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
 Low pitch
 “gently sighing”
 Heard over lung fields
 5:2 ratio inspiration:expiration
 Bronchovesicular
 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
• Fine short interrupted
crackling sounds
 Gurgles
• Continuous, low-
pitched, coarse,
gurgling, louder
sounds
 Friction rub
• Superficial, grating or
creaking sounds
 Wheeze
• Continuous, high
pitched, squeaky
musical sounds
Normal and Abnormal Breath Sounds
Assessing the Thorax and Lungs
1. Introduce self, verify the client’s identity
and explain the procedure
2. Perform hand hygiene
3. Provide for client privacy
4. 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
Absence of
breath
Areas and sequence in aucultating the sounds
posterior thorax
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
Tympanic over the
Percussion pattern of anterior
underlying stomach
thorax
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