the thorax and lungs assessment [autosaved]
TRANSCRIPT
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Arlyn C. Mendenilla, RN
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Nurses encounter clients with respiratory problems in virtually everyarea of practice and virtually every practice setting.
Nursing care of clients with respiratory problems may range fromprevention of the spread of common cold in a school setting to sustainingthe life of a client in respiratory failure in the intensive care unit.
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Thorax identifies the portion of the bodyextending from the base of the necksuperiorly to the level of the diaphragm.
The thoracic cage is constructed of thesternum, 12 pairs of ribs, 12 thoracicvertebrae, muscles, and cartilage.
The thorax consists of the anterior thoraciccage and the posterior thoracic cage.
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The thoracic cavity consists of themediastinum and the lungs.
The lungs are cone-shaped, elastic structuressuspended within the thoracic cavity.
The apex of the lungs extends slightly abovethe clavicle.
The base of the lungs is at the level of thediaphragm.
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Before beginning the assessment, the nursemust be familiar with series of imaginarylines on the chest wall and be able to locatethe position of each rib and some spinous
processes.
These landmarks help the nurse to identify
the position of underlying organs ( ex. Lobesof the lung) and to record abnormal findings.
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A B C
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Anterior chest landmarks and underlying lungs; Posterior chest landmarks and underlying lungs
Lateral chest landmarks and underlying lungs.
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In adults, thethorax is oval.
Its anterioposteriordiameter is half its
traverse diameter. Overall shape is
eleptical; that is, itsdiameter is smaller
at the top than atthe base.
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Chest deformities: A, pigeon chest; B, funnel chest; C, barrel chest;D, kyphosis; E, scoliosis.
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Normal breath sounds Vesicular
Broncho vesicular
Bronchial
Adventitious breath sounds Crackles (rales) best heard on inspiration
Gurgles (rhonchi) best heard on expiration
Friction rub inspiration and expiration Wheeze - best heard on expiration
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Planning For efficiency, the nurse usually examines the posteriorchest first, then the anterior chest wall. For posterior and lateral chest examinations, the clientis uncovered to the waist and in a sitting position. The sitting or lying position maybe used for anteriorchest examination. The sitting position is preferred because it maximizes
chest expansion. Good lighting is essential, especially for chest expansion
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Assemble equipment: Stethoscope Skin marker/pencil Centimeter ruler Assessment of thorax and lungs is notdelegated to nursing aide
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1. Introduce yourself and verify the clientsidentity. Explain to the client what you aregoing to do, why it is necessary, and how theclient can cooperate.2. Perform hand hygiene and observe otherappropriate infection control procedures.3. Provide for client privacy.4. Inquire if client has any history of the following:
Family history of illness, including cancer Allergies Tuberculosis Lifestyle habits, such as smoking, and occupational
hazards Any medications being taken Current problems such as swellings, coughs, wheezing,
pain
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Assessment Normal Findings Deviation from NormalPosterior thorax
5. Inspect the shape,color and symmetryof the thorax fromposterior and
lateral views.Compare theanteroposteriordiameter to thetransversediameter.
Anteroposterior totransverese diameterratio of 1:2
Pink
Chest symmetric
Barrel chest;increasedanteroposterior totransverse diameter
Pallor, cyanosis
Chest asymmetric
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Assessment Normal Findings Deviation from Normal6. Inspect the spinal
alignment for
deformities.Have the client stand.From a lateralposition, observe thethree normal
curvatures: cervical,thoracic, and lumbar.
Spine verticallyaligned
Exaggerated spinalcurvatures( kyphosis, lordosis)
To assess for lateraldeviation of the spine(scoliosis), observe
the standing clientfrom the rear. Havethe client bendforward at the waistand observe from
behind.
Spinal column isstraight, right andleft shoulders and
hips are the sameheight
Spinal columndeviates to one side,often accentuated
when bending over.Shoulder or hips noteven
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Assessment Normal Findings Deviation from Normal7. Palpate theposterior thorax.
For clients who have norespiratory complaints,rapidly assess thetemperature andintegrity of all chestskin.
Skin intact, uniformtemperature
Skin lesions: areas ofhyperthermia
For clients who do haverespiratory complaints,palpate all chest areasfor bulges, tenderness,or abnormal
movements. Avoid deeppalpation for painfulareas, especially if afractured rib issuspected.
Chest wall intact; notenderness; no masses
Lumps, bulges;depression; areas oftenderness; movablestructures (ex. Rib)
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Assessment Normal Findings Deviation from Normal8.Palpate theposterior chest for
respiratoryexcursion.Place the palms ofboth your handsover the lower
thorax, with yourthumbs adjacent tothe spine and yourfingers stretchedlaterally. Ask the
client to take a deepbreath while youobserve themovement of yourhands and any lag inmovement.
Full and symmetricchest expansion. Whenthe client takes a deep
breath, your thumbsshould move apart anequal distance at thesame time; normallythe thumbs separate 3to 5 cm ( 1 to 2 in)
during deepinspiration
Asymmetric and/ordecreased chestexpansion
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9. Palpate the chest for vocal(tactile) fremitus.Place the palmar surfaces ofyour fingertips or the ulnaraspect of your hand or closedfist on the posterior chest,
starting near the apex of thelungs.
Bilateral symmetry of vocalfremitus.Fremitus is heard mostclearly at the apex of the
heart
Decreased or absentfremitus (asso. Wdpneumothorax)
Ask the client to repeat suchwords as bluemoon or one,two, three, or 99
Low-pitched voices ofmales are more readilypalpated than the higherpitched voices of females
Increased fremitus (asso.wd consolidated lungtissue, as in pneumonia
Repeat the two steps, movingyour hands sequentially to the
base of the lungs.Compare the fremitus on bothlungs and between the apexand the base of each lung,either 1) using one hand and
moving it from one side of theclient to the correspondingarea on the other side or 2)using two hands that areplaced simultaneously on thecorresponding areas of each
side of the chest.
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Assessment Normal Findings Deviation fromNormal10. Percuss the thorax. ask the client to bend
the head and fold thearms forward acrossthe chest.
Percuss in theintercostal spaces at
about 5 cm (2in)intervals in systematicsequence
Compare one side ofthe lung with the
other Percuss the lateral
every few inches,starting at the axillaand working down to
the eight rib
Percussion notesresonate, except over
scapula
Lowest point ofresonance is at thediaphragm
Percussion on the ribnormally elicitsdullness
Assymetry inpercussion
Areas of dullnessor flatness overlung tissue (asso.With consolidationof lung tissue or amass or fluid.
Hyperresonance isheard overemphysematous
lungs.
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Assessment Normal Findings Deviation fromNormal11. Percuss for diaphragmatic excursion.
Ask the client to take a deep breath andhold it while you percuss downward alongthe scapular line until dullness is produced atthe level of the diaphragm. Mark this pointwith a marking pencil, and repeat theprocedure on the other side of the chest.
Percussion 3 to 5cm bilaterally inwomen and 5 to 6cm in men
Diaphragm is
usually slightlyhigher on theright side
Restrictedexcursion (asso.Wd lung disorder)
Ask the client to take a few normal breathsand then expel the last breath completelyand hold it while you percuss upward from
the marked poingt to assess and mark thediaphragmatic excursion during deepexpiration on each side
Measure the distance between two marks
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Assessment NormalFindings Deviation fromNormal12. Auscultate the chest using
the flat-disc diaphragm of thestethoscope.
Normal breathsounds
Adventitiousbreath soundssounds
No breath sounds
Use the systematic zigzag
procedure used in percussion.
Ask the client to take slow,deep breaths through themouth. Listen at each point tothe breath sounds during acomplete inspiration and
expiration.
Compare findings at eachpoint with the correspondingpoint on the opposite side of
the chest.
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Assessment Normal Findings Deviation from NormalAnterior Thorax
13. Inspect
breathingpatterns.(ex.RR, rhythm)
Quiet, rhythmic, and
effortless respirations
Abnormal breathing
pattern tachypnea,bradypnea, apnea etc.
14. Inspect thecostal angleand the angle atwhich the ribs
enter the spine.
Costal angle is 90, andthe ribs insert into thespine at approximatelyat 45 angle
Costal angle is widenedassocaited with COPD
15. Palpate the
anterior chest.
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Normal17. Palpate tactile fremitus inthe same manner as for the
posterior chest.
Same as posteriorvocal fremitus;
Same as posteriorvocal fremitus;
If the breasts are large andcannot be retracted adequatelyfor palpation, this part of theexamination usually is omitted.
Fremitus is normallydecreased over heartand breast tissue
18. Percuss the anterior chest
systematically.
Percussion notes
resonate down to thesixth rib at the levelof diaphragm
Asymmetry in
percussion notes
Begin above the clavicles in thesupraclavicular space, and
proceed downward to thediaphragm.
But are flat over areasof heavy muscle and
bone
Areas of dullness orflatness over lung
tissue
Compare one side of the lungto the other.
,dull on areas overthe heart & the liver
Displace female breasts forproper examination.
and tympanic over
the underlyingstomach
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Assessment Normal Findings Deviation fromNormal19. Auscultate the
trachea.
Bronchial and tubularbreath sounds
Adventitioussound
20. Auscultate theanterior chest.Use the sequence usedin percussion, beginningover the bronchibetween the sternumand the clavicles.
Bronchovesicular andvesicular breathsounds
Adventitioussound
Document findings in
the client record usingforms or checklistsupplemented bynarrative notes when
appropriate.
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In infants thorax isrounded; that is, thediameter from the
front to the back(anteposterior) isequal to the
transverse diameter.
It is also cylindrical,nearly equal diameter
at the top and thebase.
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Also known aspectus carinatum.
A narrow transversediameter, anincreaseanteroposteriordiameter, and a
protruding sternum.
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Sternum isdepressed,narrowing theanteroposterior
diameter.
Also known aspectus excavatum.
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5
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What are the four types of AdventitiousBreath Sounds?
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Enumerate the structures that makes up the
thoracic cage.
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What are the 5 imaginary lines of the
anterior chest
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What is the preferred position during
chest examination?
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What is the normal overall shape of the
thorax?