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Home , Bronchophony, Thorax

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department

Module Four

Physical examination of

Respiratory Assessment

1 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department

THORACIC CAGE:

Anterior thoracic cage

Posterior thoracic cage

2 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department

Reference lines:

Anterior vertical lines Lateral vertical line

Posterior vertical lines

3 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department

Position of the :

(A) Anterior view of position (B) Posterior view of lung position

(C)Lateral view of left lung position (D) Lateral view of Right lung position

4 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Equipment: EXAMINATION GOWN AND DRAPE GLOVES LIGHTSOURCE MASK MARKER METRIC RULER

Assessment Procedure Normal finding Abnormal finding General Inspection Inspect for nasal flaring and pursed Nasal flaring is not observed. Nasal flaring is seen with . labored respirations (especially in small children) and is indicative of hypoxia.

Pursed lip breathing may be seen in , emphysema, or CHF.

Observe color of , , and chest. The client has evenly colored skin Ruddy to purple complexion may tone, without unusual or be seen in clients with COPD or prominent discoloration. CHF as a result of polycythemia. may be seen if client is cold or hypoxic.

Cyanosis makes white skin appear blue-tinged, especially in the perioral, nailbed, and conjunctival areas. Dark skin appears blue, dull, and lifeless in the same areas.

Inspect color and shape of nails. Pink tones should be seen in the Pale or cyanotic nails may indicate nailbeds. There is normally a 160- hypoxia. Clubbing can occur from degree angle between the base hypoxia. and the skin.

5 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Posterior INSPECTION Inspect configuration. While the client Scapulae are symmetric and Spinous processes that deviate sits with at the sides, stand behind nonprotruding. and laterally in the thoracic area the client and observe the position of scapulae are at equal horizontal may indicate . scapulae and the shape and positions. The ratio of configuration of the chest wall. anteroposterior to transverse diameter is 1:2.

Spinous processes appear straight, and thorax appears symmetric, with sloping downward at approximately a 45-degree angle in relation to the spine.

OLDER ADULT Spinal configurations may CONSIDERATIONS have respiratory implication. (an increased curve of the Ribs appearing horizontal at thoracic spine) is common in older an angle greater than 45 It results from a loss of lung degrees with the spinal resiliency and a loss of skeletal column are frequently the muscle. It may be a normal finding. result of an increased ratio between the anteroposterior transverse diameter ().

This condition (barrel chest) is commonly the result of emphysema due to hyperinflation of the lungs.

6 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Observe use of accessory muscles. The client does not use accessory , or , muscles Watch as the client breathes and note (trapezius/ shoulder) muscles to are used to facilitate assist breathing. use of muscles. inspiration in cases of acute

and chronic airway obstruction

or .

Inspect the client’s positioning. Note Client should be sitting up and Client leans forward and uses arms the client’s posture and ability to relaxed, breathing easily with arms to support weight and lift chest to support weight while breathing at sides or in l increase breathing capacity, comfortably. referred to as the tripod position. This is often seen in COPD.

PALPATION Palpate for tenderness and Client reports no tenderness, Tender or painful areas may sensation. may be pain, or unusual sensations. indicate fibrous connective performed with one or both , but Temperature should be equal tissue. the sequence of palpation is bilaterally. established. Use your to Pain over the intercostal spaces palpate for tenderness, warmth, pain, may be from inflamed pleurae. or other sensations. Start toward the Pain over the ribs is a symptom of midline at the level of the left fractured ribs. (over the apex of the left lung) and move your left to right, Muscle soreness from exercise comparing findings bilaterally. Move or the excessive work of systematically downward and out to breathing (as in COPD) may be cover the lateral portions of the lungs palpated as tenderness. at the bases. Increased warmth may be

related to local .

7 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Palpate for . Crepitus, also The examiner finds no palpable Crepitus can be occurs after called , is crepitus. an open thoracic , a crackling sensation (like or around a chest tube or rubbing against each other) tracheostomy. It also may be that occurs when air passes through palpated in areas of extreme fluid or exudate. Use your fingers and congestion or consolidation. follow the sequence when palpating. In such situations, mark margins and monitor to note any decrease or increase in the crepitant area.

Palpate for . Following the Fremitus is symmetric and easily Unequal fremitus is usually sequence described previously, use identified in the upper regions of the result of consolidation the ball or ulnar edge of one hand the lungs. If fremitus is not palpable (which increases fremitus) to assess for fremitus (vibrations of on either side, the client may need Bronchial obstruction, air air in the bronchial tubes to speak louder. A decrease in the transmitted to the chest wall). As trapping in emphysema, intensity of fremitus is normal as the you move your hand to each area, pleural effusion, or examiner moves toward the base of ask the client to say “ninety-nine.” (which all the lungs. However, fremitus should Assess all areas for symmetry and decrease fremitus). intensity of vibration. remain symmetric for bilateral positions. Diminished fremitus even with a loud spoken voice may indicate an obstruction of CLINICAL TIP the tracheobronchial tree. The ball of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation

8 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department When the client takes a deep Unequal chest expansion can breath, the examiner’s occur with severe atelectasis Assess chest expansion. Place your should move 5 to 10 cm apart (collapse or incomplete hands on the posterior chest wall with symmetrically. expansion), , chest your thumbs at the level of T9 or T10 and trauma, or pneumothorax (air in pressing together a small skin fold. As OLDER ADULT the pleural space). the client takes a deep breath, observe CONSIDERATIONS the movement of your thumbs. Decreased chest excursion at the Because of calcification of the base of the lungs is characteristic costal cartilages and loss of the of COPD. This is due to decreased accessory musculature, the older diaphragmatic function. client’s thoracic expansion may be decreased, although it should still be symmetric.

PERCUSSION

Percuss for tone. Start at the apices of Resonance is the tone Hyperresonance is elicited in cases the scapulae and percuss across the elicited over normal lung tissue. of trapped air such as in Percussion elicits flat tones over the emphysema or pneumothorax. tops of both shoulders. Then percuss the scapula. intercostal spaces across and down, comparing sides. Percuss to the lateral aspects at the bases of the lungs, comparing sides.

9 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Percuss for diaphragmatic excursion. Excursion should be equal Dullness is present when fluid Ask the client to exhale forcefully and bilaterally and measure 3–5 cm in or solid tissue replaces air in hold the breath. Beginning at the adults. the lung or occupies the scapular line (T7), percuss the pleural space, such as in lobar intercostal spaces of the right posterior The level of the diaphragm may be pneumonia, pleural effusion, chest wall. Percuss downward until the higher on the right because of the or tumor. tone changes from resonance to position of the liver. dullness. Mark this level and allow the Diaphragmatic descent may In well-conditioned clients, client to breathe. Next ask the client to be limited by atelectasis of excursion can measure up to 7 or inhale deeply and hold it. Percuss the the lower lobes or by 8 cm. intercostal spaces from the mark emphysema downward until resonance changes to Other possible causes for dullness. Mark the level and allow the limited descent can be pain client to breathe. Measure the or abdominal changes such distance between the two marks. as extreme ascites, tumors, Perform this assessment technique on or pregnancy. both sides of the posterior thorax. Uneven excursion may be seen with inflammation from unilateral pneumonia, damage to the phrenic , or splenomegaly

AUSCULTATION Auscultate for breath sounds. To Three types of normal breath Diminished or absent breath best assess lung sounds, you will sounds may be auscultated— sounds often indicate need to hear the sounds as directly bronchial, bronchovesicular, and obstruction within the lungs as as possible. Do not attempt to vesicular. a result of secretions, mucus listen through clothing or a drape, plug, or a foreign object which may produce additional CLINICAL TIP sound or muffle lung sounds that . It may also indicate Breath sounds are considered exist. To begin, place the diaphragm abnormalities of the pleural normal only in the area specified. of the stethoscope firmly and space such as pleural Heard elsewhere, they are thickening, pleural effusion, or 10 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department directly on the posterior chest wall considered abnormal sounds. For pneumothorax. at the apex of the lung at C7. Ask example, bronchial breath sounds In cases of emphysema, the the client to breathe deeply are abnormal if heard over the hyperinflated nature of the through the mouth for each area peripheral lung fields. of (each placement of lungs, together with a loss of the stethoscope) in the locations of normal breath elasticity of lung tissue, may auscultation sequence so that you sounds: result in diminished inspiratory can best hear inspiratory and breath sounds. expiratory sounds. Be alert to the Increased (louder) breath client’s comfort and offer times for sounds often occur when rest and normal breathing if consolidation or compression fatigue is becoming a problem. results in a denser lung area OLDER ADULT CONSIDERATIONS that enhances the transmission of sound. Deep breathing may be especially difficult for the older client, who may fatigue easily. Thus offer rest as needed. Auscultate from the apices of the lungs Sometimes breath sounds may be hard to hear with obese or heavily at C7 to the bases of the lungs at T10 and later- ally from the down to muscled clients due to increased distance to underlying lung tissue. the seventh or eighth . Listen at each site for at least one complete respiratory cycle. Follow the auscultating sequence shown.

11 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Auscultate for adventitious No adventitious sounds, such as Adventitious lung sounds, such as sounds. Adventitious sounds are (discrete and discontinuous crackles (formerly called rales) sounds) or (musical and sounds added or superimposed and wheezes (formerly called continuous), are auscultated. over normal breath sounds and rhonchi) are evident. heard during auscultation. Be careful to note the location on the chest CLINICAL TIP wall where adventitious sounds are If you hear an abnormal sound heard as well as the location of during auscultation, always have such sounds within the respiratory cycle. the client , then listen again and note any change. Coughing may clear the lungs.

Auscultate voice sounds.

Bronchophony: Ask the client to repeat Voice transmission is soft, The words are easily understood the phrase “ninety-nine” while you muffled, and indistinct. The and louder over areas of auscultate the chest wall. sound of the voice may be increased density. This may heard but the actual phrase indicate consolidation from cannot be distinguished. pneumonia, atelectasis, or tumor.

Over areas of consolidation or : Ask the client to repeat the Voice transmission will be soft and compression, the sound is letter “E” while you listen over the chest muffled but the letter “E” should louder and sounds like “A.” be distinguishable. wall.

Over areas of consolidation or Transmission of sound is very faint Whispered : Ask the client compression, the sound is and muffled. It may be inaudible. to whisper the phrase “one–two– transmitted clearly and distinctly. In such areas, it three” while you auscultate the chest sounds as if the client is wall. whispering directly into the stethoscope.

12 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Anterior Thorax Inspection Inspect for shape and configuration. The anteroposterior diameter is Anteroposterior equals Have the client sit with arms at the less than the transverse transverse diameter, resulting sides. Stand in front of the client and diameter. The ratio of in barrel chest. This is often assess shape and configuration. anteroposterior diameter to the seen in emphysema because transverse diameter is 1:2. of hyperinflation of the lungs.

Inspect position of the . Sternum is positioned at midline and is a markedly Observe the sternum from an anterior straight. sunken sternum and adjacent and lateral viewpoint. cartilages (often referred to as OLDER ADULT funnel chest). It is a congenital CONSIDERATIONS malformation that seldom The sternum and ribs may be causes symptoms other than more prominent in the older self- consciousness. client because of loss of subcutaneous fat.

Pectus carinatum is a forward protrusion of the sternum causing the adjacent ribs to slope back word (often referred to as pigeon chest). Both conditions may restrict expansion of the lungs and decrease lung capacity.

13 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Watch for sternal retractions. Retractions not observed. Sternal retraction are noted, with severely labored breathing.

Observe quality and pattern of Respirations are relaxed, effortless, Labored and noisy breathing is respiration. Note breathing and quiet. They are of a regular often seen with severe asthma characteristics as well as rate, rhythm, rhythm and depth at a rate of 10– or chronic . and depth. 20 per minute in adults. and may be normal in Abnormal breathing patterns CLINICAL TIP some clients. include tachypnea, bradypnea, , When assessing respiratory , Cheyne-Stokes patterns, it is more objective to respiration, and Biot’s describe the breathing pattern, respiration. rather than just labeling the pattern.

Inspect intercostal spaces. Ask the No retractions or bulging of Retraction of the intercostal client to breathe normally and observe intercostal spaces are noted. spaces indicates obstruction of the intercostal spaces. the or atelectasis.

Bulging of the intercostal spaces indicates trapped air such as in emphysema or asthma.

Observe for use of accessory muscles. Use of accessory muscles muscles (sternomastoid, Ask the client to breathe normally and (sternomastoid and rectus scalene, and trapezius) are used observe for use of accessory muscles. abdominis) is not seen with normal to facilitate inspiration in cases respiratory effort. After strenuous of acute or chronic airway exercise or activity, clients with obstruction or atelectasis. normal respiratory status may use neck muscles for a short time to The abdominal muscles and enhance breathing. the internal are used to facilitate expiration in COPD.

14 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department PALPATION Palpate for tenderness, sensation, No tenderness or pain is palpated Tenderness over thoracic muscles and surface masses. Use your fingers over the lung area with can result from exercising (e.g., respirations. pushups) especially in a previously to palpate for tenderness and sedentary client. sensation. Start with your hand positioned over the left (over the apex of the left lung) and move your hand left to right, comparing findings bilaterally. Move your hand systematically downward toward the midline at the level of the and outward at the base to include the lateral aspect of the lung. The established sequence for palpating the anterior thorax serves as a guide for positioning your hands.

CLINICAL TIP

Anterior thoracic palpation is best for assessing the right lung’s middle lobe

Palpate for crepitus as you would on No crepitus is palpated. In areas of extreme congestion or the posterior thorax. consolidation, crepitus may be palpated, particularly in clients with lung .

15 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Palpate for fremitus. Using the Fremitus is symmetric and easily Diminished vibrations, even with sequence for the anterior chest identified in the upper regions of a loud spoken voice, may indicate described previously, palpate for the lungs. A decreased intensity of an obstruction of the fremitus using the same fremitus is expected toward the tracheobronchial tree. base of the lungs. However, technique as for the posterior Clients with emphysema may thorax. fremitus should be symmetric bilaterally. have considerably decreased CLINICAL TIP fremitus as a result of air trapping. When you assess for fremitus on the female client, avoid palpating the . Breast tissue dampens the vibrations.

Palpate anterior chest expansion. Thumbs move outward in a Unequal chest expansion can Place your hands on the client’s symmetric fashion from the midline. occur with severe atelectasis, anterolateral wall with your thumbs pneumonia, chest trauma, along the costal margins and pointing pleural effusion, or toward the . As the client pneumothorax. takes a deep breath, observe the movement of your thumbs. Decreased chest excursion at

the bases of the lungs is seen with COPD.

16 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department PERCUSSION Percuss for tone. Resonance is the percussion tone Hyperresonance is elicited in cases elicited over normal lung tissue. of trapped air such as in Percuss the apices above the . emphysema or pneumothorax. Then percuss the intercostal spaces Dullness may characterize areas of increased density such as across and down, comparing sides. consolidation, pleural effusion, or tumor.

Percussion elicits dullness over breast tissue, the , and the liverand flatness is detected over the muscles and bones.

Auscultation Auscultate for anterior breath Three types of normal breath Abnormal voice sounds. sounds, adventitious sounds, and sounds may be auscultated— voice sounds. Place the diaphragm of bronchial, bronchovesicular, and the stethoscope firmly and directly on vesicular. the anterior chest wall. Auscultate from the apices of the lungs slightly above the clavicles to the bases of the lungs at the sixth rib. Ask the client to breathe deeply through the mouth in an effort to avoid transmission of sounds that may occur with nasal breathing. Be alert to the client’s comfort and offer times for rest and normal breathing if fatigue is becoming a problem, particularly for the older client. Listen at each site for at least one complete respiratory cycle.

17 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department

CLINICAL TIP Again, do not attempt to listen through clothing or other materials. However, if the client has a large amount of on the chest, listening through a thin T-shirt can decrease extraneous sounds that may be misinterpreted as crackles.

18 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Performance checklist

Respiratory System

The student nurse should be able to:

Competency Level Trial 1 Trial 2 Performance criteria Comment Done Done with Not done Done Done with Not done correctly assistance (0) correctly assistance (0) (2) (1) (2) (1) -Collect appropriate objective data about related to general survey. -Collect appropriate subjective data related to respiratory system. - , (dyspnea), wheezing, cough dry or produce , sputum or . - Sputum or hemoptysis characteristics: color, odor, amount, frequency and consistency.

Physical examination General Done Done with Not done Done Done with Not done correctly assistance (0) correctly assistance (0) Inspection (2) (1) (2) (1) Inspect for nasal flaring and pursed lip breathing. Observe color of face, lips, and chest. Inspect color and shape of nails.

Posterior Thorax Trial 1 Trial 2 Comment Inspection Done Done with Not done Done Done with Not done correctly assistance (0) correctly assistance (0) (2) (1) (2) (1) - Inspect configuration. - Observe use of accessory muscles. - Inspect the client’s positioning.

Palpation - Palpate for tenderness and sensation. - Palpate for crepitus. - Palpate for fremitus. - Assess chest expansion.

19 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley

King Saud University Application of Health Assessment Nursing College NUR 225 Medical Surgical Nursing Department Percussion - Percuss for tone. - Percuss for diaphragmatic excursion. Auscultation - Auscultate for breath sounds. - Auscultate for adventitious sounds. - Auscultate voice sounds. Anterior Thorax Inspection

- Inspect for shape and configuration. - Inspect position of the sternum. - Watch for sternal retractions. . - Observe quality and pattern of respiration. - Inspect intercostal spaces. - Observe for use of accessory muscles.

Palpation - Palpate for tenderness, sensation, and surface masses. - Palpate for crepitus. - Palpate for fremitus. - Palpate anterior chest expansion. Percussion - Percuss for tone. Auscultation - Auscultate for anterior breath sound, adventitious sounds, voice sounds.

Documentation.

Evaluated by: ______Date Evaluated: ______

Name and Signature of Faculty Total grade ______

20 Health assessment in nursing fifth edition Janet R. Weber / Jane H. Kelley