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 Lungs: (A) Anterior view of lung 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 STETHOSCOPE LIGHTSOURCE MASK SKIN 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 lip breathing. labored respirations (especially in small children) and is indicative of hypoxia. Pursed lip breathing may be seen in asthma, emphysema, or CHF. Observe color of face, lips, 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. Cyanosis 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 nail 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 Thorax INSPECTION Inspect configuration. While the client Scapulae are symmetric and Spinous processes that deviate sits with arms at the sides, stand behind nonprotruding. Shoulders and laterally in the thoracic area the client and observe the position of scapulae are at equal horizontal may indicate scoliosis. 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 ribs sloping downward at approximately a 45-degree angle in relation to the spine. OLDER ADULT Spinal configurations may CONSIDERATIONS have respiratory implication. Kyphosis (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 (barrel chest). 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 Trapezius, or shoulder, 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 atelectasis. 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. Palpation may be pain, or unusual sensations. indicate fibrous connective performed with one or both hands, but Temperature should be equal tissue. the sequence of palpation is bilaterally. established. Use your fingers 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 scapula fractured ribs. (over the apex of the left lung) and move your hand 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 infection. 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. Crepitus, also The examiner finds no palpable Crepitus can be occurs after called subcutaneous emphysema, is crepitus. an open thoracic injury, a crackling sensation (like bones or around a chest tube or hairs 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 fremitus. 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.” pneumothorax (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 thumbs 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), pneumonia, 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 percussion 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