THORAX AND LUNGS ASSESSMENT

THORAX AND LUNGS ASSESSMENT

·         How to measure the chest. Take the measurement at the nipple level with a tape measure; observe for
chest size, shape, movement of the chest with breathing, and any retractions.

·         Adolescents. In the older school-age child or adolescent, note evidence of breast development.

·         Assess respiratory characteristics. Evaluate respiratory rate, rhythm, and depth; report any noisy or
grunting respirations.

·         How to assess breath sounds. Using a stethoscope, the nurse listens to breath sounds in each lobe of
the lung, anterior and posterior, while the patient inhales and exhales; describe, document, and report absent
or diminished breath sounds, as well as unusual sounds such as crackling or wheezing.

BODY PART TECHNIQUE NORMAL FINDINGS

Thorax and Lungs Inspection. » The chest contour is symmetrical and the chest is
twice as wide as deep (anteroposterior diameter in a
(Anterior and Posterior) Have the client sit comfortably. Inspect for 1:2 ratio). The spine is straight. Posteriorly the ribs
the shape, position of the spine, the slope of tend to slope across and down. The ribs are
the ribs, retraction of the intercostal spaces prominent in a thin person. There is no bulging or
(ICS) on inspiration, and bulging of the ICS retraction of the ICS during breathing. The chest
on expiration. wall moves symmetrically during respiration. 

Observe for symmetry of the chest wall  

during respiration
 
 
» No lumps, masses, areas of tenderness.
 
» Sides of the thorax expand symmetrically. The
Palpation examiner’s thumb separates approximately 3-5
centimeters during the excursion.
Palpate for lumps, masses, areas of
tenderness.  

Measure chest excursion (to determine the  

depth of breathing). Place hands on the
lower portion of the rib cage with the  
thumbs 2 inches apart pointing towards the
spine and fingers.  
  » Vibrations are prominent over the areas near the
bronchi. It increases with the intensity of the voice.
Elicit tactile fremitus (a thrill felt by theVibrations are strongest between the first and
hand on the chest wall while the client is second ribs along the sternum anteriorly and
speaking). Place the palms of the hand between the scapulae posteriorly.
bilaterally symmetrical on the chest. Start
from the top of the chest wall going down.  
Each time the hands move, ask the client to
say “ninety-nine” or “one--one—one” with  
the same intensity of the voice.
 
 
 
Percussion
 
For the anterior thorax, the client is
preferably in a lying position. For the  
posterior thorax, the client is in a sitting
position with the arms folded across the » Percussion note varies with the thickness of the
chest. This position will separate the chest wall:
scapulae to further expose the lungs for
assessment. Using indirect percussion,  
percuss in the ICS over symmetrical areas
of the chest starting from the » Resonance- the sound created by air-filled lungs.
supraclavicular area. Compare one side of It is clear, long, low pitch.
the chest to another.
 
 
» Dull- short, high pitch, soft and thudding, heard
  over the heart.

   

  » Flat- absolute dullness; absence of air in the

underlying tissue.
 
 
 
» Tympany- moderately loud with music quality
  with a specific pitch. Noted in the left upper
quadrant of the abdomen.
 
 
 
Location Percussion Note
    L R
Supra-  
 
clavicular Flat
 1st ICS Resonant
2nd ICS Dull Resonan
t
3rd ICS Dull Resonan
t
4th ICS Dull Resonan
t
5th ICS Dull Resonan
 
t
  6th ICS Resonant Resonan
t
  7th ICS Tympanic Dull
8th ICS Tympanic Dull
  9th ICS Tympanic Dull
 
 
 
 
» Normal breath sounds differ in character
  depending on the area of the lung being auscultated.

   

  » Bronchovesicular sounds are medium-pitched

sound or medium intensity, heard posteriorly
  between the scapulae. The sounds have a blowing
quality with the inspiratory phase equal to the
  expiratory phase.

Auscultation  

To assess the movement of air through the » Vesicular sounds are heard over the lung
tracheobronchial tree, the room must be periphery. The sounds are created by air moving
quiet. through the smaller airways. They are soft, breezy,
and low-pitched and the inspiratory phase is about
three times longer than the expiratory phase.

» Bronchial sounds are hollow high pitched;

whistling sounds which are normal if heard over
large airways like the trachea.
 

Flipped Classroom:  For additional reference, you can click the actual video for the method of assessing the
thorax and the lungs: https://www.youtube.com/watch?v=j5D9hkppDGY 

Overview
1.    The thorax and lungs should be assessed anteriorly, posteriorly, and laterally

Nursing Points

General

1.    Supplies needed

a.    Stethoscope

Assessment

1.    Anterior

a.    Inspect

              i.        Size and shape of the thorax

1.    Anterior-Posterior diameter should be approximately ½ the lateral diameter

2.    Barrel Chest – COPD

             ii.        Symmetry

1.    Expansion should be symmetrical on inspiration

            iii.        Ribs should slope downward from the sternum outward

            iv.        Observe for signs of distress

1.    Tachypnea

2.    Retractions

3.    Cyanosis

             v.        Observe the overall rate and rhythm of respiration

            vi.        Inspect skin color and condition on the thorax

b.    Palpate

              i.        Using 2 fingers, press lightly on the skin over the anterior chest, feeling for crepitus – feels like
“rice crispies” under skin

1.    Indicates subcutaneous air

c.    Percuss

              i.        Starting at the Apex, percuss in the intercostal spaces moving left to right and downward

             ii.        Should hear the resonance

            iii.        May hear dullness over heart and liver

d.    Auscultate

              i.        Listen for audible cough, wheezing, or stridor

             ii.        Lung sounds

1.    Bronchial

a.    Upper areas

b.    High pitch

c.    Insp < Exp

2.    Bronchovesicular

a.    Middle areas

b.    Moderate pitch

c.    Insp = Exp

3.    Vesicular

a.    Outer areas

b.    Low pitch

c.    Insp > Exp

            iii.        Listen from left to right starting at the apex and moving downward, including the lateral areas.

1.    The only way to hear the right middle lobe is to listen near the axilla on the right side.

            iv.        Should listen in 10-12 areas on the front

             v.        BEST heard with stethoscope directly on skin

            vi.        Listen to one full respiration in each area

           vii.        Make note of any adventitious sounds

1.    Crackles

2.    Rhonchi

3.    Wheezes

4.    Stridor

5.    *See Lung Sounds lesson in Respiratory Course for details

2.    Posterior

a.    Inspect – same as anterior

b.    Palpate – same as anterior, plus:

              i.        Tactile fremitus

1.    Use the palm of your hands to palpate from the apex down in 5 places as the patient says the word
“ninety-nine”

2.    Should feel vibrations equally bilaterally

1.    Decreased vibration = fluid consolidation

             ii.        Expansion

1.    Place hands on lower rib cage with thumbs touching, ask the patient to inhale deeply

2.    Should see hands expand and return symmetrically

c.    Percuss – same as anterior,

              i.        Avoid scapula

d.    Auscultate – same as anterior

              i.        Avoid scapula

              ii.       8-10 locations

ABDOMINAL ASSESSMENT 

·       In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in
a supine position with the knees slightly flexed to relax abdominal muscles.

Inspection of the abdomen

·       Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).

·       Contour (flat, rounded, scaphoid)

·       Distension

·       Respiratory movement.

·       Visible peristalsis.

·       Pulsations

Normal Findings:

·       Skin color is uniform, with no lesions.

·       Some clients may have striae or scar.

·       No venous engorgement.

·       The contour may be flat, rounded, or scaphoid

·       Thin clients may have visible peristalsis.

·       Aortic pulsation may be visible on thin clients.

Auscultation of the Abdomen

·       This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by
palpation or percussion.

·       The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of the
abdominal muscles.

·       Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds are
relatively high-pitched, the bell may be used in exploring arterial murmurs and venous hum.
Peristaltic sounds

·       These sounds are produced by the movements of air and fluids through the gastrointestinal tract.
Peristalsis can provide diagnostic clues relevant to the motility of the bowel.

·       Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

o   Divide the abdomen into four quadrants.

o   Listen to overall auscultation sites, starting at the right lower quadrants, following the cross pattern of the
imaginary lines in creating the abdominal quadrants. This direction ensures that we follow the direction of
bowel movement.

o   Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listens for at least 5
minutes, especially at the periumbilical area, before concluding that no bowel sounds are present.

o   The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 seconds.
It is suggested that the number of bowel sounds may be as low as 3 to as high as 20 per minute, or roughly,
one bowel sound for each breath sound.

o   Some factors that affect bowel sound:

§  Presence of food in the GI tract.

§  State of digestion.

§  Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis).

§  Bowel surgery

§  Constipation or Diarrhea.

§  Electrolyte imbalances.

§  Bowel obstruction.

Percussion of the abdomen

·       Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, and
masses, and in assessing solid structures within the abdomen.

·       The direction of abdominal percussion follows the auscultation site at each abdominal guardant.

·       The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness.
·       Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will
percuss as dull, such as liver in the RUQ, spleen at the 6th or 9th rib just posterior to or at the midaxillary line
on the left side.

·       Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.

Percussion of the liver

·       The palms of the left hand are placed over the region of liver dullness.

·       The area is struck lightly with a fisted right hand.

·       Normally tenderness should not be elicited by this method.

·       Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.

Renal Percussion

·       Can be done by either indirect or direct method.

·       Percussion is done over the costovertebral junction.

·       Tenderness elicited by such method suggests renal inflammation.

Palpation of the Abdomen

Light palpation

·       It is a gentle exploration performed while the client is in a supine position. With the examiner’s hands
parallel to the floor.

·       The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, but
gently palpating with slow circular motion.

·       This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding.

·       Tensing of abdominal musculature may occur because of:

o   The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen.

o   The client is ticklish or guards involuntarily.

o   Presence of subjacent pathologic condition.

Normal Findings:
·       No tenderness noted.

·       With smooth and consistent tension.

·       No muscles guarding.

Deep Palpation

·       It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the
fingers into the abdominal wall.

·       The abdominal wall may slide back and forth while the fingers move back and forth over the organ being
examined.

·       Deeper structures, like the liver, and retroperitoneal organs, like the kidneys, or masses may be felt with
this method.

·       In the absence of disease, the pressure produced by deep palpation may produce tenderness over the
cecum, the sigmoid colon, and the aorta.

Liver palpation

·       There are two types of bimanual palpation recommended for palpation of the liver. The first one is the
superimposition of the right hand over the left hand.

o   Ask the patient to take 3 normal breaths.

o   Then ask the client to breathe deeply and hold. This would push the liver down to facilitate palpation.

o   Press hand deeply over the RUQ

·       The second methods:

o   The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs.

o   Place the examiner’s right hands parallel to the costal margin or the RUQ.

o   Upward pressure is placed beneath the client to push the liver towards the examining right hand, while the
right hand is pressing into the abdominal wall.

o   Ask the client to breathe deeply.

o   As the client inspires, the liver may be felt to slip beneath the examining fingers.

Normal Findings:
·       The liver usually cannot be palpated in a normal adult. However, in extremely thin but otherwise well
individuals, it may be felt the coastal margins.

·       When the normal liver margin is palpated, it must be smooth, regular in contour, firm, and non-tender.

BODY PART TECHNIQUE NORMAL FINDINGS

ABDOMEN Divide the abdomen into 4 imaginary  
quadrants. Draw a vertical line from the
xiphoid process to the symphysis pubis and  
a horizontal line across the umbilicus. 
These quadrants are labeled right upper  
quadrant (RUQ), left upper
quadrant (LUQ), right lower  
quadrant (RLQ), and left lower
quadrant (LLQ).  

   

Ask the client if he needs to void. Drape the  

upper chest and legs.  Expose the abdomen
from the xiphoid process to the symphysis  
pubis. The client lies in a supine position
with arms down at the sides; a small pillow  
may be placed under the head.
 
 
 
 
 
Inspection
 
Inspect the abdomen for skin integrity,
color, contour, symmetry, movement or  
pulsations, and color and placement of the
umbilicus.  

 
  

»  Skin is unblemished, no scars, color  is uniform,

flat,  rounded (convex), or scaphoid (concave),

»  Symmetrical movements caused by respiration,

aortic pulsation at epigastric area visible in thin
persons

»  Umbilicus is flat or concave, positioned midway

between the xiphoid  process and the  symphysis
pubis

»  Color is the same as the surrounding skin.

  Auscultation  

Warm the diaphragm of the stethoscope. A  

cold stethoscope may cause the client to
contract the abdominal muscles and the »  There are clicks and gurgles, the frequency of
contractions may be heard during which has been estimated at from 5-34 per minute. 
auscultation. The diaphragm is used Occasionally, borborygmi (loud prolonged gurgles
because intestinal sounds are high – pitched of hyperperistalsis) the familiar “stomach growling”
sounds. Place the diaphragm in each of the can be heard.
4 quadrants' overall auscultation sounds.
 
 
 
Percussion
 
Reveals the presence of air in the stomach
and abdomen.  

To identify the boarders start percussion at  

the right iliac rest upward along the
midclavicular line. Percuss each quadrant  
starting from the right clockwise.
 
Palpation
»  Tympany predominates because of the presence
Perform light palpation first to detect areas of air in the stomach and intestines
of tenderness, muscle guarding, (Voluntary
tightening of abdominal muscles), lumps of »  Percussion is dull at the liver’s lower border.
masses, consistency and organomegaly.
 
Depress the abdominal wall lightly, about 1
cm. with the pads of your fingers. Move the
  

 
finger pads in a slight circular motion.
Palpate all 4 quadrants.
 
Palpate the liver using deep palpation.
 
Stand on the client’s right side.  Place your
left hand on the posterior thorax at about
»  Soft abdomen, no tenderness, no muscle
the 11th or 12th rib and then apply upward
guarding, no lumps, or masses, or organomegaly.
pressure. With the fingers of the right hand
pointing upward, place the hand on the
 
RUQ well below the liver’s lower border,
then press gently until you reach the depth
 
of 1 ½  - 2 inches. Ask the client to take a
deep breath using the abdominal muscles.
 
As he inhales, tries to palpate the liver’s
edge as it descends.
 

»  Liver’s edge feels firm and not tender.

Flipped Classroom:  For additional reference, you can click the actual video for the method of assessing the
thorax and the lungs: https://www.youtube.com/watch?v=4fxKy3ykiB8

BREAST EXAMINATION

Inspection of the Breast

·       There are 4 major sitting positions of the client used for clinical breast examination. Every client should be
examined in each position.

o   The client is seated with her arms on her side.

o   The client is seated with her arms abducted over the head.

o   The client is seated and is pushing her hands into her hips, simultaneously eliciting contraction of the
pectoral muscles.

o   The client is seated and is learning over while the examiner assists in supporting and balancing her.

·       While the client is performing these maneuvers, the breasts are carefully observed for symmetry, bulging,
retraction, and fixation.

·       An abnormality may not be apparent in the breasts at rest a mass may cause the breasts, through invasion
of the suspensory ligaments, to fix, preventing them from upward movement in position 2 and 4.
·       Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory
ligaments.

Normal Findings:

·       The overlying the breast should be even.

·       May or may not be completely symmetrical at rest.

·       The areola is rounded or oval, with the same color, (Color varies from light pink to dark brown depending
on race).

·       Nipples are rounded, everted, the same size and equal in color.

·       No “orange peel” skin is noted which is present in edema.

·       The veins may be visible but not engorge and prominent.

·       No obvious mass noted.

·       Not fixated and moves bilaterally when hands are abducted over the head, or is leaning forward.

·       No retractions or dimpling.

Palpation of the Breast

·       Palpate the breast along with imaginary concentric circles, following a clockwise rotary motion, from the
periphery to the center going to the nipples. Be sure that the breast is adequately surveyed. Breast examination
is best done 1-week post menses.

·       Each areolar areas are carefully palpated to determine the presence of underlying masses.

·       Each nipple is gently compressed to assess for the presence of masses or discharge.

Normal Findings:

·       No lumps or masses are palpable.

·       No tenderness upon palpation.

·       No discharges from the nipples.

·       NOTE: The male breasts are observed by adapting the techniques used for female clients. However, the
various sitting position used for the woman is unnecessary.

 
BODY PART TECHNIQUE NORMAL FINDINGS
BREASTS Inspection Females: variable in size depending on body build.

Ask the client to remove the top gown or * obese - large and pendulous.
drape to allow simultaneous visualization
of both breasts. Have the client sit  
comfortably with arms at the side. Inspect
the breast for size, symmetry, and contour *Slender - thin and small. 
or shape. Inspect the skin of the breast for
color, retraction, or dimpling.  

  *Young clients - firms, elastic in consistency, cone-

shaped symmetrical, skin surface smooth.
 
 
 
*older women - breasts sag, nipples lower, stringy
Palpation and nodular.

Assist the client in a supine position.  This  

position allows the breast tissues to flatten
evenly against the chest wall facilitating  
palpation. Ask the client to raise his/her
hand and place it under the head.  Palpate Males: flat, symmetrical. If obese maybe slightly
the breasts for lumps or masses, areas of rounded.
tenderness, and consistency of breast
tissues.   

   

The palmar surface of the three fingers is »  Color of the skin same with the abdomen, no
used to compress the breast tissues against retraction, no dimpling.
the chest wall.
 
 
»  No mass or lump, no areas of tenderness.
 
 
Perform palpation in a clockwise rotary
motion from the boarders going inward. »  In younger clients, borders of the breasts are
clearly delineated. In older clients irregular
consistency, glandular/nodular.

»  Lobular feel of glandular tissue is normal.

»  The lower edge of each breast may feel firm and

 hard.

»  Premenstrual fullness, nodularity, and tenderness

maybe present.

»  Warm to touch and smooth.

AREOLA

 
Inspection
 
Inspect the size, shape, color, and
symmetry. »  Round or oval, color darker than surrounding
 
skin, symmetrical.
 
 
  »  For dark–skinned clients, color is darker than
  other skin surfaces.
 
   
 
   
 
   »  No masses and areas of tenderness.
Palpation
 
Palpate for masses and areas of tenderness. 
 

 
NIPPLES Inspection

Inspect for size, shape position, discharge,

and lesions.
»  Round or inverted, equal in size, similar in color,
nipples point in one direction, no discharge, no
 
lesion, no dimpling, and no crusting.
 
 
Palpation
»  No masses, no tenderness, no discharge.
Using the thumb and index finger,
compress the nipple to determine any
discharge.
 
Flipped Classroom:  For additional reference, you can click the actual video for the method of assessing the
thorax and the lungs: https://www.youtube.com/watch?v=76g_tNWMhCE

MALE GENITALIA EXAMINATION ( Overview) 

Risk Factors for Testicular Cancer

1.    Age 20-34 (15-35)

2.    History of undescended testes

3.    Early puberty

4.    Family history

5.    White race

6.    Higher social class

7.    Obesity

8.    Never married or late marriage

9.    Maternal use of oral contraceptives or diethylstilbestrol during early pregnancy

10. Maternal abdominal/pelvic x-ray during pregnancy

11. Mother or sisters with breast cancer

Warning Signs for Cancer of the Testicle

1.    A small, hard, painless lump-about the size of a pea

2.    Feeling of heaviness in the testicle

3.    Enlargement of the testicle

4.    Change in how the testicle feels to the touch

5.    Sudden accumulation of fluid/blood in the scrotum

6.    Dull ache in the groin

7.    Swelling or tenderness in other parts of the body (groin, breast, neck)

Testicular Self-Examination

1.    Perform after a warm bath/shower

2.    Use both hands and start on the right testicle

3.    Place index and middle finger underneath testicle

4.    Place thumb on top of testicle

5.    GENTLY roll the testicle between thumbs and fingers

6.    Check all sides of the right testicle and repeat procedure on left testicle

7.    Find the epididymis on the top and back of each testicle.

8.    Examine the testes in the mirror while standing. Look for unusual contours and swelling of testes (noting
that one usually hangs lower than the other) 

End of Chapter 4 (continuation part 1)….

HEART (CARDIAC) and GREAT VESSELS ASSESSMENT

HEART (CARDIAC) and GREAT VESSELS ASSESSMENT

Inspection of the Heart

·       The chest wall and epigastrium is inspected while the client is in supine position. Observe for pulsation
and heaves or lifts

Normal Findings:

·       Pulsation of the apical impulse may be visible. (this can give us some indication of the cardiac size).

·       There should be no lift or heaves.

Palpation of the Heart

·       The entire precordium is palpated methodically using the palms and the fingers, beginning at the apex,
moving to the left sternal border, and then to the base of the heart.

Normal Findings:

·       No, palpable pulsation over the aortic, pulmonic, and mitral valves.

·       Apical pulsation can be felt on palpation.

·       There should be no noted abnormal heaves, and thrills felt over the apex.

Percussion of the Heart

·       The technique of percussion is of limited value in cardiac assessment. It can be used to determine borders
of cardiac dullness.

Auscultation of the Heart

·       Anatomic areas for auscultation of the heart:

·       Aortic valve – Right 2nd ICS sternal border.

·       Pulmonic Valve – Left 2nd ICS sternal border.

·       Tricuspid Valve – – Left 5th ICS sternal border.

·       Mitral Valve – Left 5th ICS midclavicular line

Positioning  the client for auscultation:

1.    If the heart sounds are faint or undetectable, try listening to them with the patient seated and leaning
forward, or lying on his left side, which brings the heart closer to the surface of the chest.

2.    Having the client seated and leaning forward is best suited for hearing high-pitched sounds related to
semilunar valves problem.

3.    The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve problems and
extra heart sounds.

Auscultating the heart:

1.    Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral

2.    Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound is best
heard over the mitral valve; S2 is best heard over the aortic valve.

3.    Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.

4.    Count heart rate at the apical pulse for one full minute.

Auscultation of Heart Sounds

Normal Findings:

·       S1 & S2 can be heard at all anatomic site.

·       No abnormal heart sounds are heard (e.g. Murmurs, S3 & S4).

·       Cardiac rate ranges from 60 – 100 bpm.

Flipped Classroom:  For additional reference, you can click the actual video for method of assessing the thorax
and the lungs: https://www.youtube.com/watch?v=G5CwcxF43KQ