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Assessment of Thorax and Lungs. Christine M. Wilson Viterbo University. Objectives. Landmarks Structures Function Developmental/transcultural Subjective data Objective data. Anterior Landmarks. Clavicle Suprasternal notch Sternum Sternal angle Intercostal spaces Xiphod process

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assessment of thorax and lungs

Assessment of Thorax and Lungs

Christine M. Wilson

Viterbo University

objectives
Objectives
  • Landmarks
  • Structures
  • Function
  • Developmental/transcultural
  • Subjective data
  • Objective data
anterior landmarks
Anterior Landmarks
  • Clavicle
  • Suprasternal notch
  • Sternum
  • Sternal angle
  • Intercostal spaces
  • Xiphod process
  • Costal angle
posterior landmarks
Posterior Landmarks
  • Vertebra prominens (C7)
  • Spinous processes
  • Scapula
reference lines
Reference Lines

Anterior Chest

  • Midsternal
  • Midclavicular
reference lines6
Reference Lines

Posterior Wall

  • Vertebral Line
  • Scapular Line
reference lines7
Reference Lines

Axillary Area

  • Midaxillary
  • Anterior Axillary
  • Posterior Axillary
position in chest
Position in Chest
  • Lobes of the lung
  • Trachea
  • Bronchial Tree
functions of respiration
Functions of Respiration

Major Functions

  • Supply oxygen to body for energy production
  • Remove carbon dioxide as a waste from energy production
  • Maintain pH balance of arterial blood
  • Maintain heat exchange
developmental considerations
Developmental Considerations

Fetal Life

  • At 5 weeks primitive lung buds emerge
  • By 16 weeks there are the same # of conducting airways as in the adult.
  • At 32 weeks surfactant sufficient to sustain life
  • At birth 70 million primitive alveoli kick in
developmental considerations11
Developmental Considerations

The Aging Adult

  • Lungs more rigid; harder to inflate
  • Less surface available for gas exchange
  • Common increase in AP diameter
  • Kyphosis: Front to back curvature spine
  • May fatigue more easily
transcultural considerations
Transcultural Considerations
  • Largest chests (descending order): whites, blacks, Asians, Native Americans
  • Fetal lung maturity reached earlier in black population
  • Incidence of TB is higher in Asian Americans
subjective data
Subjective Data
  • Cough
  • Shortness of breath
  • Chest pain with breathing
  • History of respiratory infections
  • Smoking history
  • Environmental exposure
  • Self care behavior
objective data posterior chest
Objective Data-Posterior Chest

Inspect

  • Shape and configuration
    • A/P diameter should be less than transverse by 1:2
  • Position
  • Skin color and condition
posterior chest
Posterior Chest

Symmetric chest expansion

  • Place hands at T9-T10
  • Equal movement of thumbs with inhaling
posterior chest16
Posterior Chest

Tactile fremitus

  • Place ulnar edge on skin; client repeats 99
  • Symmetry is expected
  • Decreases if sound transmission is obstructed

Palpate chest wall

posterior chest17
Posterior Chest

Percussion

  • Find predominant note over lung fields
  • Begin at apices
  • Use same pathway side to side
lung percussion sounds
Lung Percussion Sounds
  • Resonance: non-musical; healthy lung
  • Hyper-resonance: slightly musical; too much air, i.e. emphysema/pneumothorax
  • Dull: muffled; organ or abnormal density, i.e. pneumonia
  • Flat: soft thud; i.e. muscle mass, bone
posterior chest19
Posterior Chest

Diaphragmatic Excursion

  • Find lower lung border in expiration and inspiration
  • Measure: Should measure 3-5cm, equal distance bilaterally.
posterior chest20
Posterior Chest

Auscultation

  • Use diaphragm of stethoscope; place firmly
  • One full breath at each position
  • Use same pathway
    • side to side comparison
breath sounds
Breath Sounds
  • Bronchial
    • Loud, harsh sounds over trachea
  • Bronchovesicular
    • Moderate, mixed sounds over bronchi
  • Vesicular
    • Soft, rustling sounds over periphery
decreased or absent
Decreased or Absent

Obstruction

  • Secretions, mucus plug, foreign body

Emphysema

  • Loss of elasticity; air already in lungs

Silent chest

  • No air is moving in or out of lungs; ominous sign
increased sounds
Increased Sounds

Bronchial sounds heard over wrong area

  • Solid tissue conducts sounds to surface better
  • Found in pneumonia with consolidation or fluid in intra-pleural space
adventitious sounds
Adventitious Sounds

Crackles (Rales): Fine

  • Fine, discontinuous high-pitched, short crackling sound on inspiration which are not cleared by coughing. (Roll a strand of hair at ear)
  • Found in pneumonia and heart failure
adventitious sounds25
Adventitious Sounds

Crackles: Coarse

  • Loud, low-pitched bubbling or gurgling sounds
  • Start in inspiration, may be in expiration
  • Decrease with coughing, but comes back
  • Found in pulmonary edema and terminally ill with suppressed cough reflex
adventitious sounds26
Adventitious Sounds

Wheeze: High pitch

  • High-pitched, musical squeaking sound that predominates with expiration
  • Indicates narrowed passageway
  • Obstruction from acute asthma or chronic emphysema
adventitious sounds27
Adventitious Sounds

Wheeze Low-pitch

  • Single note which is more prominent on expiration
  • Air flow obstruction
    • bronchitis or tumor
adventitious sounds28
Adventitious Sounds

Stridor

  • High-pitched, crowing sound with inspiration
  • Louder in neck
  • Upper airway obstruction
  • Croup, acute epiglottis, or foreign body inhalation
objective data anterior chest
Objective Data-Anterior Chest

Inspect

  • Shape and configuration
  • Facial expression
  • Level of consciousness
  • Color and condition
  • Respiration rate/quality
anterior chest
Anterior Chest

Symmetric chest expansion

  • Place hands at costal margins
  • Equal movement of thumbs with inhaling
anterior chest31
Anterior Chest

Tactile fremitus

  • Apices to MCL
  • Side to side
  • Symmetry expected

Palpate chest wall

objective data anterior chest32
Objective Data-Anterior Chest

Percussion

  • Dullness over breast tissue, liver, cardiac borders
  • Tympany over gastric

Auscultation

  • Displace breast and listen over chest wall