Lecture 6: Pulmonary Assessment: Thorax & Lungs Flashcards
Learning Objectives
Learn the structure and function of the thorax and lungs
Understand the methods of examination of the respiratory system
Identify lung sounds that are normal
Describe the characteristics of adventitious lung sounds
Accurately record the assessment
Structure and Function
Objective Data: Pulmonary Inspection
Facial expression- relaxed, anxious? (do not describe as normal)
-Skin color of face, lips, cheeks
-Nasal flaring
-Nailbeds for capillary refill, clubbing, shape and color
-Conversational dyspnea
-Client’s positioning (tripod)-chest forward maximal use of accessory muscles
-Chest shape
-Use of accessory muscles
*Muscles of neck, back, abdomen, intercostal muscles
Secondary polycythemia- body’s response to chronic hypoxia in patients with COPD, kidneys produce more erythropoietin to manufacturer red blood cells which carries the O2 through the body
Tri pod position- chest forwards-allows us to use all of our accessory muscles
Use of accessory muscles including sternomastoid, diaphragm
Inspection- Respiration
Rate:
12 to 20 breaths/minute in resting adult
Rhythm:
Even, regular
Symmetry
Retractions:
chest wall appears to cave in
Paradoxical breathing:
diaphragm moves in opposite direction than it should when inhaling/exhaling- acute respiratory distress
Inspection: Skin Tone
Normal- evenly colored skin tone, appropriate for race
Ruddy to purple-secondary polycythemia- Chronic Obstructive Pulmonary Disease (COPD)-chronic hypoxia (low levels of O2 in body tissue)-erythropoietin in kidneys stimulates red blood cell (RBC) production
Cyanosis- makes white skin appear blue-tinged- indicates hypoxia/decreased perfusion
Pallor/pale- hypoxia (low levels of O2), anemia
Jaundice (yellow)- excess bilirubin in blood-liver disease
- Dark-skinned clients- sclera will be jaundice
Abnormalities of Thoracic Cage: Barrel Chest
AP to Transverse Diameter = 1:1
(2 hands to 2 hands, like 2:2)
Ribs horizontal
Costal angle >90 degrees
Associated with normal aging, emphysema
Abnormalities of Thoracic Cage: Pectus Excavatum
Funnel Chest
Abnormalities of Thoracic Cage: Pectus Carinatum
Pigeon Chest
Abnormalities of Thoracic Cage: Scoliosis
Abnormalities of Thoracic Cage: Kyphosis
hypoxia level via pulse oximetry
SaO2 > 92%
Clubbing
(increased capillary density from chronic hypoxia)
normal is 160 degrees
clubbing is 180
Clubbing present 80% of lung cancer patients
Normal nail beds are flat, notice the downward sloping of the nail bed with clubbing
Normal nail beds are pink, notice the pallor and cyanosis of the clubbed nail beds
Schamroth Sign (fingers together to see for normal gap)
Capillary Refill
Clubbing present 80% of lung cancer patients
Normal nail beds are flat, notice the downward sloping of the nail bed with clubbing
Normal nail beds are pink, notice the pallor and cyanosis of the clubbed nail beds
Respiratory patterns
Normal is regular and comfortable at rate of 12 -20 per min and regular
Tachy meaning more than 24 breaths min and shsllow as in fever
Brady meaning less than 10 breaths per minute as in well conditioned athletes
Hyper increased rate and increased depth with severe anxiety
Kussmaul in diabetic ketoacidosis rapid, deep and labored
Hypo decreased rate, decreased depth, irregular, overdose of narcotics
Cheyne-Stokes which is irregular pattern with alternating periods of deep, rapid breathing followed by period of apnea or no breathing
Air trapping increasing difficulty in getting breath out in COPD, air is trapped in the lungs during expiration
Pulmonary Exam- Palpation
Position of trachea (trachea moves away from collection of fluid or tension pneumothorax, moves toward collapsed lung or consolidation)
Chest bones and muscles
Crepitus (air in the subcutaneous tissue)
Palpate for thoracic expansion
Tactile Fremitus (vibration transmitted, use ulnar surface of hand)
Palpate for pleural friction rub - feels like leather rubbing on leather
Thoracic Expansion
assessment of chest movement
Have patient inhale
Thumbs should come together
Have patient exhale
Thumbs should separate
Palpation of Tactile Fremitus
Palpable vibrations when the patient speaks
Sound generated from the larynx
Vibrations of air in the bronchial tubes transmitted to the chest wall
Best felt parasternally at 2nd ICS
-Decreases as you progress down
Use the palmar base or ball of hands
Note symmetry
“99” or “blue moon”
Percusion
Percuss for resonance, hyperresonance, dullness
-Helps determine if underlying structure is air filled, fluid or solid
-Use indirect (mediate) percussion to elicit sound
-Start at apices and percuss band of normally resonant tissue across tops of both shoulders
-Percuss in interspaces
*Contralateral -Avoid percussing over scapulae and ribs
Normal:
Resonance: low-pitched, clear, hollow sound that predominates in healthy lung tissue in adult
Percussion Notes
Resonance: dull (chart)
Auscultation
DO NOT LISTEN OVER CLOTHES or GOWNS!
Listen anteriorly, posteriorly and laterally in proper locations and order
Listen for normal, adventitious, bilaterally
Use the diaphragm of the stethoscope
Right middle lobe best heard axillary area
Auscultating posterior chest
Patient’s head bent slightly forward,
arms crossed in front over chest
Directions for Client
Take deep breath through open mouth
If you hear adventitious lung sounds, ask client to cough and try to clear
Discourage hyperventilation
-Use deep, slow breaths
Normal Breath Sounds: Bronchial
Normal location:
Trachea
Quality: Harsh or hollow
Pitch: High
Amplitude: Loud
Duration: Insp < Exp 1:2
Normal Breath Sounds: Bronchovesicular
Normal Location:
Over major bronchi
(sternal border)
Quality: Mixed
Pitch: Medium
Amplitude: Moderate
Duration: Insp = Exp 1:1
Normal Breath Sounds: Vesicular
Normal location:
Peripheral lung tissue
Quality: soft, blowing
Pitch: Low
Amplitude: Soft
Duration: Insp > Exp 2.5:1
Adventitious (Unexpected) Breath Sounds
ask pt to cough and if clears it normal (?)
- disscontinuous
Discrete/Intermittent
Crackles
Pleural friction rub - continuous
connected:
Wheeze
Rhonchi
Stridor
Adventitious Breath Sounds:Discontinuous
crackles
Crackles:
High-pitched, discontinuous sounds heard during inspiration
Crackling or popping sound
Bases in lungs
Causes: fluid, i.e. pulmonary edema (CHF)
Adventitious Sounds: Discontinuous
Pleural Friction Rub
Pleural Friction Rub
Mechanism:
inflamed pleura cause friction during respiration
Usually, unilateral
Coarse, low, grating
Like pieces of leather rubbing, walking on fresh snow, “creaky”
Causes: inflammation of the pleura, tissues that line the lungs
Painful
–
Break the words down:
Visceral = internal organs in the main cavities of the body
Parietal = relating to the wall of the body or of a body cavity
Adventitious Sounds: Continuous
Wheeze
Wheeze
high pitched/musical
Mechanism: air flow through compressed or swollen airways
Predominate in expiration
Examples: COPD, asthma, tumors, bronchitis
Adventitious SoundsContinuous
Rhonchi
Rhonchi
low pitched, musical snoring, heard throughout cycle
Mechanism: airflow obstruction by secretions
Clears somewhat with cough or suctioning
Bronchitis major cause in outpatients
Adventitious SoundsContinuous:
STRIDOR
medical emergency
Obstruction or constriction of larynx
Increased pitch, inspiratory, crowing sound
Louder in neck
Originates larynx or trachea
Examples: anaphylaxis, croup in children, epiglottis
Medical emergency- ABCs- airway, breathing, circulation- may skip the history during emergency- what is the priority?
Vocal Resonance/Voice sounds
Egophony- (EE to AY changes)
Bronchophony
Whispered pectoriloquy
Pathology that increases lung density enhances transmission of voice sounds.
Egophony
Auscultate chest while person phonates a long E sound
Normal:
hear E sound through stethoscope
Abnormal:
sound changes to bleating long A sound
Indicates consolidation or compression
Bronchophony
Ask patient to say “ninety-nine” several times in a normal voice
Auscultate several symmetrical areas over each lung
Normal:
Sounds should be muffled and indistinct
Abnormal:
if sounds are louder and clearer- consolidation
Whispered Pectoriloquy
Ask patient to whisper “ninety-nine” several times
Auscultate several symmetrical areas over each lung
Normal:
faint sounds or nothing
Abnormal:
Positive whispered pectoriloquy = you hear sounds clearly
Abnormal Exam Findings: Lobar Pneumonia
Percussion- dull (abnormal density)
Tactile Fremitus- increased
Bronchophony, egophony and whispered pectoriloquy present
Abnormal bronchial sounds in areas where they don’t belong
Abnormal Exam Findings: Pneumothorax
Pneumothorax:
Percussion- hyperresonant (abnormal density)
Tactile Fremitus- decreased or absent
Breath sounds ↓or absent
Usually, unilateral
Unequal chest expansion
No adventitious sounds
Tracheal shift away from affected side
Abnormal Exam Findings: pleural effusion
Pleural Effusion (excess fluid between layers of pleura outside lungs)
-Percussion - dull to flat
-Tactile fremitus - decreased or absent
-Breath sounds decreased or absent
-Tracheal shift away from affected side
-CHF, Cancer, Pneumonia
Abnormal Exam Findings: COPD
Chronic Obstructive Pulmonary Disease (COPD) Sequela-bronchitis & emphysema)
- ↑ AP diameter, ↓chest expansion
- Percussion- hyperresonant (due to air trapping, too much air)
- Tactile fremitus- decreased
- Breath sounds- decreased with prolonged expiration, occasional wheeze
Abnormal Exam Findings: Atelectasis (lung collapse)
↓expansion on affected side
Percussion: Dull (abnormal density)
Tactile fremitus- decreased or absent
Breath sounds decreased or absent over affected area
Occasional fine crackles if bronchus patent
Tracheal shift toward affected side
Blunt injury, medical procedures
Summary for Thorax & Lungs Exam:
Inspection
Thoracic cage, respirations, skin color, condition, nail beds, clubbing, cap refill, persons’ facial expression& LOC
Palpation
Confirm symmetric expansion, tactile fremitus, crepitus, detection of any lumps, masses, or tenderness
Percussion
Lung fields
Auscultation
Assess breath sounds, not abnormal/ adventitious breath sounds
Perform bronchophony, egophony, or whispered pectoriloquy, if needed.
Respiratory Practicum
- Introduce self to client. Two identifiers for patient verification. (1) (patient safety)
- Explain procedure and rationale for assessment. (1) (patient-centered care)
- Provide for privacy. (1) (patient-centered care)
- Wash hands. (1) (patient safety)
- Position- patient in relaxed seated position
- Inspect-
Facial expression (2)
Skin color (2)
Resp rhythm (2)
Use of accessory muscles (2)
Assess AP/T diameter (2)
Capillary Refill (2)
Nail clubbing (2) - Palpate
Anterior (front) chest for crepitus (2)
Posterior (back) chest for tactile fremitus (2)
Posterior (back) chest respiratory expansion (2) - Percuss
Posterior (back) chest for resonance (2)
9.Auscultate
Anterior, lateral and posterior (normal, adventitious, compare bilaterally)
Instruct client to take deep breaths, with attention to avoid hyperventilation (2)
- **Place stethoscope on bare skin (4)
- Auscultate anterior or posterior and left or right lateral (2)
- Use contralateral placement of stethoscope, which is no greater than 2 inches apart (2)
- Chart (10)
Date, time, signature, credentials, only chart what you assess, do not chart what you omit, correct use of abbreviations, landmarks, bilaterally, do not use “normal or good” to describe findings, do not use complete sentences
