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Upper and lower divisions

Assessing the • Upper airway warms, moisturizes

• Lower airway, where oxygenation and
ventilation occur
Thorax and Structure and
The thorax
the Lungs Function • One of the most dynamic regions of the body

NCM 101-SY 2020-2021 Overview • Bony thoracic cage

• Thoracic cavity
• Thoracic nerves in the chest (T1 to T12)
• Phrenic nerve
• Intercostals nerves

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• At the end of the respiratory system assessment

the learner should be able to: Structure and Function
• Review the anatomy & physiology
• Describe the component of health history that Overview (cont.)
should be elicited during the assessment of thorax
and lungs
• Reference lines
Learning • Identify the structural landmarks of the Thorax
and Lungs. – Anterior
• Midsternal
Objectives • Describe specific assessment to be made during
the assessment of the above system. • Midclavicular
• Identify the equipment needed for assessment • Anterior axillary lines
of thorax and lungs. – Posterior
• Discuss the importance of assessing the thorax • Vertebral line
and lungs.
• Scapular line
• Identify normal and abnormal findings in the
• Posterior axillary line
assessment of the thorax and lungs.
• Demonstrate proper assessment of assessing • Midaxillary line
thorax and lungs.

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Structure and Function

Overview (cont.)

• Lobes of the lungs

– Oblique fissure
– The left lung has
two lobes
– The right lung has
three
– Horizontal (minor)
fissure
– RML

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Structure and
Function Trachea and Pleurae
Overview (cont.)
• Pleurae
• Lobes of the lungs • Visceral pleura – lines outside of lungs,
dipping down into the fissures
– Upper, middle, and • Parietal Pleura – lines inside of chest wall and
lower lung fields diaphragm
• Lubricating fluid between the pleurae
– Base prevents friction
– Apex • Trachea and Bronchi
• Transport gasses between environment and
– Auscultate lung
– Anteriorly • Dead space is space filled with air (about 150
ml) but not available for gaseous exchange
– Posteriorly • Goblet cells in bronchi secrete mucus that
entraps particles
• Cilia in bronchi sweep particles upward

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Structure and Function Considerations

Overview (cont.) General Considerations
• Anterior thoracic landmarks o Warm equipment, such as a stethoscope, before using it to prevent
– Involve the ribs and their associated interspaces
– Suprasternal (jugular) notch chilling the patient.
– Sternal angle
• Site of the apex of the heart
o Attempt to reduce the noise level in the room while auscultating for
• Bifurcation of the right and left mainstem breath sounds to ensure accuracy in listening. Also, the presence of chest
bronchi
– Intercostal space (ICS) hair may mimic the sound of crackles and bumping the stethoscope
– Costal angle against clothing may distort the sound.
o Obtain the patient’s subjective data as well as the physical examination
findings. For example, the physical data may be normal; however, the
patient may verbalize that he or she is having difficulty breathing. In this
case, the patient needs to be monitored closely to assess for possible
complications.

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Structure and Function

Overview (cont.) Lifespan considerations
• Posterior thoracic landmarks Infant and Child Considerations
o Avoid anterior thorax chest percussion in an infant because it is often unreliable due
– Vertebral processes to the infant’s small chest size.
– Spinous process of T1 o Auscultate a child’s lungs before performing other assessment techniques that may
cause crying. o Expect to hear breath sounds that are harsher or more bronchial than
– Lower tip of the scapula those of an adult.
– 11th floating rib Older Adult Considerations
o In the older adult patient, expect to find a reduction in respiratory effort due to age
– 12th floating rib related changes. A common finding in the elderly is kyphoscoliosis, a skeletal deformity
affecting the spinal column, which causes the anteroposterior (AP) diameter to
increase and the thorax to shorten. Also, the alveoli of the lung tissue decreases, which
reduces the amount of alveolar surface area available for gas exchange.

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Equipment Needed
• Examination gown or drape
• Clean gloves
• Stethoscope Posterior
• Light source Thorax
• Mask
• Skin marker
• Metric ruler

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STEPS
STEPS NORMAL FINDINGS ABNORMAL FINDINGS
Introduce self
Inspect the shape and symmetry Anteroposterior to transverse Barrel chest; increased
of the thorax from posterior and diameter in ratio of 1:2 anteroposterior to transverse
Identifies client using 2 identifiers lateral views. Compare Thorax symmetric diameter Thorax asymmetric
anteroposterior diameter to the
transverse diameter
Explains the procedure and purpose to the client
GENERAL Inspect the spinal alignment for Spine vertically aligned Exaggerated spinal curvatures
deformities: (kyphosis, lordosis)
Gather necessary equipment STEPS Have the client stand. From a
lateral position, observe the three Spinal column is straight, right
Performs medical asepsis (hand wash) don gloves if necessary/if (3) normal curvature: cervical, and left shoulders and hips are at Spinal column deviates to one
thoracic, and lumbar. same height. side, often accentuated when
situation requires
To assess for lateral deviation of bending over. Shoulders or hips
the spine (scoliosis), observe the not even.
Provides privacy for the client standing client from the rear.
Have the client bend forward at
the waist, and observe from
behind.

Position the client comfortably, seated if possible

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✓ Family history of illness (cancer, allergies,

tuberculosis)
Inquire if the client ✓ Lifestyle habit (smoking and occupational
hazards
has any history of ✓ Medications being taken
the following: ✓ Current problems (swelling, coughs,
wheezing pain)

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General
Palpation
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STEPS
Palpate the posterior thorax
For clients who do not have
respiratory complaints, rapidly
assess the temperature and
integrity of all chest skin.
For clients who do have
respiratory complaints, palpate all no masses
chest areas for bulges,
tenderness, and abdominal
movements. Avoid deep palpation
for painful areas, especially if a
fractured rib is suspected.
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STEPS NORMAL FINDINGS ABNORMAL FINDINGS
Palpate the posterior chest for respiratory
excursion (thoracic expansion):
Place the palms of both hands over the lower thorax, with Full and symmetric thorax Asymmetric and/or decreased
your thumbs adjacent to the spine and your fingers stretched expansion (i.e., when the client thorax expansi
laterally. Ask the client to have a deep breath while you takes a deep breath, your
observe the movement of your hands and any lag in thumbs should move apart an
movement equal distance and at the same
time; normally the thumbs
separate 3 to 5 cm [1.2 to 2 in.]
during deep inspiration)
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STEPS NORMAL FINDINGS ABNORMAL FINDINGS
Palpate the chest for vocal (tactile)
fremitus.
Place the palmar surfaces of your Bilateral symmetry of vocal fremitus Decreased or absent fremitus
fingertips of the ulnar aspect of your Fremitus is heard most clearly at the (associated with pneumothorax)
Palpation hand or closed fist on the posterior
chest, starting near the apex of the
apex of the lungs Increased fremitus (associated with
consolidated lung tissue, as in
lungs. pneumonia)
Ask the client to repeat such words as Low-pitched voices of males are more
“99” or “1,2,3” readily palpated than higher pitched
Respiratory Tactile voices of females
Expansion Fremitus
Repeat the two steps, moving your
hands, sequentially to the base of the
lungs
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STEPS NORMAL FINDINGS ABNORMAL FINDINGS
Compare the fremitus on both lungs and
NORMAL FINDINGS ABNORMAL FINDINGS
between the apex and the base of each
lung, either:
Using one hand and moving it to one
Skin intact; uniform temperature Skin lesions; areas of side of the client to the corresponding
hyperthermia area on the other side.
Using two hands that are placed
simultaneously on the corresponding
areas of each side of the chest.
Chest wall intact; no tenderness; Lumps, bulges; depressions; areas
of tenderness; movable structures
(e.g., rib)
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2. Percussion
Percussion
✓ Place non-dominant hand with middle finger
(pleximeter finger) pressed and hyperextended firmly
Determines whether underlying
tissue is filled with air, liquid or solid
on the patient's right or left mid-back area (lower
material levels of lungs posteriorly). The firmer the finger is
pressed to the chest wall, the louder the percussion
note tends to be.
Position and boundaries of certain
organs
✓ Make sure the other fingers and palm are not pressed
against the patient's chest.

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✓ Use the tip of the middle finger (plexor finger) of the

dominant hand to tap firmly on the top third (middle
or distal phalanx) of the pleximeter finger of the non-
dominant hand at least twice (it is advisable to keep
Percussion fingernails short). The sound should be hollow,
representing an air-filled lung.

Diaphragmatic
Thorax
Excursion

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PROCEDURE

1. Positioning

✓ Make sure the patient is undressed down to

the waist. Pattern of
Assessment
✓ Position the patient on the examination table For
at a 30- to 45-degree angle and approach Percussion
from the right side. Examining the posterior
of the lung requires the patient to be leaning
forward or sitting on the edge of the bed.

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STEPS
Percuss the thorax.
Ask the client to bend the head and fold
the arms forward across the chest.
Rationale:
• Percuss in the intercostal spaces at
about 5-cm (2-in.) intervals in a
systematic sequence.
• Compare one side of the lung with the
other.
• Percuss the lateral thorax every few
inches, starting at the axilla and working
down to the eighth rib
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STEPS
Percuss the diaphragmatic excursion
▪ Ask the client to exhale and hold
his breath, as he holds his breath should be equal on both side
percuss from scapula down to
where the sound changes for
resonant to dullness, mark the spot
with a pen.
▪ Now ask the client to inhale deeply
and hold his breath as you percuss
further down to the new area of
dullness , then mark this spot too.
▪ Repeat this process to the other
side.
▪ Measure the distance between the
set of mark on each side,
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NORMAL FINDINGS
Percussion notes resonate, except over
scapula
Lowest point of resonance is at the
diaphragm (i.e., at the level of the 8th
to 10th rib posteriorly)
Note: Percussion on a rib normally
elicits dullness
NORMAL FINDINGS
Normally this distance is 3-5 cm and
ABNORMAL FINDINGS
Asymmetry in percussion notes Areas of
dullness or flatness over lung tissue
(associated
ABNORMAL FINDINGS
less than 3–5 cm the patient may have
a pneumonia or a pneumothorax in
which a chest x-ray is diagnostic for
either
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Auscultation
Breath Sounds Vocal Resonance
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STEPS NORMAL FINDINGS ABNORMAL FINDINGS
Auscultate the chest using the
flat-disc diaphragm of the
stethoscope
• Use the systematic zigzag Vesicular and bronchovesicular breath Adventitious breath sounds (e.g.,
procedure used in percussion sounds crackles, gurgles, wheeze, friction rub;
• Ask the client to take slow, deep
Absence of breath sounds
breaths through the mouth. Listen
at each point to the breath sounds
during a complete inspiration and
expiration
• Compare findings at each point
with the corresponding point on
the opposite side of the chest
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STEPS NORMAL FINDINGS ABNORMAL FINDINGS
Assess voice sounds. Use the same pattern
for evaluating voice sounds as for
auscultation. This sequence will be followed
for different findings:
• Bronchophony: ask the client to say In normal lung tissue, the sound
“ninety-nine” each time you place the will be muffled.
stethoscope on the chest
• Egophony: ask the client to say “e” each In normal lung tissue, you should If the lung tissue is
time you place the stethoscope on the hear “e” (as in “beet”). consolidated, the “e” sound
chest. will change to a nasal “a”
(as in “say”).
.In normal lung tissue, only faint the whispered sounds will
• Whispered pectoriloquy: ask the client to sounds will be heard be clear and distinct.
whisper “one, two, three” each time you
place the stethoscope on the chest.
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Anterior Thorax Chest Deformities

Pectus
Carinatum

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STEPS NORMAL FINDINGS ABNORMAL

FINDINGS Chest Deformities
Inspect breathing patterns Quiet, rhythmic, and
effortless respirations

• Inspect the coastal angle Costal angle is less

and the angle at which the than 90°, and the ribs Costal angle is Pectus
ribs enter the spine insert into the spine widened Excavatum
at approximately a (associated with
45° angle chronic
obstructive
pulmonary
disease)

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Chest Deformities

Normal
Chest Barrel
Chest

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Palpation

General Respiratory Tactile

Palpation Excursion Fremitus

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STEPS NORMAL FINDINGS ABNORMAL FINDINGS

Palpate the anterior chest

Palpate the anterior chest for respiratory
excursion.
• Place the palms of both your hands on the
lower thorax, with your fingers laterally along
the lower rib cage and your thumbs along the
coastal margins.
• Ask the client to take a deep breath while you
observe the movement of your hands.
Palpate for tactile fremitus in the same manner
as the posterior chest.
If the breasts are large and cannot be retracted
adequately for palpation, this part of the
examination usually is omitted.
Full symmetric excursion;
thumbs normally separate 3 to
5 cm (1.2 to 2 in.)
Same as posterior vocal
fremitus; fremitus is normally
decreased over heart and breast
tissue
Asymmetric Fremitus refers to vibratory tremors that
and/or decreased
respiratory
can be felt through the chest by palpation.
excursion
To assess for tactile fremitus, ask the
patient to say “99” or “blue moon”. While
the patient is speaking, palpate the chest
Same as posterior
fremitus
from one side to the other.

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Percussion

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Tympanic percussion (a drum-like sound when percussing over

hollow organs): over the Traube's space, an area overlying the
gastric bubble and bordered by the sixth rib, anterior axillary
line, and left costal margin. Left pleural effusion produces a dull
percussion sound over Traube's space.
Pattern of
Assessment
Note the presence of pathological percussion sounds. A "stony
dull" or flat percussion note sounds duller than the "standard"
dull sound. It resembles the percussion note heard over the
thigh and is indicative of a pleural effusion. A hyper-resonant
percussion note is a pathological percussion sound indicative of
hyper-inflated lungs from advanced COPD, emphysema, or a
pneumothorax

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STEPS NORMAL FINDINGS ABNORMAL FINDINGS

Percussion notes resonate Asymmetry in

Percuss the anterior chest down to the sixth rib at the percussion notes Areas
systematically. level of the diaphragm but of dullness or flatness
are flat over areas of heavy over lung tissue
muscle and bone, dull on
areas over the heart and the
liver, and tympanic over the
underlying stomach.
Begin above the clavicles in the
supraclavicular space, and proceed
downward to the diaphragm.
Compare one side of the lung to the
other.
Displace the female breasts for
proper examination.

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Appreciate the quality of percussion sounds.

The normal findings on the chest percussion Auscultation
are:
Trachea
Resonant percussion: heard over a normal air-
filled lung.

Dull percussion (the sound heard over solid Lung sounds

tissues): over the liver in the right lower anterior
chest and over the heart in the left anterior
chest. When percussion of the lungs elicits this
sound, it is indicative of consolidation.

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NORMAL BREATH SOUNDS

TYPE DESCRIPTION LOCATION CHARACTERISTIC

Bronchial High-pitched, loud, Anteriorly over the Louder than

harsh sounds trachea; not vesicular sounds;
created by air normally heard over I:E ratio = 1:2
moving through lung tissue
trachea
Bronchovesicular Moderate intensity, Between the Equal inspiratory
moderate-pitched scapulae and lateral and expiratory
blowing sounds to the sternum at phase
created by air the 1st and 2nd ICS I:E ratio = 1:1
moving through
larger airway
Vesicular Soft intensity, low- Over peripheral Best heard on
pitched, gentle lung fields; best inspiration; about
sighing sounds heard on base of 2.5 times longer
created by air the lungs than expiratory
moving through phase
bronchioles and I:E ratio: 5:2
alveoli

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STEPS NORMAL FINDINGS ABNORMAL FINDINGS

Name Description Cause Location
Auscultate the trachea Bronchial and tubular Adventitious breath
breath sounds sounds Crackles (rales) Fine, short Air passing Most commonly
interrupted crackling through fluid or heard in the bases
sounds; best heard mucus in any air of lower lungs
Bronchovesicular and on inspiration but can
be heard o both I and
passage

Auscultate the anterior chest vesicular breath sounds Adventitious breath E. May not be
cleared by coughing
Use the sequence used in sounds
Gurgles (rhonchi) Continuous low- Air passing Loud sounds can
percussion, beginning over the pitched, coarse through narrowed be heard over most
bronchi between the sternum gurgling, harsh, air passages due lung areas but
louder sounds, with to secretions, predominate over
and the clavicles. moaning or snoring swelling or the trachea and
quality; best heard on tumors bronchi
expiration but may be
heard on both I and
E. May be altered by
coughing

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Name Description Cause Location

Friction Rub Superficial grating or Rubbing together Heard most often in

creaking sounds of inflamed areas of greatest
heard during pleural surfaces thoracic expansion
inspiration and (lower anterior and
expiration. Not lateral chest)

Auscultation
cleared by coughing.

Wheeze Continuous, high- Air passing Heard over all lung

pitched squeaky through a fields
musical sounds. Best constricted
heard on expiration. bronchus as a
Not usually altered by result of
coughing. secretions,
tumors or
swellings

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References:

 Kozier, Barbara et al. (2016). Fundamentals of Nursing.

Concepts, Process and Practice. 10th ed Ed. New
Jersey, Prentice Hall Pearson

 Weber J. & Kelley J. (2007). Health Assessment in

Nursing. (3rd Ed.) Philadelphia, Lippincott Williams
and Wilkins (Read pp. 360)

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