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1 of 10 Normal Breath Sounds (Kozier 613) Type Description Location

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1 of 10 Normal Breath Sounds (Kozier 613) Type Description Location 1 of 10 Normal Breath Sounds (Kozier 613) Type Description Location Characteristics Vesicular Soft-intensity, low-pitched, Over peripheral lung; Best heard on “gentle sighing” sounds created best heard at base of inspiration, which is by air moving through smaller lungs about 2.5 times longer airways (bronchioles & alveoli) than the expiratory phase (5:2 ration) Broncho-vesicular Moderate-intensity and Between the scapulae Equal inspiratory & moderate-pitched “blowing” and lateral to the expiratory phases (1:1 sounds created by air moving sternum at the first and ratio) through larger airway (bronchi) second intercostal spaces Bronchial High-pitched, loud, “harsh” Anteriorly over the Louder than vesicular (tubular) sounds created by air moving trachea; not normally sounds; have a short through the trachea heard over lung tissue inspiratory phase and long expiratory phase (1:2 ratio) Adventitious Breath sounds (Kozier 613) Name Description Cause Location Crackles (rales or Fine, short, interrupted Air passing through Most commonly heard crepitations) cracking sounds; alveolar rales fluid or mucus in any in the bases of the are high pitched. Sound can be air passage lower lung lobes simulated by rolling a lock of hair near the ear. Best heard on inspiration but can be heard on both inspiration and expiration. May not be cleared by coughing. Gurgles (rhonchi) Continuous, low-pitched, Air passing through Loud sounds can be coarse, gurgling, harsh, louder narrowed air passages heard over most lung sounds with a moaning or as a result of secretions, areas, but predominate snoring quality. Best heard on swelling, tumors. over the trachea and expiration but can be heard on bronchi both inspiration and expiration. May be altered by coughing. Friction rub Superficial grating or creaking Rubbing together of Heard most often in sounds heard during inspiration inflamed pleural areas of greatest and expiration. Not relieved by surfaces. thoracic expansion coughing. (e.g. lower anterior and lateral chest) Wheeze Continuous, high-pitched, Air passing through a Heard over all lung squeaky musical sounds. Best constricted bronchus as fields. 2 of 10 heard on expiration. Not a result of secretions, usually altered by coughing. swelling, tumors Absence of breath n/a Associated with Can be “heard” sounds collapsed and surgically wherever airflow is removed lobes or lacking. severe pneumonia Assessing the Thorax & Lungs (Kozier 614) Planning Equipment For efficiency, the nurse usually examines the • Stethoscope posterior chest first, then the anterior chest. For • Skin marker/pencil posterior and lateral chest examinations, the client • Centimeter rule is uncovered to the waist and in a sitting position. A sitting or lying position may b e used for anterior chest examination. The sitting position is preferred because it maximizes chest expansion. Good lighting is essential, especially for chest inspection. Delegation Assessment of the thorax and lungs is not delegated to a UAP. However, many aspects of breathing are observed during usual care and may be recorded by persons other than the nurse. Abnormal findings must be validated and interpreted by the nurse Implementation Performance 1. Prior to performing the procedure, introduce self and verify the client's identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Discuss how the results will be used in planning further care or treatments. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. In women, drape the anterior chest when it is not being examined. 4. Inquire if the client has any history of the following: family history of illness, including cancer, allergies, tuberculosis; lifestyle habits such as smoking & occupational hazards (e.g. inhaling fumes); medications being taken; current problems (e.g. swellings, coughs, wheezing, pain) Assessment [Posterior thorax] Normal Findings Deviations from Normal 5. Inspect the shape and • Anteroposterior to • Barrel chest; increased symmetry of the thorax transverse diameter in anteroposterior to from posterior and lateral ratio of 1: 2 transverse diameter views. Compare the • Chest symmetric • Chest asymmetric anteroposterior diameter to the transverse diameter 3 of 10 6. Inspect the spinal • Spine vertically aligned • Exaggerated spinal alignment for deformities. • Spinal column is curvatures (kyphosis, Have the client stand. straight, right and left lordosis) From a lateral position, shoulders and hips are • spinal column deviates to observe the three normal at the same height one side, often curvatures: cervical, accentuated when thoracic, and lumbar bending over. Shoulders ◦ To assess for lateral or hips not even. deviation of spine (scoliosis), observe the ☼ See chart on page 7 for standing client from the abnormal chest configurations rear. Have the client bend forward at the waist and observe from behind. 7. Palpate the posterior • Skin intact; uniform • Skin lesions; areas of thorax. temperatures hyperthermia ◦ For clients who have • Chest wall intact; no • lumps, bulges; no respiratory tenderness; no masses depressions; areas of complaints, rapidly tenderness; movable assess the temperature structures (e.g. rib) and integrity of all chest skin. ◦ For clients who do have respiratory complaints, palpate all chest areas for bulges, tenderness, or abnormal movements. Avoid deep palpation for painful areas, especially if a fractured rib is suspected. In such a case, deep palpation could lead to displacement of the bone fragment against the lungs 8. Palpate the posterior chest • Full and symmetric • Asymmetric and/or for respiratory excursion chest expansion. For decreased chest (thoracic expansion). Place example, when the expansion. the palms of both your client takes a deep hands over the lower breath, your thumbs thorax with your thumbs should move apart an adjacent to the spine and equal distance and at 4 of 10 your fingers stretched the same time; normally laterally.(a) Ask the client the thumbs separate 3 to to take a deep breath while 5 cm (1.5 to 2 inches) you observe the movement during inspiration. o your hands and any lag in movement. • (a) Position of the nurse's hands when assessing respiratory excursion on the posterior thorax. 9. Palpate the chest for vocal • Bilateral symmetry of • Decreased or absent (tactile) fremitus, the vocal fremitus fremitus (associated with faintly perceptible • Fremitus is heard most pneumothorax) vibration felt through the clearly at the apex of • Increased fremitus chest wall when the client the lungs (associated with speaks • Low-pitched voices of consolidated lung tissue, ◦ Place the palmar males are more readily as in pneumonia). surfaces of your palpated that higher fingertips or the ulnar pitched voices of aspect of your hand or females closed fist on the posterio chest, starting 5 of 10 near the apex of the • (b) Areas and sequence lungs [(b) spot 1] for palpating tactile ◦ Ask the client to repeat fremitus on the such words as “blue posterior chest moon” or “one, two, three” ◦ Repeat the two steps, moving your hands sequentially to the base of the lungs, through positions 2-5 in (b). ◦ Compare the fremitus on both lungs and between the apex and the base of each lung, using either one hand and moving it from one ☼ See pg 10 for chart side of the client to the on Voice Sounds corresponding area on the other side or using two hand that are placed simultaneously on the corresponding areas of each side of the chest. 10. Percuss the thorax Percussion of the thorax is performed to determine whether underlying lung tissue is filled with air, liquid, or solid material and to determine the positions and boundaries of certain organs. Because percussion penetrates to a dept of 5 to 7 cm (2 to 3 inches) it detects superficial rather than deep • • lesions. Percussion sounds (c) Normal percussion (d) sequence for posterior and tones are described in sounds on the posterior chest percussion Kozier on page 583 and chest Brunner on 504.(c) ☼ See chart on page 9 for ◦ Ask the client to bend characteristics of Percussion the head and fold the Sounds. arms forward across the chest. Rationale: 6 of 10 This separates the scapula and exposes more lung tissue to percussion. ◦ Percuss in the intercostal spaces at about 5 cm (2in) intervals in a systematic sequence (d) ◦ Compare one side of the lung with the other ◦ Percuss the lateral thorax every few inches, starting at the axilla and working down to the eighth rib 11. Percuss for diaphragmatic • Excursion is 3 to 5 cm • Restricted excursion excursion (movement of (1.5 to 2 in) bilaterally (associated with lung the diaphragm during in women and 5-6 cm disorder). maximal inspiration and (2 to 3 in) in men. expiration) • Diaphragm is usually ◦ Ask the client to take a slightly higher on the deep breath and hold it right side. while you percuss downward along the scapular line until dullness is produced at the level of the diaphragm. Mark this point with a marking pencil, and repeat the procedure on the other side of the chest. ◦ Ask the client to take a few normal breaths and then expel the last breath completely and hold it while you percuss upward from the marked point to assess and mark the diaphragmatic excursion during deep expiration on each side 7 of 10 ◦ Measure the distance between the two marks 12. Auscultate the chest using • Vesicular and • Adventitious breath the flat disc diaphragm of bronchovesicular breath sounds (e.g. crackles, the stethoscope (best for sounds gurgles, wheeze, friction transmitting the high rub) pitched breath sounds). • Absence of breath sounds ◦ Use the systematic zigzag procedure used in percussion ◦ Ask the client to take slow, deep breaths through the mouth. Listen at each point to the breath sound during a complete inspiration and expiration ◦ Compare findings at each point with the corresponding point on the opposite side of the chest.
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