?

Decreased ability to cough forcefully?

Nursing Diagnoses
P: Activity intolerance
E: decreased oxygenation 2 0 emphysema
P: Ineffective airway clearance
E: pulmonary congestion, diminished cough reflex
P: Risk for aspiration
E: diminished cough reflex, impaired swallowing
P: Risk for infection
E: thick sputum, decreased resp. function
Nursing Diagnoses

Ineffective breathing pattern

Fatigue

Impaired gas exchange

Risk for suffocation

Inability to sustain spontaneous ventilation

Ventilatory weaning response dysfunction

Teaching Opportunities

Immunizations

TB testing

Concerns with cold and cough

Allergies

Asthma

When to seek care

OTC medications