Assessment of Thorax, Breast,

Heart and Lungs

Aubrey A. Dayrit, MA, RN
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 GENERAL APPROACH
• Undressed the patient to the waist
• Good lighting
• Orderly fashion
 PE techniques
 Comparison of one side to another
 Work from above down
• Visualize the underlying tissue
• Examine the posterior thorax – sitting position
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Focus of Assessment & Documentation
of Lungs and thorax
• Inspection – position of the trachea, thoracic configuration and
symmetry, ventilatory pattern, muscle movements, masses or
lesions

• Palpation – symmetry of ventilatory movements, tactile

fremitus, tenderness and masses, crepitus

• Percussion – tones, diaphragmatic excursion

• Auscultation – quality of breath sounds, voice transmission

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INSPECTION
• Count the respiratory rate and its pattern
• Assess skin for color changes, texture, lesions

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INSPECTION: Anterior, posterior, and lateral thorax
PROCEDURE NORMAL FINDINGS DEVIATIONS FROM
NORMAL
Color Pink Pallor, cyanosis
Intercostal Spaces Even and relaxed Bulging, retracting
Chest symmetry Equal Unequal
Rib slope Less than 90° downward Horizontal or ≥ 90°
Respiration Patterns Even, 14-20/min, unlabored Uneven, labored <12 or >20,
shallow, deep
Anterior-posterior to lateral 1:2 ratio >1:2 ratio or <1:2 ratio
diameter
Shape and position of Level with ribs Depressed or projecting
sternum
Position of trachea Midline Deviated to one side
Chest expansion 3 inches deep inspiration Less than 3 inches 13
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BARREL CHEST

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INSPECTION
Posterior Thorax
A. Inspect
1. Configuration – shape of the chest 1:2 or 5:7 (AP and
lateral)
2. Deformities – kyphosis, scoliosis, lordosis
3. Use of accessory muscles
- abnormal retraction of the interspaces during
inspiration and expiration
- localized bulge: mass, tension pneumothorax
- localized retraction: collapse or fibrosis

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 Inspection of Posterior Thorax

4. Client’s positioning

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SCREENING FOR SCOLIOSIS

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 Palpation of Posterior Thorax
1. Temperature, skin integrity, tenderness and sensation
2. Crepitus – palpable sensation caused by the presence of small air or
bubbles in the subcutaneous tissue.
3. Surface characteristic

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 Palpation of Posterior Thorax
4. Fremitus
 Vibration perceptible on palpation and produced
phonation
 Decreased vibration as it move along to the periphery
of the airways
 Increased vibration on the major airways

5. Chest expansion
 Observe thumb movement for lag.
 Separate 3 to 5 cm
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Sequence in Palpation of Posterior Thorax

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Sequence in Palpation of Anterior Thorax

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PROCEDURE
Palpation of Posterior Thorax
Palpate Thorax for thoracic
expansion by the following
methods:
* Place hands on posterior
thorax at level of 10th
vertebra. Gently press skin
between thumbs and have
client take deep breath
* Anteriorly, press skin
together at lower sternum
and have patient take deep
breath. Observe thumb
movement.
NORMAL FINDINGS
3 to 5 cm symmetrical
thoracic expansion
* Symmetrical expansion
(thumbs move apart equal
distance in both directions)
* Symmetrical expansion
(thumbs move apart equal
distance in both directions)
DEVIATION FROM
NORMAL
Less than 3 cm thoracic
expansion asymmetrical
expansion seen with
atelectasis or pneumonia
* Asymmetrical expansion
(thumb movement apart
is unequal)
* Asymmetrical expansion
(thumb movement apart
is unequal)
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 NORMAL FINDINGS DEVIATION FROM NORMAL

Palpate the posterior chest for Full and symmetric chest Asymmetric and/or decreased
respiratory expansion. expansion (that is, when the chest expansion
• Place the palms of both your client takes a deep breath, your
hands over the lower thorax or thumb should move apart at an
at the 10th vertebrae, gently equal distance and at the same
press the skin between the time; normally the thumb
separate 3 to 5 cm during deep
thumbs as your fingers
inspiration)
stretched laterally. Ask the
client to take a deep breath
while you observe the
movement of your hands and
any lag in movement.

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 DEVIATION FROM
NORMAL FINDINGS
NORMAL
Palpate the posterior
thorax.
• Assess the temperature Skin intact; uniform Skin lesions; areas of
and integrity of all chest temperature, free of hyperthermia
skin. lesions
• Palpate all chest areas
for bulges, tenderness, Chest wall intact; no Lumps, bulges;
or abnormal tenderness; no masses depressions; areas of
movements. Avoid tenderness; movable
deep palpation for structures
painful areas,
especially if a fractured
rib is suspected.
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 Palpate the chest for vocal DEVIATION FROM
NORMAL FINDINGS
(tactile) fremitus. NORMAL
• Place the ball or the ulnar aspect
of your hand, starting near the Bilateral symmetry of vocal Decreased or absent
apex of the lungs. fremitus; fremitus (obese,
• Ask the client to repeat such Fremitus is heard most pneumothorax,
words as “blue moon” or “one, two, clearly at the apex of the emphysema);
three.” lungs;
• Compare the fremitus; either Low-pitched voices of
1) using one hand and moving it males are more readily Increased fremitus -
from one side to the corresponding palpated than higher consolidated area
area on the other side or pitched voices of females (pneumonia, tumor)
2) using two hands that are placed
simultaneously on the
corresponding areas of each side
of the chest.
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Video
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 Percuss Posterior Thorax
Percuss for tone –
 Resonance sound
elicited;
 Hyperresonance for
emphysema,
pneumothorax;
 Dullness for
presence of fluid and
solid tissue (lobar
pneumonia, tumor)

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 Bates’ “Ladder” Pattern for
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Percussion and Auscultation
Sequence in Percussion and Auscultation
of Anterior Thorax

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 Steps in Performing Diaphragmatic Excursion

 Instruct to take a deep breath and hold it.

 Starts percuss at the apex of the scapulae downward till tone

changes and mark the skin with marking pencil.

 Then instruct to breathe several times, exhale completely and

hold it.

 Repeat the percussion from scapulae apex and mark the point
where tone changes.
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 PROCEDURE NORMAL FINDINGS DEVIATIONS FROM
NORMAL
Percuss over shoulder Resonance Hyperresonance is heard
apices and at posterior, over emphysematous
anterior, and lateral lungs
intercoscal spaces Dullness heard over solid
masses or fluid
Percuss for posterior, Diaphragm descends 3- Diaphragm descends less
diaphragmatic 6cm from T10 (with full than 3 cm owing to
excursions bilaterally, expiraton held) to T12 atelectasis of lower lobes,
(with full inspiration emphysema, ascites, or
held) tumors
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Purpose of Auscultation
1. Airflow through the tracheobronchial tree
2. Depth of ventilation and presence of ventilation in
all lobes
3. Presence of fluid, mucus or other obstruction
4. Condition of the surrounding lung tissue and
pleural space

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Auscultate the chest using
the flat-disc diaphragm of
the stethoscope.
• Use the systematic zigzag
procedure used in
percussion.
• Ask the client to take slow,
deep breaths through the
mouth.
• Compare findings
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DEVIATION FROM
NORMAL FINDINGS
NORMAL
Vesicular = I greater Adventitious breath
than E sounds (e.g., crackles,
rhonchi, wheeze,
Bronchovesicular friction rub;
I=E Absence of breath
-Between scapula sounds (associated
- Below clavicle with collapsed and
-Main bronchi surgically removed
lung lobes)
Tracheal or bronchial =
Expiration greater than
inspiration
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Sequence of Auscultating the Posterior
Thorax

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 Normal Breath Sounds
Breath Sounds Duration of I Pitch of Intensity of Location
&E Expiration Expiration

Vesicular I>E Relatively Low Soft Peripheral lung fields

Increased in
inspiratory

Bronchovesicular I=E Intermediate Intermediate Posterior – between

(equal) the scapulae
Anterior – around the
upper sternum

Bronchial E>I High Loud Over the manubrium

Increased in
expiratory
Equal

Tracheal I>E High Very loud Trachea

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 PROCEDURE NORMAL FINDINGS DEVIATION FROM
NORMAL
Large-stem bronchi Bronchovesicular Bronchovesicular
breath sounds heard breath sounds heard
over mainstem bronchi over lung periphery

Below clavicles and

between scapulae
(inspiratory phase
equal to expiratory
phase)

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 PROCEDURE NORMAL FINDINGS DEVIATION FROM
NORMAL
Lung Periphery Vesicular (low, soft, Decreased breath
breezy) breath sounds sounds: obstruction,
heard over lung pleural thickening,
periphery (inspiration pleural effusion, or
longer than expiration) pneumothorax

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 PROCEDURE NORMAL FINDINGS DEVIATION FROM NORMAL

Ausculate breath Lung clear to Crackles usually are

sounds for auscultation on auscultated during
adventitious sounds inspiration and inspiration
expiration
Occur late in inspiration:
pneumonia and congestive
heart failure

Occur early in inspiration:

bronchitis, asthma, and
emphysema
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PROCEDURE NORMAL DEVIATION FROM NORMAL
FINDINGS
Fine crackles are popping, high pitched, and
very brief

Coarse crackles are bubbling sounds,

lower in pitch, and not quite so brief
(pneumonia, pulmonary edema, &
fibrous)

Sibilant wheezes (high pitched musical

sounds) are heard on inspiration or
expiration in acute asthma and chronic
emphysema
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PROCEDURE NORMAL DEVIATION FROM NORMAL
FINDINGS
Sonorous wheezes are low-pitched
moaning sounds heard mostly on
expiration in bronchitis, single
obstruction, and snoring before sleep
apnea.

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Auscultate for altered voice sounds
PROCEDURE NORMAL FINDINGS DEVIATION FROM NORMAL

Bronchopony Sounds muffled Sounds loud and clear over

(says ‘’99) consolidation from pneumonia,
atelectasis, or tumor
Whispered Sounds muffled Sounds loud and clear over areas
pectoriloquy of consolidation
(“1,2,3”)
Egophony Sounds like muffled Sounds like “ay” over areas of
(“ee”) “ee” consolidation or compression

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 Pediatric Variations
Infant Anteroposterior (AP) diameter is equal to transverse
diameter (1:1)- shape nearly circular
5 to 6 years AP diameter reaches that of the adult 1:2 or 5:7 ratio
old
Respirations should be unlabored and quiet

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Respiratory Rates in Children
Age Respiratory Rate (breaths/min)

Newborn 30- 60

Early childhood 20 - 40

Late Childhood 15-25

Age 15 years and 14-20

older

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Pediatric Variations (Percussion)

Infant and young children

- normally hyperresonant throughout because of
thinness of chest wall. Any decrease in resonance is equal
to dullness in the adult.

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Pediatric Variations (Auscultation)
Bell or small diaphragm should be used to localize
findings, especially in infants and young children.

Breath sounds will be louder and harsher owing to

close proximity to origin of sounds from thin chest
wall

Wheezes and rhonchi occur more frequently in

infants and young children

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Geriatric Variations
• Increase in normal respiratory rate (16-25)
• Loss of elasticity, fewer functional capillaries, and
loss of lung resiliency
• Decreased to cough effectively
• Accentuated dorsal curve (kyphosis)
• Sternum and ribs maybe more prominent
• Decreased thoracic expansion
• Increased diaphragmatic breathing

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Geriatric Variations
• Hyperresonance of thorax due to age-related
emphysemic changes
• Decreased breath sounds and increase retention od
mucus due to decreased pulmonary function
• Increased in AP diameter (up to 5:7 AP-to-
transverse diameter ratio) due to loss of resiliency
and loss of skeletal muscle strength
• Resonance of percussive may increase

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Geriatric Variations
• Hyperresonance of thorax due to age-related
emphysemic changes
• Decreased breath sounds and increase retention od
mucus due to decreased pulmonary function
• Increased in AP diameter (up to 5:7 AP-to-
transverse diameter ratio) due to loss of resiliency
and loss of skeletal muscle strength
• Resonance of percussive may increase

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 ANTERIOR DEVIATION FROM
NORMAL FINDINGS
THORAX NORMAL
Inspect for the: Abnormal breathing patterns
 shape and Quiet, rhythmic, and effortless and sounds
configuration respirations

 position of the Midline and straight Pectus excavatum, pectus

sternum carinatum
Inspect Barrel chest configuration –
 slope of the ribs Slope downward with horizontal position of the ribs
symmetric intercostal spaces
 breathing Retraction - ↑ inspiratory
patterns No retractions or bulging of effort, result of an
intercostal spaces obstruction of the respiratory
 intercostal tract
spaces Bulging – trapped air
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 ANTERIOR NORMAL DEVIATION FROM
THORAX FINDINGS NORMAL
Observe for use of Not seen Use of sternomastoid,
accessory muscle scalene, and trapezius
After strenuous exercise
or activity, may use neck
muscles for a short time
to enhance breathing

Inspect for the Costal angle is less Costal angle is widened

costal angle and the than 90, and the ribs (associated with COPD)
insert into the spine at
angle
approximately at 45
angle
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NURSING DIAGNOSES

• Ineffective airway clearance related to shallow

coughing and thickened mucus

• Impaired gas exchange r/t chronic lung tissue damage

• Ineffective airway clearance r/t chronic allergy

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NURSING DIAGNOSES

• Ineffective Breathing Pattern: hyperventilation r/t

hypoxia and lack of knowledge of controlled breathing
techniques

• Impaired Gas Exchange r/t smoking and/or frequent

exposure to air pollution or dangerous substance

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NURSING DIAGNOSES

• Ineffective Airway Clearance r/t bronchospasm and

increased pulmonary secretion (Pediatric)

• Impaired Gas Exchange r/t poor muscle tone and

decreased ability to remove secretions

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ASSESSMENT OF BREAST AND AXILLAE

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Assessment
• Lumps or lesions, or swelling
• Change in size or firmness
• Redness, warmth, or dimpling of breasts
• Tenderness or pain
• Timing in menstrual cycle
• Change in position of nipple and nipple discharge
• Age of menstruation
• Birth to children and age
• Previous breast surgeries

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 Assessment
• Family History
• Self care: Breast self-examination
• Use of hormones, birth control or antidepressants
• Exposure to radiation, benzene, or asbestos
• Use of alcohol and caffeine
• Diet and daily exercise routine
• Last breast exam
• Last mammogram

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 Risk Factors
• Increasing Age • Regular alcohol intake
• Personal history • Previous breast irradiation
• Family history • Hormone replacement with
progesterone
• Early Menarche and late
menopause • No or poor breast self-
examination
• No natural children
• Poor screening
• First child after age 30
• Higher education and
socioeconomic status

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Lateral view of the female
breast

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Assessment Technique: Inspection
PROCEDURE NORMAL FINDINGS DEVIATIONS FROM
NORMAL
Size and symmetry Relatively equal with Recent change to
slight variations unequal size

Recent increase in size

of one breast may
indicate inflammation
or abnormal growth
Shape Round and pendulous Retraction or dimpling
may be due to fibrosis
or malignant tumor
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Assessment Technique: Inspection (AREOLA & NIPPLES
PROCEDURE NORMAL FINDINGS DEVIATIONS FROM
NORMAL
Size Relatively the same, Large variations
slight variations
Color Pink to dark brown Inflamed
(varies with skin and
hair color)
Shape Round, oval, everted Inversion, if it occurs
after maturation or
changes with
movement.
Recent retraction or
previously everted,
suggests malignancy
Inspect the Areola and Nipples

Dimpling Discoloration

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Assessment Technique: PALPATION

PROCEDURE NORMAL FINDINGS DEVIATIONS FROM

NORMAL
Temperature Warm Erythema

Elasticity Elastic Lumpy

Tenderness Nontender; slightly Painful
tender
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Assessment Technique: PALPATION
PROCEDURE NORMAL FINDINGS DEVIATIONS FROM
NORMAL
Masses Bilateral firm Masses or nodules
inframammary Malignant tumors are
transverse ridge at base most often found in
of breast upper outer quadrant,
usually unilateral with
irregular, poorly
delineated borders
Hard
Nontender
Fixed to underlying
tissues
Fibroadenomas
Assessment Technique: PALPATION
PROCEDURE NORMAL DEVIATIONS FROM NORMAL
FINDINGS
Masses Benign
-1-5cm, round or oval, mobile,
firm, solid, elastic, nontender,
single or multiple in one or both
breasts

Fibrocystic Disease (Benign)

consists of bilateral, multiple, firm,
regular, firm, rubbery, mobile
nodules with wee demarcated
borders
Assessment Technique: PALPATION
PROCEDURE NORMAL FINDINGS DEVIATIONS FROM
NORMAL
Nipple (Discharge) None Unilateral serous,
Clear yellow (2 days serosanguineous, clear,
after childbirth yellow, dark red.
Assessment Technique: PALPATION
PROCEDURE NORMAL FINDINGS DEVIATIONS FROM
NORMAL
Lymph nodes (in the None palpable (<1cm) Palpable lymph nodes
following areas; (>1cm)
supraclavicular,
subclavian,
intermediate, brachial,
scapular, mammary,
internal mammary)
Nursing Diagnosis

•Ineffective therapeutic regimen

management related to knowledge
deficit of breast self-examination

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American Society (2005)
• Monthly BSE for women age 20 years or older
• Breast clinical examination for women age 20 to 39 every
3 years and every year for women age 40 and older
• Annual mammography for women age 40 years and older

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 CARDIOVASCULAR ASSESSMENT

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• Located in the neck and drain blood from the head, brain, face and
neck and convey it toward the heart.

• Observe jugular venous pressure

- observe the person from the right side
- positioning: HOB 30 – 45 degrees head
slightly to the left
- provide tangential lighting to neck area
measure the distance (in cm) from the
sternal angle to the top of distended
jugular vein
- pulsations visible at >3cm is abnormal 99
Assessing the Highest Point of Distention
of the Jugular Vein
 Neck Vessels
• Observes the jugular venous pulse
• Evaluates jugular venous pressure
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 DEVIATION FROM
Jugular Veins NORMAL FINDINGS
NORMAL
Inspect the jugular
veins for distention.

•The client is placed Veins not visible Veins visibly

in a semi-Fowler’s (indicating right distended
position, with head side of heart is
supported on a functioning
small pillow. normally)
 Carotid NORMAL FINDINGS
DEVIATION FROM
Arteries NORMAL
Auscultates the No sound heard Presence of bruit
carotid artery. on auscultation in one or both
arteries
 DEVIATION FROM
Carotid Arteries NORMAL FINDINGS
NORMAL
Palpate the carotid Symmetric pulse Asymmetric volumes;
artery. volumes;
(Use extreme caution.) Full pulsations, Decreased
thrusting quality; pulsations;
Elastic arterial wall
Increased pulsations;

Thickening, hard,
rigid, beaded,
inelastic walls

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 NORMAL DEVIATION FROM
HEART (PRECORDIUM)
FINDINGS NORMAL
Simultaneously inspect and palpate the
precordium

•Inspect and palpate the aortic and No pulsations Pulsations

pulmonic areas, observing them at
an angle and to the side, to note
No pulsations Pulsations
the presence or absence of
No lifts to Diffuse lifts or
pulsations. heaves heaves

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 DEVIATION FROM
PALPATION NORMAL FINDINGS
NORMAL
• Palpate the apical area for
Pulsations visible in PMI displaced
pulsation, noting its specific location 50% of adults and laterally or lower
(it may be displaced laterally or palpable in most PMI Diameter over 2 cm
in the 5th LICS or to
lower) and diameter. If displaced MCL
laterally, record the distance Diameter of 1 to 2
cm
between the apex and the MCL in
centimeters. Aortic pulsations
Bounding abdominal
•Inspect and palpate the epigastric pulsations
area at the base of the sternum for
abdominal
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 NORMAL DEVIATION FROM
HEART (PRECORDIUM)
FINDINGS NORMAL
Palpate for the presence of abnormal
pulsations, lifts, or heaves.

•Inspect and palpate the tricuspid No pulsations Pulsations

area for pulsations and heaves or
lifts.
No pulsations Pulsations
No lifts to Diffuse lifts or
heaves heaves
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 Palpate major precordial
landmarks
a. APETM (usually ball of your hand)
b. Note any pulsations, thrills, or
rubs: describe location, amplitude,
duration, and direction of impulse
c. Perform palpation in 3 different
positions: supine forward sitting
or left lateral decubitus
d. Normal findings: pulsatile
movements (PMI)
e. Deviations from normal: vibrations
or palpable thrills or heaves

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PALPATING AORTIC AREA

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PALPATING PULMONIC AREA

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PALPATING APICAL, MITRAL, & TRICUSPID AREA
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AUSCULTATION Cardiac Landmark
Aortic 2nd ICS right
sternal border
•Heart rate and
rhythm Pulmonic 2nd ICS left sternal
border
Erb 3rd ICS left sternal
•Heart sounds border
and murmurs Tricuspid 5th ICS left lower
sternal border
Mitral 5th ICS left MCL
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 DEVIATION FROM
AUSCULTATION NORMAL FINDINGS
NORMAL
Auscultates the heart in all four S1: Usually heard at all sites Increased or decreased
anatomic sites: aortic, Loudest at the apex (mitral intensity
pulmonic, tricuspid, and apical area) - 5th ICS MCL
(mitral). tricuspid area – left sternal Varying intensity with different
border beats
- Identifies S1 and S2
S2: Usually heard at all sites Increased intensity at the aortic
- Auscultates for extra heart (usually louder at the area.
sounds base)
Loudest at the base Increased intensity at the
(pulmonic area) pulmonic area

S3: In children & young adults Sharp-sounding ejection clicks

S4: in many older adults S3 in older adults (HF)

S4 maybe a sign of HPN

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ABNORMAL HEART SOUND

S3 ventricular gallop

S4 atrial gallop
Murmurs
Pericardial friction

Videos
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