COLLEGE OF HEALTH SCIENCE

DEPARTMENT OF NURSING AND MIDWIFERY

POST GRADUATE PROGRAM
COURSE ; ADVANCED ADULT NURSING
ASSESSMENT
PRESENTATION ON CHEST AND LUNGS
ASSESSMENT
PREPARED BY 1. CHALA KENE ID GSR
/9536/11
2. BERIHUN DEMEKE ID GSR
/6505/11
Presentation outlines
 Objectives
 Anatomic overview of thorax and lungs
 Assessment of posterior thorax
 Demonstration(at end of presentation)
 Assessment of anterior thorax
 Documentation
 Common nursing diagnosis
 Video shows as summary
Objectives of this presentation
At the end of this presentation you will expected to:
 Explain the anatomical overview of thorax and lungs
 Describe how extracting history of respiratory abnormalities and
lungs.
 Perform physical examination on chest and lungs.
 Interpreting findings after the assessment of chest and lungs.
 Thorax anatomy overview
 The thoracic cage is a bony structure which is defined by the
sternum, 12 pairs of ribs and 12 thoracic vertebrae.
 It floor is the diaphragm, a musculotendinous septum that separates
the thoracic cavity from the abdomen.
 The first seven ribs attach directly to the sternum through the costal
cartilages
 Ribs 8,9 and 10 attach to the costal cartilage above; and ribs 11 and
12 are “floating”.
Some of the important landmarks 5
1. Supra sternal Notch
 Hollow U shaped depression just above the sternum in between
the clavicles.
2. Sternum- has three parts- manubrium, the body and the xiphoid
process.
 Walk your fingers down the manubrium a few centimeters until
you feel a bony ridge, the manubriosternal angle.
 Often called the “angle of Louis” which is continuous with the
second rib and is a useful place to start counting ribs.
 The angle of Louis also marks the site of tracheal bifurcation
into the right and left bronchi
3. Costal angle 6
 The right and left costal margins form an angle where they meet at
the xiphoid process.
4. Vertebral prominence
 Flex your head and feel for the most prominent bony protruding at
the base of the neck.
 This is the spinous process, C7
 If two bumps seem equally prominent the upper one is C7 and the
lower one is T1
Reference Lines

8
helps to identify specific underlying structure for documentation.
 On the anterior chest, note the mid sternal line and the mid
clavicular line.
 The posterior chest wall has the vertebral line and the scapular
line.
9
 Lung anatomy overview 10
 The apex of each lung rises about 2-4 cm above the inner third of the
clavicle.
 The lower border of the lung crosses the six rib at the mid clavicular
line.
 Each lung is divided in half by oblique fissure
 The right lung is further divided by the horizontal (minor) fissure
 Therefore the right lung has three lobes and the left has two lobes
11
 ASSESSMENT OF CHEST AND LUNGS 12
Subjective Data
 Ask for cough, shortness of breath, chest pain with breathing, past
history of respiratory infections, cigarette smoking, Environmental
exposure, self care behaviors and
 Ask additional question for the aging adults.
Questions to collect subjective data
Cough
1. Do you have a cough? When did it start? Gradual or onset?
2. How long have you had it? How often do you cough? Time of cough?
3. Dou you cough up any phlegm or sputum? How much? What colour is it?
Shortness of breath
1. Are you having any shortness of breathing?
2. With in the last day, have you been short of breath?
3. Is affected by the position such as lying down?
4. Occurs at any specific time of day or night?
Chest pain with breathing
1. Any chest pain with breathing? When did it start? Constant or does
it come and go?
2. What have you done to treat it? Medication or heat application?
History of respiratory infection
1. Any past lung disease such as bronchitis,asthma,pneumonia?
2. Any family hx of allergies, TB or asthma?
Smoking history
1. Do you smoke cigarette or cigars? At what age did you start?
2. How many packs per day do you smoke now? For how long?
3. Have you ever tried to quite? What helps?
4. Why do you think it did not work?
5. What activities do you associated with smoking?
Environment exposure
1. Are there any environmental condition that may affect your breathing?
2. Where do you work? At factory, chemical, plant cool mine ,farming
3. Do you wear mask to protect your lung at this work area?
4. Do you do any thing to monitor your exposure?
5. Do you have periodic examination, pulmonary function test, x-ray image?
Patient centered care
Last TB, skin test, chest X-ray study, pneumonia vaccine or influenza immunization?
Additional history for the aging adult
1. Tell me about your usual amount of physical activities?
2. Have you noticed any shortness of breath or fatigue with your daily activities?
3. Do you have any chest pain with breathing? After about of coughing? After a fall?
Objective Data
 Physical examination more discussed in this presentation. 17
 Equipment needed:- stethoscope ,small ruler(in cm), marking pen.
General guideline
 Expose the chest fully
 Proceed in ordinary fashion
 Compare one side with other
 Examine the posterior thorax and lung first while the patient is in
the sitting position
 Ask the patient to lie supine while examining the anterior chest
 Relate all other findings in the thorax with findings
The posterior thorax
18
A.Inspect the posterior chest
 Stand midline behind the patient.
 Note the shape and configuration of the chest wall.
 The thorax and scapulae are symmetric.
 The anteroposterior diameter is less than the transverse
diameter.
Abnormal
 AP =Transverse diameter or ‘‘barrel chest’’
 This shape is normal during infancy, aging.
 Abnormally exhibited in case of obstructive diseases
 Asymmetric expansion in large pleural effusion.
B. Palpate the posterior chest
19
 Focus on area of tenderness, respiratory expansion and fremitus.
 No pain on palpation
1.Tenderness
 Intercostal tenderness can develop over inflamed pleurae.
 Tenderness , bruising and bony “step off” are common over fracture
rib.
 Crepitus and chest wall edema are seen in mediastinitis.
 Crepitus is a crackling sensation palpable over the skin surface.
2. Respiratory Expansion
By placing your warmed hands on the
posterolateral chest wall with thumbs at the
level of T10.
Pinch up a small fold of skin between your
thumbs.
Ask the person to take a deep breath.
As the person inhales deeply, your thumbs
should move apart symmetrically.
Note any lag expansion
Abnormal
 Unequal chest expansion occurs with marked atelectasis, lobar
pneumonia, chronic fibrosis of the underling lung and pleura,
unilateral bronchial obstruction ,pleural pain with associating with
splinting and paralysis of the hemi diaphragm.
 Pain accompanies deep breathing when the pleurae are inflamed.
3. Tactile Fremitus
22
 Fremitus is a palpable vibration.
 Sounds generated from the larynx are transmitted through
patent bronchi and through the lung parenchyma to the chest
wall where you feel them as vibrations.
 These are resonant phrases that generate strong vibrations.
 Use the palmar base of the fingers of one hand and touch the
person’s chest while he/she repeats the words “ninety-nine” or
“Arba-Arat”.
 23
Start over the lung apices and palpate from one side to another.
 Symmetry is important, the vibrations should feel the same in
the corresponding area on each side.
 Avoid palpating over the scapulae because bone damps out
sound transmission
Abnormal
 Decreased fremitus occurs when anything obstructs
transmission of vibrations as obstructed bronchus,
pneumothorax or neoplasm.
 Increased fremitus with consolidation of lung tissue as lobar
pneumonia.
C. Percuss the posterior chest 24
 Start at the apices and percuss at the tops of the shoulders.
 Then percussing in the interspaces, make a side- to side
comparison all the way down.
 Categorize what you hear as normal, dull, or hyper resonant.
 Resonance is the low pitched, clear sound predominates in
healthy lung tissue.
Proper Technique 25
 Hyperextend the middle finger of one hand and place the
distal interphalangeal joint firmly against the patient's chest.
 With the end (not the pad) of the opposite middle finger, use a
quick flick of the wrist to strike first finger.
 Practice your technique until you can consistently produce a
"normal" percussion note on your partner before you work
with patients.
 Abnormal
 A dull note signals abnormal density in the lungs as with
pneumonia, atelectasis ,pleural effusion or tumor.
 Generalize hyper resonance is common over the hyper inflated
lungs of COPD or asthma.
 Unilateral hyper resonance suggests a large pneumothorax.
Estimating diaphragmatic excursion
 Ask the patient to exhale fully and keep
 Percuss the posterior chest down from area of resonance to area
of dullness and mark.
 Then ask the patient to breath in deep and hold, continue per
cussing down until resonance changes to dullness and mark.
 Measure the vertical distance between the two points.
 Do the same for the other side.
 Normally it should be 5-6cm.
 D. Auscultate the posterior chest
28
 The passage of air through the tracheo-bronchial tree creates a
characteristic set of noises audible through the chest wall.
 Before beginning auscultation, ask the patient to cough once or
twice to clear the mild atelectasis or airway mucus that can produce
unimportant extra sound.
1. Breath sounds

29
Instruct the person to breathe through the mouth, a little bit deeper
than usual.
 Use the flat diaphragm end- piece of the stethoscope.
 Listen to at least one full respiration and compare side to side.
 You should expect to hear four types of normal breath sounds.
1. Vesicular
2. Broncho-vesicular
3. Bronchial
4. Tracheal or tubular
2. Adventitious sounds 31
 Note the presence of any adventitious sounds.
 Added sounds that are not normally heard in the lungs.
 They are caused by moving air colliding with secretions in the
tracheo bronchial passage ways and include crackles(rales),
wheezes and rhonchi.
 Cracles/rales: discontinuous or intermittent non musical sounds.
 Eg. pneumonia
 Wheezes: relatively high pitched ,musical sounds which are
longer than crackles….audible through mouth or chest wall.
 Eg. Asthma case
 Rhonchi suggest secretions in large airway.
3. Voice sounds
33
 The spoken voice can be auscultated over the chest wall like tactile
fremitus.
 Ask the person to repeat a phrase while you listen over the chest wall.
 Normal voice transmission is soft, muffled, and indistinct.
 You can hear sound through the stethoscope but cannot distinguish
exactly what is being said.
 Pathology that increases lung density enhances transmission of voice
sounds.
 Voice sound maneuvers that are performed if you suspect lung
pathology are the following:
 Bronchophony, Ego phony and Whispered pectoriloquy
Technique
34
1. Bronchophony
 Ask the person to repeat ‘ninety nine” while you listen with the
stethoscope over the chest wall.
 Listen especially if you suspect pathology.
 Normal findings- normal voice transmission is soft, muffled,
and indistinct.
 You can hear sound through the stethoscope but can not
distinguish exactly what is being said.
 Abnormal Findings pathology that increases lung density will
enhance transmission of voice sounds. You auscultate a clear
“Ninety- Nine.”
 The words are more distinct than normal and sound close to
your ear.
2. Egophony- (Greek: the voce of a goat) 35
 Ausculate the chest while the person phonates a long “ee-ee-ee-
ee” sound.
 Normally, you should hear “eeeeee” through your stethoscope.
 Abnormal – over areas of consolidation or compression the
spoken “eeee” sound changes to a bleating long “aaaaa” sound.
If this is present record “EA change”
3. Whispered pectoriloquy
36
 Ask the person to whisper a phrase like “one-two- three” or
“ninety nine” as you auscultate.
 The normal response is faint, Muffled and almost inaudible.
 Abnormal with consolidation the whispered voice is transmitted
very clearly and distinctly.
 It sounds as if the person is whispering right into your
stethoscope, “one-two-three’.
 The Anterior thorax
A.Inspect the anterior chest 37
 Note the shape and configuration of the chest wall.
 The costal angle is within 90 degrees.
 Assess the quality of respirations.
 Normal relaxed breathing is automatic and effortless, regular and
even, and produces no noise..
 The chest expands symmetrically with each inspiration.
 There should be no retraction or bulging of the interspaces on
inspiration.
 Respiratory rate is within normal limits for the person’s age with
regular pattern of breathing
Abnormal
38
 Noisy breathing occurs with severe asthma or chronic
bronchitis.
 Unequal chest expansion occurs with obstructed or collapsed
lung as with pneumonia.
 Abnormal retraction occurs in sever asthma, COPD, or upper
airway obstruction.
 Lag occurs in underling disease of the lung or pleura.

 Barrel chest horizontal ribs and costal angle>90 degrees.

2. Palpate the Anterior Chest
39
 Note any tenderness and superficial lumps or masses, skin
mobility , turgor, temperature and moisture.
Palpate symmetric chest expansion.
 Place your hand on the antero- lateral wall with the thumbs along
the costal margins and pointing toward the xiphoid process.
 Ask the person to take a deep breath.
 Watch your thumbs move apart
symmetrically and note smooth
chest expansion with your fingers.
Abnormal – a lag in expansion
occurs with atelectasis, pneumonia.
Assess tactile (vocal) fremitus.

40
Begin palpating over the lung apices in the supraclavicular areas.
 Compare vibrations from one side to the other as the person
repeats “ninety-nine” (44).
 When examining a woman , gently displace the breast as
necessary.
 A palpable grating sensation with
breathing indicates pleural friction
fremitus.
3. Percuss the Anterior Chest
41
 Begin percussing the apices in the supraclavicular areas.
 Then percussing the interspaces and comparing one side to the
other move down the anterior chest.
 Do not percuss directly over female breast tissue, it produces a
dull note.
 Shift the breast tissue over slightly using the edge of your
stationary hand.
 Note the borders of cardiac dullness normally found on the
anterior chest and never confuse with lung pathology
 In the right hemi thorax, the upper border of liver dullness is located
in the 5th intercostals space in the right mid- clavicular line.
On the left, tympany is evident over the gastric space.
Abnormal 43
 Lung are hyper inflamed with chronic emphysema, which
results in hyper resonance where you would expect cardiac
dullness.
 Dullness behind the right breast occurs with the right middle
lobe pneumonia.
4. Auscultate the Anterior Chest
44
 Auscultate the lung fields over the anterior chest from the
apices in the supra- clavicular areas down to the 6th rib.
 Progress from side to side as your move downward and listen
to one full respiration in each location.
 Like percussion displace the breast and listen directly over the
chest wall.
 Evaluate normal breath sound; note any abnormal breath
sounds and adventitious sounds.
 If necessary, assess the voice sounds on the anterior chest.
 Common Nursing diagnosis
Actual
 Insomnia related to dyspnea as evidenced by wakeup at nigh 3 times.
 Ineffective breathing pattern related to inflammatory processes as
manifested by cyanosis.
 Impaired gas exchange related to altered oxygen supply as
manifested by clubbing of finger.
 Ineffective airway clearance related to copious secretions as
evidenced by crackle sound on auscultation over the left lower lobe
of the lung.
Potential
 Potential ineffective airway clearance related to bronchial secretion
and obstruction.
 Potential activity intolerance related to imbalance between oxygen
supply and demand.
Summary of what we have seen by Video assist

02. Thorax and Lungs

Reference

 Bates’ Guide to Physical Examination and history

taking 12th edition 2017.
 Carolyn Jarvis Physical Examination and Health
Assessment 7th edition 2016.
THANK YOU 4 UR ATTENTION!!!!
 If You say ‘‘I understand your problem to
the patient’’ it may be equivalent to
behavioral providing a pices of soft for a
patient tears. Empathetic response