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ASSESSMENT OF THORAX AND LUNGS
Anatomy and Physiology
Current Health Status
- - shortness of breath
- - cyanosis
- - cough
- - sputum
- - chest pain
- Past Health History
- - prior lung disease
- - exposure to respiratory disease
- - allergies
- - smoking
- - OTC nasal sprays or medications
- - use of oxygen
- - vaccinations
Remove all clothing to waist. Sit on an exam table or stand.
- Shape of chest -
- A. AP Diameter - (Antero-posterior diameter)
- B. Barrel Chest - AP diameter compared to transverse diameter is 1:1
- C. Pigeon Breast (Pecus carinatum) - AP diameter is increased
- D. Funnel Breast - (Pecus excavatum)
- E. Kyphosis
- F. Poker Spine
- G. Scoliosis
- H. Lordosis
- Slope of Ribs - normally ribs are inserted into the spine at a 45E angle and inserted into the costal angle at a 45E angle.
- Abnormal Retraction of Interspaces During Inspiration
- A. Substernal retractions
- B. Intercostal retractions
- C. Suprasternal retractions
- Pattern of Respiration
- A. Men & women - breathe diaphragmatically
- Women - breathe thoracically or costaly
Rate Depth, Type and Rhythm of Breathing
- A. Eupnea, 16-20 BPM
- B. Tachypnea, respirations over 20 BPM
- C. Bradypnea, respirations under 10 BPM
- D. Apnea, absence of respirations
- E. Hyperpnea, increase in depth of respirations
- F. Cheyne-Stokes, altering hyperpnea and shallow respirations, followed by periods of apnea.
- G. Biot's, shallow breathing interrupted by apnea
- H. Kussmauls, increase in rate and depth
- Apneustic, long inspiration, short expiration
- Use of Accessory Muscles.
- A. Sternocleidomastoid muscle
- B. Scalenus
- Symmetry of Chest Expansion
- Lips, Nailbeds, Nares
- Identify Areas of Tenderness, Lesions, Masses, or Crepitation
- Respiratory Excursion. (Thoracic expansion) Can be assessed in anterior or posterior chest.
- Tactile Fremitus (vocal fremitus) - client says "99" while examiner palpates the thorax using palmar surface of fingers or ulnar aspect of hand.
- A. Normal fremitus
- B. Increased vocal fremitus
- C. Decreased or absent vocal fremitus
- Vibration (fremitus) During Quiet Inspiration and Expiration
- Palpate for Tracheal Deviation.
- Percussion penetrates to a depth of approximately 5-7 cm. It is used to determine the relative amounts of air, liquid, or solid material in the underlying lung.
- Resonance - loud, low pitched hollow sound of a long duration.
- Abnormal percussion notes:
- Hyperresonance - occurs with increased amounts of air. Loud, low-pitched booming sound with a long duration.
- Dullness - occurs with fluid, pus, consolidation, or tumors. Medium soft intensity with a thud-like sound.
- Flatness- large amount of fluid over an area with little underlying air. (Pleural effusion). Soft, high-pitched sound with a very short duration.
- Diaphragmatic excursion
- Symmetrical Areas Should be Compared in Regard to
- Presence of Adventitious Breath Sounds.
Instruct client to breathe slightly more deeply and slowly than normal respiration. Client should breathe through open mouth.
|| Duration of inspiration and expiration
|| Diagram of sound
|| Normal Location
|| Abnormal Location
Inspiration > expiration 5 : 2
|| Peripheral lung
|| Over trachea and sternum
|| Inspiration = expiration 1 : 1
|| First and second intercostal spaces at the border over major bronchi
|| Peripheral lung
| Bronchial (tubular)
|| Inspiration < expiration 1 : 2 Pause between inspiration and expiration
|| Over trachea
|| Lung areas
- Changes in Normal Breath Sounds
- A. Deep breathing changes normal vesicular sounds to bronchovesicular sounds
- B. Breathing through the nose will alter normal breath sounds
- C. Fluid filling the alveoli will convert vesicular sounds to bronchovesicular sounds (early pneumonia).
- D. Large amounts of fluid collecting will change vesicular to bronchial sounds (lung consolidation).
E. No breath sounds
- obstructed bronchus
- fractured ribs with splinting
- barrel chest
- thickened pleura
- air and fluid in pleural place
- Egophony - when listening over a normal peripheral lung you will hear the sound "eee" when the patient voices "eee." When the lung is compressed by fluid (pleural effusion), you will hear the sound "aye."
- Adventitious Sounds
- A. Crackles (rales)
- Fine - high pitched
- Coarse - low pitched
- B. Wheezes
- Sonorous (coarse) - low pitched
- Sibilant (wheezes) - high pitched (usually occurs during expiratory phase of respiration. Inspiratory wheezes indicate severe narrowing of the airway.)
a. monophonic wheezes
b. polyphonic wheezes
- C. Rhonchi (gurgles)
- D. Friction rub - loud dry creaking or grating sound heard best over lower anterolateral thorax
- E. Stridor - an inspiratory wheeze that is louder over the neck than the thorax.
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