Thoracic and Lung Assessment Chapter 16 page 297

PHYSICAL EXAMINATION Collecting Objective Data

• Complete examination consists of inspection, palpation, percussion, and auscultation of the posterior and anterior thorax Preparation of the client :

• Have the client remove all clothing from the waist up and put on an examination gown or drape.

• Explain the procedure before initiating the examination

• The patient must sit in an upright position with arm relaxed at the sides.

• Make sure that the room temperature is comfortable for the client. Equipments

• Examination gown and drapes • Gloves • Stethoscope • Light source • Mask • Skin marker • Metric ruler Key Assessment points:

• Provide privacy for the client • Keep your hands warm • Remain nonjudgmental about client’s habits and lifestyle General Assessment

• Inspect: • For nasal flaring and pursed lip breathing • Color and shape of nails • Observe color of face, lips, and chest Posterior Thorax : INSPECTION

• Inspect the scapulae and chest wall configuration • Observe for use of accessory muscles and assess chest expansion • Inspect client’s positioning • While the patient sits with her arms at the side, stand behind her • Note the client’s posture and his ability to support weight while breathing comfortably PALPATION

• Palpate for tenderness and sensation. • Normal : Client reports no tenderness, pain, or unusual sensations. Temperature should be equal bilaterally Palpate for crepitus.

Palpate surface characteristics. • Normal : Skin and subcutaneous tissue are free of lesions and masses . Palpate for Fremitus

• Fremitus is symmetric and easily identified • It is not palpable on either side, the client may need to speak louder. • A decrease in the intensity of fremitus is normal as the examiner moves toward the base of the lungs. Assess chest expansion. • Normal : When the client takes a deep breath, the examiner’s thumbs should move 5- 10 cm apart symmetrically Percussion

• Percuss for tone. • Normal : Resonant and Flat tones in appropriate areas Percuss for diaphragmatic excursion. • Normal : Excursion should be equal bilaterally and measure 3-5cm in adults • The level of the diaphragm may be higher on the right • In well-conditioned clients, excursion can measure up to 7-8 cm Auscultation

Auscultate for breath sounds, adventitious sounds • Normal : • Breath sounds are considered normal only in the area specified. • Heard elsewhere, they are considered abnormal sounds • Sometimes breath sounds may be hard to hear with obese or heavily muscled clients

• Normal : No adventitious sounds, such as crackles or wheezes Sequence for Auscultation Adventitious Breath Sounds

ABNORMAL SOUND CHARACTERISTICS SOURCE ASSOCIATED CONDITION

DISCONTINOUS SOUNDS : a. Fine Crackles  High pitched, short popping  Inhaled air suddenly opens  Crackles occurring late in sound heard during the small deflated air inspiration are associated inspiration and not cleared passages that are coated with restrictive disease such with coughing; sounds are and sticky with exudates as pneumonia and CHF. discontinuous and can be Crackles occurring early in stimulated by rolling a strand inspiration are associated of hair between your fingers with obstructive disorders near your ear. such as bronchitis, asthma, or emphysema

b. Coarse Crackles  Low-pitched bubbling, moist  Inhaled air comes into  May indicate pneumonia, sounds that may persist from contact with secretions in the pulmonary edema and early inspiration to early large bronchi and trachea pulmonary fibrosis, also in expiration; also described as COPD softly separating velcro CONTINOUS SOUNDS : a. Pleural Friction rub  Low pitched, dry, grating  Sound is the result of  Pleuritis sound; sound is much like rubbing of two inflamed crackles, only more pleural surfaces superficial and occurring during both inspiration and expiration

b. Wheeze (Sibilant)  High pitched, musical  Air passes through  Sibilant wheezes are often sounds heard primarily constricted passages heard in cases of acute during expiration but may (caused by swelling asthma or chronic also be heard on inspiration secretions, or tumor) emphysema

c. Wheezes (Sonorous)  Low pitched snoring or  Same as sibilant wheezes.  Sonorous wheezes are often moaning sounds heard The pitch of the wheezes heard in cases of bronchitis primarily during expiration cannot be correlated to the or single obstructions and but may be heard throughout size of the passageway that snoring before an episode of the respiratory cycle. These generates it. sleep apnea. wheezes may clear with Stridor is a harsh honking wheeze coughing with severe broncholaryngospasm, such as occurs with croup Auscultate voice sounds:

• Bronchophony : ask the client to repeat the phrase “99” while you auscultate the chest wall

• Normal : Voice transmission is soft, muffled and indistinct. The sound of the voice may heard but the actual phrase cannot be distinguished • Egophony : ask the client to repeat the letter “E” while you listen over the chest wall

• NORMAL : Voice transmission will be soft and muffled but the letter “E” should be distinguishable Whispered Pectoriloquy : ask the client to whisper the phrase “1-2-3” while auscultating the chest wall

• normal : Transmission of sound is very faint and muffled. It may be inaudible Anterior Thorax : INSPECTION

• Inspect for shape and configuration, position of sternum, slope of ribs, intercostal spaces • Normal : • The ratio of anteroposterior diameter to the transverse diameter is 1:2 • Sternum is positioned at midline and straight • Retractions not observed • Ribs slope downward with symmetric intercostal spaces. Costal angle is within 90° • No retractions or bulging of intercostal spaces • Observe quality and pattern of respiration, use of accessory muscles • Normal : • Respirations are relaxed, effortless and quiet. • 10-20 cycle per min in adult. • Use of accessory muscles is not seen with normal respiratory effort. • After strenuous exercise or activity, individuals with normal respiratory status may use neck muscles for a short time to enhance breathing Sequence for Palpation • Palpate for fremitus; anterior chest expansion

• Normal : Fremitus is symmetrical and easily identified in the upper regions of the lungs. A decrease intensity of fremitus is expected toward the base of the lungs; Palpation

• Palpate for tenderness, sensation • Normal : No tenderness or pain is palpated over the lung area

• Palpate the surface masses • Normal : No unusual surface masses or lesions are palpated

• Assess for crepitus as you would on the posterior thorax • Normal : No crepitus is palpated Percussion

• Percuss for tone • Normal : • Resonant, dull, flat, and typanitic in appropriate areas Normal percussion tones heard from anterior thorax Auscultation

• Auscultate for anterior breath sounds, adventitious sounds, and voice sounds • Place the diaphragm of the stethoscope firmly and directly on the anterior chest wall. • Auscultate from the apices of the lung slightly above the clavicles to the bases of the lungs at the 6th rib. • Ask the client to brathe deeply through his mouth in an effeort to avoid transmission of sounds that may occur with nasal breathing. • Be alert of the client’s comfort and offer times to rest and normal breathing if fatigue is becoming a problem particularly for the older clients. • Listen at each site for at least one complete respiratory cycle. Sequence of Auscultating the anterior thorax Location of breath sounds for the anterior thorax

•B = bronchial sounds •V = vesicular sounds •BV = bronchove- sicular sounds Respiration Pattern Type Description Clinical indication

Normal 12-20/min and regular Normal breathing pattern

Tachypnea >24/min and shallow May be a normal response to fever, anxiety or exercise Can occur with respiratory insufficiency, alkalosis, pneumonia or pleurisy Bradypnea <10/min and regular May be normal in well conditioned athletes Can occur with medication-induced depression of the respiratory center, diabetic coma, neurologic damage Hyperventilation Increase rate and increased depth Usually occurs in extreme exercise, fear or anxiety Kausmaul’s respiration are a type of hyperventilation associated with diabetic ketoacidosis. Disorders of the CNS, overdose of ASA, severe anxiety Hypoventilation Decrease rate, decreased depth, irregular Overdose of narcotics or anesthesia pattern Chyne-Strokes respiration Regular pattern characterized by alternating May result from severe CHF, drug overdosage, periods of deep, rapid breathing followed by inc. ICP, RF periods of apnea May be noted in elderly persons during sleep, not related to any disease process Biot’s respiration Irregular pattern characterized by varying May be seen with meningitis or severe brain depth and rate of respirations followed by damage periods of apnea DOCUMENTATION

Objective Datas • Respitrations 18 cpm, relaxed and even • Antero posterior less than transverse diameter • Chest expansion symmetric • No retracting or bulging of intercostals spaces • No tenderness noted on palpation • Tactile fremitus symmetric. Percussion tones resonant over all lung fields • Diaphragmatic excursion 4cm and equal bilaterally • Vesicular breath sounds auscultated over lung fields • No adventitious sounds present Appropriate Nursing Diagnosis

• Wellness Diagnoses • Readiness for enhance breathing pattern • Health-seeking behaviour: requests information on TB skin testing, how to quit smoking, or on exercise to improve respiratory status • Risk Diagnoses • Risk for respiratory infection related to exposure to environmental pollutants and lack of knowledge of precautionary measures • Risk for activity intolerance related to imbalance between oxygen supply and demands • Risk for imbalanced nutrition: less than body requirements related to fatigue secondary to dyspnea • Risk for ineffective health maintenance related to lack of knowledge of condition, infection transmission, and prevention of recurrence • Risk for impaired oral mucous membranes related to mouth breathing • Actual Diagnoses • Anxiety related to dyspnea and fear of suffocation • Activity intolerance related to fatigue secondary to inadequate oxygenation • Ineffective airway clearance related to inability to clear thick, mucous secretions secondary to pain and fatigue • Impaired gas exchange related to chronic lung tissue damage secondary to chronic smoking • Ineffective airway clearance related to bronchospasm and increased pulmonary secretions • Ineffective breathing pattern: hyperventilation related hypoxia and lack of knowledge of controlled breathing techniques • Disturbed sleep pattern related to excessive coughing • Impaired gas exchange related to poor muscle tone and decreased ability to remove secretions secondary to the aging process The END