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Thoracic & lung

assessment

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Structure & Function


THORACIC
Sternum
12

CAGE

and Clavicle

Ribs and thoracic vertebrae

Muscles
Cartilage

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Vertical lines references


1

10
11

4
5
6
7

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Lateral imaginary landmarks

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Posterior landmarks

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Thoracic cavity
Lungs
Pleural

membranes

Trachea

and bronchi

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Collecting
subjective data
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The nursing health history


History

of present health concern

COLDSPA

Question
Difficulty
Chest

pain?

Cough?

Past

breathing?

Wheezing?

Health History

Family

History

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Collecting
objective data
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Physical assessment
General

Inspection
Inspect

for nasal flaring and pursed


lip breathing

Observe

for color of face, lips, and

chest
Inspect

color and shape of nails


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Respiratory patterns

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Respiratory patterns

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Inspection
Anterior/Posterior/Lateral

Chest

Inspect

respiratory rate, rhythm, depth, and


symmetry of chest movements.

Shape

and symmetry (configuration)

Movement

with breathing:

Women - more thoracic respiratory movements;

Men

and infants - more abdominal respiratory


movements.

Condition of chest skin


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Inspect

configuration

Normal

: Scapulae are symmetric &


non-protruding.
1:2

ratio (anteroposterior to tranverse


diameter)

Abnormal

: Scoliosis,

Kyphosis,
Barrel chest,
Pectus excavatum,
Pectus carinatum
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Observe

muscles

Inspect

for use of accessory

the clients positioning

Note for posture & ability to support


weight while breathing comfortably

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Palpation
is

useful in assessing
1. Tracheal position,
2. Tenderness and crepitus,
3. Chest excursion,
4. Tactile fremitus

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1. Tracheal Position
Place

your thumb and index


finger on either side of the
trachea, and note position
and distance between
trachea and
sternocleidomastoid
muscle.

Normal:

Trachea should be

midline.
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2. Chest Tenderness and Crepitus


Use

light palpation to
assess for tenderness and
crepitus.

Normal:

Non-tender, no
deformities or crepitus.

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3. Chest Excursion
Anteriorly,

place
hands vertically on
the chest with fingers
spread on the costal
margin and thumbs
together at the costal
angle (like a
butterfly).
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Posteriorly,

place
hands vertically on
the chest with fingers
spread and the
thumbs together at
the spine at the
eighth to tenth rib
(like a butterfly).
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4. Tactile Fremitus
Place the balls of your
hands with your fingers
hyperextended or the ulnar
surface of your hand on the
patients chest.

Have patient say 99 as


you palpate vibrations.

NORMAL:

Equal bilaterally
and diminished midthorax.
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PERcussion
Anterior/Posterior/Lateral
Use

Chest

indirect or mediate percussion

Percuss
Note

over intercostal spaces.

for the following sounds:

1. Resonance
2. Hyperresonance
3. Dull
4. Flat
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Thorax percusion sound


Resonance

to second intercostal
space on left;

Slight

dullness over third through


fifth intercostal space over heart.

Resonance

to fourth intercostal
space on right

Dullness

from approximately fifth


to just above costal margin over
liver.
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Percusion sequence

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Percuss for diaphragmatic excursion


Ask

client to EXHALE forcefully and hold


breath, percuss the ICS downward beginning
at the scapular line (T7) of the right posterior
wall until tone changes from resonance to
dullness. Mark this level and allow client
breathe.

Ask

the client to INHALE deeply & hold.


Percuss the ICS from the first mark downward
until resonance changes to dullness. Then
mark the level and allow client to breathe.

Measure
NORMAL

the distance between the two marks.


: 36 cm diaphragmatic excursion.
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Auscultation
Auscultate
Use

for Breath Sounds

the diaphragm of the stethoscope

Listen

to one full respiratory cycle at


each site.

NORMAL:

With no adventitious
sounds, lungs are clear to
auscultation. No crackles, wheezes,
or rubs.
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Auscultation sequence

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Adventitious breath sounds


1.

Crackles or rales - sounds resulting from


air bubbling through moisture in the
alveoli or from collapsed alveoli popping
open

2.

Wheezing - caused by the narrowing of


an airway by spasm, inflammation, mucus
secretions,or a solid tumor

3.

Rhonchi lowerpitched, sonorous


wheezes, may even have a snoring or
rattle-like quality.
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4.

Stridor - is a harsh, high-pitched,


continuous honking sound resulting from an
upper airway obstruction, a partial
obstruction, or a spasm of the trachea or
larynx.

5.

Grunting - is a larger airway sound heard


predominantly on expiration. It results from
retention of air in the lungs, which prevents
alveolar collapse.

6.

Friction rubs - results from the rubbing


together of the parietal and visceral layers
of an inflamed pleura, which produces a
high-pitched grating or squeaking sound.
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Auscultate Voice Sounds


Bronchophony:

Have patient

say 1, 2, 3;

Egophony:

Have patient say

ee

Whispered

pectoriloquy:
Have patient whisper 1, 2, 3;
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Lung Cancer
Leading

cause of cancer deaths in


men and women:

163,510

deaths from lung cancer in


2005 (90,490 men; 73,020 women).

60

percent diagnosed with lung


cancer die within first year.

75

percent die within 2 years.

5-year

survival rate is 15 percent.


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Risk Factors for Lung Cancer


Smoking
Asbestos
Radon
Occupational

exposure to cancer-causing

agents:
Marijuana
Radiation

therapy.

Recurring

lung inflammation.

Mineral
Family

exposure

history

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Warning Signs of Lung Cancer

Persistent cough

Changes in respiratory pattern

Unexplained dyspnea

Blood-streaked sputum

Hemoptysis

Rust-colored or purulent sputum

Chest, shoulder, or arm pain

Recurring pleural effusion,


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pneumonia, or bronchitis