Chest[1]

PHYSICAL ASSESSMENT THE THORAX AND LUNGS

Assessing The Thorax and Lungs

Anatomy of the Chest

Anatomy of the Chest 

Chest bones      



Sternum Manubrium Xiphoid process Clavicles 12 Pairs of ribs 12 Thoracic vertebrae Scalpula

Chest Landmarks 

Anatomical mapping • •

•

right anterior axillary line Right midclavicular line Midsternal line

Chest Landmarks 

Anatomical mapping •

• •

posterior axillary line midaxillary line Anterior axillary line

Chest Landmarks 

Anatomical mapping •

•

Vertebral line Scapular line

Anatomy of the Lungs 

Lungs   



Right has 3 lobes Left has 2 lobes Oblique fissure divides upper & lower lobes

Trachea  

Anterior to esophagus Branches into right & left bronchi 

 

Right wider, shorter, more vertical ( aspiration)

Bronchioles Alveoli

Anatomy of the Lungs 

Mapping of the lungs  Anterior

chest primarily upper lobes

Anterior Chest Landmarks

Anatomy of the Lungs 

Mapping of the lungs  Posterior

chest primarily lower lobes

Posterior Chest Landmarks

Lateral Chest Landmarks

Chest Shape and Size 

The adult chest • •

• •

The thorax is oval Anteroposterior diameter is half its transverse diameter Elliptical Diameter is smaller at the top than at the base

Deformities of the Chest Pectus Carinatum • • • •

Pigeon chest May be caused by rickets Protruding sternum Narrow transverse diameter

Deformities of the Chest Pectus Excavatum •

Funnel Chest •

•

•

Congenital defect Depressed sternum Narrow anteroposterior diameter

Deformities of the Chest Barrel Chest •

•

Ratio of anteroposterior diameter to transverse diameter is 1:1 seen in clients with kyphosis and emphysema

Deformities of the Chest Kyphosis •

Excessive convex curvature of the thoracic spine

Deformities of the Chest Lordosis

Deformities of the Chest Scoliosis •

Lateral deviation of the spine

Normal Breath Sounds 

Types of breath sounds 

Vesicular    



Bronchovesicular    



Low pitch “gently sighing” Heard over lung fields 5:2 ratio inspiration:expiration Medium pitch Blowing sounds Heard over main bronchus 1:1 ratio inspiration:expiration

Bronchial (tracheal/tubular)    

High pitch, loud Harsh sounds Heard over trachea 1:1 ratio, maybe 1:2

Adventitious Breath Sounds 

Crackles •



Gurgles •



Continuous, lowpitched, coarse, gurgling, louder sounds

Friction rub •



Fine short interrupted crackling sounds

Superficial, grating or creaking sounds

Wheeze •

Continuous, high pitched, squeaky musical sounds

Normal and Abnormal Breath Sounds

Assessing the Thorax and Lungs 1. 2. 3. 4.

Introduce self, verify the client’s identity and explain the procedure Perform hand hygiene Provide for client privacy Inquire if the client has any history of the following: • • • • •

Family history of illness including cancer, allergies and tuberculosis Lifestyle habits such as smoking Occupational hazards Medications being taken Current problems

Assessing the Posterior Thorax 5. Inspect the shape and symmetry of the thorax form posterior to lateral views 6. Inspect the spinal alignment for deformities Exaggerated spinal curvatures

Assessing the Posterior Thorax 7. Palpate the posterior thorax 8. Palpate the posterior chest for respiratory excursion Full and symmetric chest expansion Thumbs should move apart an equal distance and at the same time Normally the thumb separates 3 to 5 cm during deep inspiration

Assessing the Posterior Thorax 9. Palpate the chest for vocal (tactile) fremitus Bilateral symmetry of vocal fremitus Decreased or absent, or increased fremitus

Assessing the Posterior Thorax Palpating the chest for vocal fremitus using the palmar surfaces of the fingertips

Palpating the chest for vocal fremitus using ulnar aspect of the hand

Assessing the Posterior Thorax 10. Percuss the thorax. Determine air, fluid or solid materials in the lungs Determine the positions and boundaries of certain organs Penetrates to a depth of 5-7cm (2-3 in)

Percussion Technique

Assessing the Posterior Thorax

Percussion notes resonant, except over scapula Asymmetry in percussion,areas of dullness or flatness over lung tissue Percussion pattern of the Posterior thorax

Assessing the Posterior Thorax 11. Percuss for diaphragmatic excursion Excursion is 3 to 5 cm (1 ½ to 2 in. bilaterally in women, 5 to 6 cm (2 to 3 in) in men Diaphragm is usually slightly higher on the right side

Assessing the Posterior Thorax 12. Auscultate the chest using flat-disc diaphragm of the stethoscope Normal Breath sounds Adventitious breath sounds

Areas and sequence in aucultating the posterior thorax

Absence of breath sounds

Assessing the Anterior Thorax 13. Inspect breathing patterns. 14. Inspect the costal angle and the angle and at which the ribs enter the spine Costal angle is less than 90 degrees The ribs insert into the spine at approximately 45 degrees Costal Angle is widened

Assessing the Anterior Thorax 15. Palpate the anterior chest. 16. Palpate for respiratory excursion Full symmetric excursion Thumbs normally separates 3 to 5cm (1 ½ to 2 in) Fingers are placed laterally along the lower rib cage, and thumbs along the costal margins

Assessing the Anterior Thorax 17. Palpate tactile fremitus in the same manner as for the posterior chest Fremitus is normally decreased over the heart and breast tissue Areas and sequence for palpating tactile fremitus on the anterior chest

Assessing the Anterior Thorax 18. Percuss the anterior chest systemetically Resonance down to the sixth rib at the level of the diaphragm Flat over the areas of heavy muscles and bone Dull on the areas over the heart and the liver Percussion pattern of anterior thorax

Tympanic over the underlying stomach

Assessing the Anterior Thorax 19. Auscultate the trachea. 20. Auscultate the anterior chest. 21. Document findings in the client record.

Lifespan Considerations I. Infants •

•

Thorax is rounded, cylindrical, anteroposterior equal to transverse diameter Tends to breath using the diphragm

II. Children • • •

1:2 ratio at 6 years old Breath abdominally than thoracically Should be assessed for scoliosis by age of 12

Lifespan Considerations III. Elders •

• • •

•

•

Kyphosis and osteoporosis alter the size of cavity Anteroposterior diameter of the chest widens Inspiratory muscles becomes less powerful Expiration may require use of accessory muscles Elastic tissue of the alveoli loses its strechability Cilia in the iarwy decerese in number

Breathing is so characteristic of life; studying, sleeping, talking, eating and exercising all involve breathing