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Assessing the Thorax and Lungs

Purpose: To determine functional status and to detect any alteration in physiologic process. A complete physical assessment of the chest and lungs, together with the history, will provide the examiner with important clues to diagnose and treat various pathologic conditions.

Preparation
● Provide privacy during assessment.
● Interview patient prior to assessment focusing on any history of cough, sputum production, allergies, dyspnea at rest or on exertion, chest pain, asthma, bronchitis, emphysema, tuberculosis, cyanosis, pallor, exposure to environmental irritants, or smoking.
● A specific sequence should be used when assessing the chest and lungs—inspection, palpation, percussion, and auscultation.

Special Considerations
Pediatric Patient
• There are special considerations when assessing the thorax and lungs of an infant.The anterior-posterior diameter noted on inspection of an infant is equal to the lateral or transverse diameter (1:1). The lateral diameter increases in proportion to the anteroposterior diameter.
• The chest wall is thin, and the rib cage is soft and pliant.
• Respiratory rate will vary with age.
• Hyperresonance will be demonstrated upon auscultation throughout the lungs owing to the thin chest wall.
• The bell of the stethoscope or small diaphragm should be used to localize findings.
• Wheezes and rhonchi occur more frequently in infants and young children.
• See Table 4.6A for respiratory rates for children.

Elderly Patient
• Chest expansion is often decreased owing to muscle weakness, physical disability, or calcification of the rib articulations.
• Bony prominences are marked, and there is a loss of subcutaneous tissue.
• The dorsal curve of the thoracic spine may be pronounced (kyphosis), along with flattening of the lumbar curve.
• The anterior-posterior diameter is increased in relation to the lateral diameter.
• The pace of the physical examination should be adapted to the individual need.

Relevant Nursing Diagnoses
● Possible impaired tissue perfusion due to disease
● Impaired gas exchange related to infection

Expected Outcomes
The outcome of assessing the thorax and lungs will include the following:
● Inspection of symmetry of movement on expansion, anteriorposterior to lateral diameter, and the use of accessory muscles
● Palpation of tactile fremitus
● Percussion for diaphragmatic excursion, resonance notes
● Auscultation of vesicular, bronchovesicular, bronchial, and adventitious breath sounds

Implementation
1. Wash hands.
Rationale: Reduces transmission of microorganisms.

2. Organize equipment.
Rationale: Organizing equipment before beginning an assessment enhances efficiency.

3. Explain assessment to patient.
Rationale: Careful explanation reduces the patient’s anxiety.

4. Expose anterior, posterior, and lateral chest with patient in sitting position.
Rationale: Exposure of the chest in the sitting position facilitates easy access for inspection, palpation, percussion, and auscultation of the area.

Inspection
1. Inspect anterior, posterior, and lateral thorax for the following:
Rationale: Inspection will enable the examiner to assess the general appearance of the thorax. Inspection is important before palpation, percussion, and auscultation as the latter are more invasive.
● Color
Color should be pink without pallor or cyanosis.
● Intercostal spaces
The intercostal spaces should be even and relaxed, without bulging or retracting.
● Chest symmetry
Both sides of the chest should be equal.
● Costal angle
The costal angle is formed by the blending together of the costal margins at the sternum. It is usually no more than 90 degrees, with the ribs inserted at approximately 45-degree angles.
● Respirations
Respirations should be even, 12–20/min, unlabored.
● Anterior-posterior to lateral diameter
Normal is a 1:2 ratio (anterior-posterior diameter is approximately one half the lateral diameter). This information will provide the examiner with shape and symmetry of the chest. A barrel chest, which results from compromised respiration, chronic obstructive pulmonary disease (COPD), for example, will demonstrate an increase in the anteroposterior diameter.
● Shape and position of sternum
Sternum should be level with the ribs. Two structural variations of the sternum are pigeon chest (pectus carinatum), a prominent sternal protrusion, and funnel chest (pectus excavatum), which is an indentation of the lower sternum above the xiphoid process.
● Position of trachea
Trachea should be midline without deviation to either side.
● Chest expansion
Chest should expand approximately 3 inches upon inspiration.

Palpation
1. Drape anterior chest.Use finger pads or palm of hands to palpate posterior chest. Have patient lean forward and fold arms across chest.
Rationale: Palpation of the chest will enable the examiner to assess the thoracic muscles and skeleton, and to feel for pulsations, areas of tenderness, bulges, depressions, and unusual movements. The anterior chest should be draped while you are assessing the posterior chest to ensure privacy. Leaning forward increases the area of the lungs. Palpation, percussion, and auscultation of the posterior lungs will be done while the patient remains in the sitting position.

2. Palpate upper, middle, and lower thorax for sensation.
Rationale: No pain or tenderness should be present.

3. Palpate upper, middle, and lower thorax for vocal fremitus. Have the patient say “99” while palpating.
Rationale: Vibration should be decreased over the periphery of the lungs and increased over the major airways. Vibration will be increased over areas of consolidation and decreased over airway with obstruction.

4. Palpate the thorax for expansion. Place hands at level of 10th rib on the posterior thorax, and have patient take a deep breath. Observe thumb movement. 2- to 3-inch symmetric expansion should be noted upon inspiration.

5. Place hands on the lower sternum anteriorly and have patient take a deep breath. Observe thumb movement. Symmetric expansion of 2 to 3 inches should be noted.

Percussion
1. Percuss over shoulder apices and at posterior, anterior, and lateral intercostal spaces moving from apex to base of lungs.
Rationale: Percussion will provide the examiner with information concerning areas of the thorax and lungs that are air-filled or that may have consolidation (fluidfilled). The impact of the examiner’s finger produces a vibration against the underlying tissue, and percussion tones can be heard (resonance). Resonance, a loud, low-pitched, hollow sound is percussed in healthy lungs. The more dense the medium, as in fluid or masses, for example, the quieter (dullness) the percussion tone. The percussion tone over air-filled lungs is loud, lowpitched, and has a boomlike quality (hyperresonance), as in emphysema.

2. Percuss for diaphragmatic excursions bilaterally.
● Ask patient to inhale deeply and hold.
● Percuss along the scapular line until you locate the lower border (noted by a change from resonance to dullness).
● Mark the point with a pencil and have the patient breathe.
● Ask the patient to exhale as much as possible and hold.
● Percuss up from the marked point and mark where the change from dullness to resonance occurred. Have the patient breathe.
● Measure and record the distance in centimeters. The excursion distance of the diaphragm is usually 3 to 5 cm. The descent of the diaphragm may be limited by emphysema, ascites, tumor, or pain.

Auscultation
1. Instruct patient to take slow, deep breaths through his mouth while you auscultate the intercostal spaces with the diaphragm of the stethoscope. Auscultate over the following areas:
Rationale: Auscultation of the chest provides the examiner with important clues to the condition of the lungs. Listen for two full breaths while comparing each side of the thorax moving the stethoscope from the apex of the lungs to the base.
● Trachea
Bronchial (tubular)/ tracheal breath sounds are heard over the trachea. They are high-pitched, loud, with the expiratory phase of respiration often longer than the inspiratory phase.
● Bronchial airway, including below clavicles and between scapulae
Bronchovesicular breath sounds, medium in pitch, are heard over the main bronchus area and over the upper-right posterior lung field. The inspiratory phase should equal expiratory phase.
● Lung periphery
Vesicular (soft, breezy) breath sounds, low in pitch, are heard over lung periphery. The inspiratory phase should be longer than the expiratory phase.

2. Auscultate breath sounds for adventitious sounds, including wheezes, rales, and rhonchi.
Rationale: Lungs should be clear to auscultation on inspiration and expiration. If abnormal sounds are heard, ask patient to cough and note if adventitious sound is still present.

3. Auscultate for altered voice sounds over lung periphery where any previous lung abnormality was noted.
● Bronchophony patient says “99” while examiner auscultates.
● Whispered pectoriloquy patient whispers “one, two, three” while examiner auscultates.
● Egophony patient says “eee” while examiner auscultates.
Rationale: Auscultation for altered voice sounds will provide the examiner with clues regarding the presence of consolidation in the lung tissue. The voice vibrates and transmits sounds through the lung fields. The sounds should be muffled in healthy lungs, but may be loud and clear in any condition that consolidates lung tissue.

Evaluation and follow up activities
● Compare assessment findings to normal findings
● Record and report normal and abnormal findings
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