ASSESSING THE RESPIRATORY SYSTEM (Thorax & Lungs)

ASSESSMENT NORMAL FINDINGS DEVIATION FROM NORMAL

1. Examine the back of the chest first, The diameter of the thorax should be Pectus Carinatum
comparing one side with the other. Then greater from side to side than from front Pectus Excavatum
examine the front of the chest using the to back. Thoracic Kyphoscoliosis
same sequence. Observe the chest from Barrel Chest
the side as well.

2. Inspect the chest wall symmetry.
Note masses or scars that indicate
trauma or surgery. Respiratory
Rate and pattern: Count the RR.
Accessory muscle use: Observe the
diaphragm and intercostal muscles with
breathing.
Respiratory pattern must be even,
coordinated and regular with occasional
sighs.
Frequent use of accessory muscles
may indicate a respiratory breathing,
particularly when the patient purses his
lips and flares his nostrils with
breathing.

PALPATION
3. Palpate the chest wall Should feel smooth, warm and dry. Gentle palpation causes pain.
Gentle palpation shouldn’t cause
the patient pain.

4. Palpate for tactile fremitus Both lungs have equal vibrations. Vibrations that feel more intense on one
(palpable vibrations caused by the side than the other indicate tissue
transmission of air through the consolidation on that side (denser or
bronchopulmonary system.) inflamed lung tissue).
a. Ask patient to fold arms Less intense vibrations may
across chest. indicate air or fluid in the pleural
b. Lightly place your open palms spaces or a decrease in lung tissue
on both sides of the patient’s density
back w/o touching his back w/
your fingers.
c. Ask the patient to repeat the
phrase “ninety-nine” loud
enough to produce palpable
vibrations.
d. Palpate the front chest using
the same hand positions

5. Evaluating chest wall & These should separate simultaneously

symmetry and expansion and equally to a distance several cm
a. Place your hands in front of away from the sternum.
the chest wall w/ your thumbs
touching each other at the 2nd
ICS. As the patient inhales
deeply, watch your thumbs.
Repeat the measurement at
the 5th ICS.
 PERCUSSION
1. Percussing the chest wall
a. Place your non-dominant hand
over the chest wall, pressing
firmly with your middle finger.
b. Position your dominant hand
over your other hand
c. By flexing the wrist of your
dominant hand, tap the middle
finger of your non dominant
hand with the middle finger of
your dominant hand
AUSCULTATION
1. During auscultation, the client
should be instructed to breathe
only through the mouth
because mouth breathing
decreases air turbulence that
could interfere with an
accurate assessment.
a. Press the diaphragm of the
stethoscope firmly against the
skin.
b. Listen to a full inspiration and
full expiration at each site in the
sequence shown.
c. .Compare sound variations from
one side to the other
d. Document
2. Auscultating for vocal
fremitus
Bronchophony- Ask the
patient to say "99" several
times while auscultating the
chest walls.
Resonance
 Bronchial- loud and high-pitched
sounds with a hollow quality heard
longer on expiration
than inspiration from air moving through
the trachea
 Bronchovesicular- medium-
pitched and blowing sounds heard
equally on inspiration & expiration
from air moving through the large
airways, posteriorly between the
scapula & anteriorly over
bronchioles lateral to the sternum
at the 1ST and 2ND ICS
 Vesicular - soft, breezy, and low-
pitched sounds heard longer on
inspiration than expiration that
result from air moving through the
smaller airways over the lung’s
periphery, with the exception of
the scapular area
Bronchophony- the sound of “ninety-
nine” will sound very faint and muffled
Hyper resonance
Abnormal breath sounds are
characterized by decreased or absent
sounds.
 Crackles- an interrupted fine
crackle (dry, high-pitched crackling,
popping sound of short duration) that
sounds like a piece of hair being
rolled between the fingers in front of
the ear or a coarse crackle (moist,
low-pitched crackling, gurgling sound
of long duration) that sounds like
water going down the drain after the
plug has been pulled on a full tub of
water
 Rhonchi- heard predominantly on
expiration over the trachea and
bronchi as a continuous, low-
pitched musical sound
 Wheezes- heard predominantly
on expiration all over the lungs as
a continuous sonorous wheeze
(low-pitched snoring) or sibilant
wheeze (high-pitched musical
sound)
 Pleural Friction Rub- heard on
either inspiration or expiration over
the anterior lateral lungs as a
continuous creaking, grating
sound
 Stridor- heard predominantly on
inspiration as a continuous
crowing sound
If it sounds clear through the
stethoscope, there is probably
consolidation of the lung
and Bronchophony is present.
Egophony- Ask the patient to
say "Eeee" several times and
auscultate the chest walls.
Whispered Pectoriloquy- Ask
the patient to whisper "1-2-3"
several times while
auscultating across the chest
walls.
Egophony- Over healthy lung areas, the
sound is understandable as an "E".
Whispered Pectoriloquy- spoken
sounds of a whispered volume by the
patient would not be heard by the
clinician auscultating a lung field with a
stethoscope.
Over consolidated lung areas, the
sound is heard as an "A" (aaay).
The lung area is abnormal if the "1-2-3"
sound is understood. This is the
abnormal '1-2-3'.