2nd SEMESTER - YEAR 1

NCM 101: HEALTH ASSESSMENT TERM

LECTURE NOTES | MR. PORNIA
03M

ASSESSMENT OF THE THORAX THORACIC LANDMARK (AXILLARY LINE)

OBJECTIVES
•Review on the anatomy & physiology of thorax and
lungs
•Identify the thoracic landmarks
•Know the different approaches in the physical
assessment of the thorax
•Know the ways on how to collect subjective data:
History Taking
•Collection of Objective Data: Physical Assessment
•Document respiratory assessment findings
ANATOMY AND PHYSIOLOGY
ANTERIOR OF THE THORAX
- provides suport and protection for many imporant
organs includings those of the lower respiratry system.

THORACIC LANDMARKS
GENERAL APPROACHES
ANTERIOR
 Greet the patient and explain the assessment
techniques that you will be using.
 Room should be warm to prevent the patient from
chilling and shivering.
 Use a quiet room that will be free from interruptions.
 Ensure that the light provides sufficient lightness
 Instruct patient to remove clothes and change to a
gown
 Place the patient in an upright sitting position
POSTERIOR  Exposed the entire area to be assessed. Provide a
drape cover the breast of women when posterior
T thorax is assessed.
 When palpating, percussing and auscultating the
anterior thorax of an obese female patient, ask them to
displace breast issue.

ENRIQUEZ | BSN 1G UNIVERSITY OF CEBU-BANILAD

 ASSESSMENT OF THE THORAX

 Visualize the underlying respiratory structures during energy and accidents.

assessment process. Do you have chest pain? Pain-sensitive nerve
 Always compare the right, and left sides of the Is the pain associated endings are located in the
with cold, fever or deep parietal pleura, thoracic
anterior and posterior thorax, as well as the right and
breathing? muscles and
left lateral thorax. tracheobronchial tree but
 Use a systematic approach every time assessment is not in lungs. Pain
performed associated with a
IMPORTANCE pulmonary origin may be
 Provides clues about underlying respiratory disorders a late sign of pulmonary
 Data helps the nurse in the formulation of nursing disease.
diagnoses as well as clues on possible risk for the
Do you have a cough?  Continuous cough are
When and how often associated with acute
development of lung disorder does it occur? infections;
 Important because certain respiratory problems  Coughs occurring early
greatly impact a person's ability to perform activities of in the morning are
daily living. associated with chronic
SUBJECTIVE DATA bronchial inflammation
HISTORY OF PRESENT HEALTH CONCERN or smoking
QUESTIONS RATIONALE  Coughs late in the
Do you experience  Dyspnea evening may be a result
of exposure to irritant
difficulty in breathing?  Gradual onset is
during the day.
indicative of lung changes
like emphysema  Coughs during
nighttime are often
 Sudden onset is
related to postnasal drip
associated with viral or
or sinusitis
bacterial infection.
Do you produce any  Non-productive cough
Do you experience any  Occurrence of edema
sputum when you cough? are often associated with
other symptom when you or angina may indicate
What color Is the respiratory imitations and
have difficulty of cardiovascular problems
sputum? How much early congestive heart
breathing?
sputum do you cough up? failure.
Has this amount  White/mucoid sputum
Do you experience  Loss of elasticity, fewer
increased or decreased - common colds, viral
difficulty of breathing functional capillaries and
recently? Does the infections & bronchitis
when you are resting or loss of lung resiliency in
do any specific activities older people may
sputum have an odor?  Yellow/ green -
that cause difficulty? experience dyspnea in bacterial infections
certain activities  Blood in the sputum -
serious respiratory
Do you have difficulty  Orthopnea and
breathing when you problem (TB)
paroxysmal nocturnal
sleep? Do you use more dyspnea may be  Pink, frothy sputum -
than one pillow when you associated with heart pulmonary edema
sleep? failure.  Increase amount -
 Changes in sleep increase exposure to
pattern may cause irritants, chronic
fatigue during the day. bronchitis & pulmonary
abscess
Do you snore when you Sleep apnea diminishes
sleep? the quality of sleep Do you wheeze when you  Wheezing - narrowing
resulting to fatigue, cough or when you are of the airways due to
depression, irritability, active? spasm or obstruction;
loss of memory, lack of congestive heart failure,
asthma or excessive

ENRIQUEZ | BSN 1G UNIVERSITY OF CEBU-BANILAD

 ASSESSMENT OF THE THORAX
secretions.
Do you have any Patients with asthma
gastrointestinal have GERD
symptoms such as (gastrointestinal reflux
heartburn, frequent disease) or more
hiccups or chronic cough? susceptible to GERD
PAST HEALTH HISTORY
QUESTION RATONALE
Have you had prior History with the disease
respiratory problem? may increase the risk for
a recurrence.
Have you ever had any Previous surgeries may
thoracic surgery, biopsy alter the appearance of
or trauma? the thorax and cause
changes in respiratory
sounds. Trauma can
cause respiratory
changes.
Have you had a chest x- Information on previous
ray, TB skin test or tests is useful for
influenza immunization? comparison with current
Have you had any Findings and gives
pulmonary studies in the Information on self-care
past? practices and possible
teaching needs.
Have you traveled to
countries like China,
Hongkong, Singapore etc.
FAMILY HISTORY
QUESTIONS RATIONALE
Is there a history of lung Lung cancer, asthma,
disease in your family? emphysema, and
exposure to viral or
bacterial respiratory
infections
Did any family members Second-hand smoke puts
in your home smoke individuals at risk for
when you are growing emphysema or lung
up? cancer later in life
Is there a history of other Some pulmonary
pulmonary disorders like asthma,
illnesses/disorders in the tend to run in families
family like asthma?
ENRIQUEZ | BSN 1G UNIVERSITY OF CEBU-BANILAD
LIFESTYLE AND HEALTH PRACTICES
QUESTIONS RATIONALE
Have you ever smoked Smoking is linked to a
cigarettes or other number of respiratory
tobacco products? Do conditions
you currently smoke? At
what age did you start?
How much do you
smoke? Have you ever
tried to quit?
Are you exposed to any Exposure to certain
environmental conditions environmental inhalants
that affect your can result in an increased
breathing? Where do you incidence of certain
work? Are you around respiratory conditions
smokers?
Are you currently taking Metoprolol, ACE
medications for breathing inhibitors, beta blockers
problems or other OTCs has persistent cough as
that affects your side effect and is
breathing? contraindicated in
patients with asthma
COLLECTING OBJECTIVE DATA
 Techniques : IPPA
 Preparation of the client
 Equipments
 Key points
INSPECTION
A SHAPE DE THE THORAX
B.SYMMETRY OF THE CHEST WAL C.PRESENCE DE
SUPERECTAVAN
D.COSTAL ANGIE
E.ANGLE OF THE RIBS
F.INTERCOSTAL SPACES
G.MUSCLES OF RESPIRATION
H.RESPIRATIONS
I. SPUTUM
A. SHAPE OF THE THORAX
• Stand in front of the patient.
• Estimate visually the transverse diameter of the
thorax
• Move to either side of the patient
• Estimate the anteroposterior (AP) diameter of the
thorax
• Compare the estimates di the visualizations
NORMAL:
 Ratio of the A diameter to the transverse diameter is
app. 1:2 to 5:7. A normal adult is wider from side to
side than from front to back
 Normal thorax is slightly elliptical in shape
 ASSESSMENT OF THE THORAX

 For infants, a barrel chest is normal.  In a heavy or obese patient, place your fingertips on
ABNORMAL FINDINGS the lower anterior borders of the thoracic skeleton.
PECTUS EXCAVATUM OR A CONCAVE CHEST WALL  Gently move your fingertips to the xiphoid process
 Depressed sternum or breastbone. NORMAL:
 Space in the chest cavity of the lungs to expand is Costal angle is less than 90 deg. During exhalation and
diminished causing difficulty of breathing, shortness of rest
breath and decreased endurance during exercise. E. ANGLE OF THE RIBS
• Stand in front of the patient
 Cardiac compression reduces stroke volume and • Visually locate the midsternal area
cardiac output causing fatigue and elevated heart rate.  Estimate the angle at which the ribs articulate with
PECTUS CARINATUM OR PROTRUDING STERNUM the sternum
 Difficulty in exhaling the air in the lungs which  In a heavy or obese patient, place your fingertips on
restricts gas exchange and causes short and fast the midsternal area.
breathing and reduced exercise tolerance.  Move your finger along the rib laterally to the
POTT’S DISEASE OR CARIES OF THE SPINE anterior axillary line. Visualize the line that is created by
 Chest falls forward and its anteroposterior diameter your hand as it traces the ribs.
in increased. Abdominal contents are crowded up into NORMAL:
the chest and push the sternum and lower ribs forward. The ribs articulate at a 45 degree angle with the
sternum.
Associated with this deformity is oftentimes a lalteral
F. INTERCOSTAL SPACES
deviation of the parts above the site of the disease • Stand in front of the patient
 When the scapulae project like wings, it is called • Inspect the ICS throughout the respiration cycle
“alar” or “pterygoid chest” • Note any bulging of the ICS and any retractions.
B. SYMMETRY OF CHEST WALL NORMAL:
 Stand in front of the patient Absence of retractions and bulging of the ICS.
 Inspect the right and let anterior thoraxes G. MUSCLES OF RESPIRATION
 Stand in front of the patient
 Note the shoulder height.
 Observe the patient's breathing for a few respiratory
 Move behind the patient
cycles, paying close attention to the thorax and the
 Inspect the right and left posterior thoraxes
neck
 Note the position of the scapula.
 Note all the muscles that are being used by the
NORMAL:
patient.
The shoulders should be of the same height, so with
NORMAL:
the scapula. No masses.
No accessory muscles used in normal breathing.
ABNORMAL FINDINGS
H. RESPIRATIONS
 Scoliosis Inspection of the respiration process includes 7
 Kyphosis components:
 Lordosis  Rate
C. PRESENCE OF SUPERFICIAL VEIN  Pattern
• Stand in front of the patient  Depth
• Inspect the anterior thorax for the presence of dilated
 Symmetry
superficial veins.
NORMAL:  Audibility
Dilated superficial veins are not seen.  Patient position
D. COSTAL ANGLE  Mode
 Stand in front of the patient. RATE OF RESPIRATION
 Visually locate the costal margins NORMAL : 12. - 20 breaths per minute in a resting
 Estimate the angle formed by the costal margins adult.
during exhalation and at rest. EUPNEA - normal breathing
ABNORMAL FINDINGS:
Tachypnea - RR greater than 20

ENRIQUEZ | BSN 1G UNIVERSITY OF CEBU-BANILAD

 ASSESSMENT OF THE THORAX

Bradypnea - RR lower than 12 ABNORMAL FINDINGS

Apnea - lack of spontaneous respiration for 10 or more SPUTUM COLOR PATHOLOGY
secs Mucoid Tracheobronchitis,
PATTERN PF RESPIRATION asthma, coryza
NORMAL: normal respirations are regular and even in Yellow or green Bacterial infection
rhythm Rust or blood-tinged Pneumonia, pulmonary
ABNORMAL infarction, TB, lung cancer
Cheyne- strokes - occur in crescendo and decresendo Black Black lung disease
patterns Pink Pulmonary edema
Biot respiration or ataxic respiration - irregularly PALPATION OF THE THORAX
irregular respiration patters A. GENERAL PALPATION
APNEUSTIC RESPIRATION B. PULSATIONS
- characterized by prolonged gasping during inspiration C. MASSES
followed by a very short, inefficient expiration. Thee D. THORACIC TENDERNESS
pauses can last 30 – 60 seconds. B. CREPITUS
AGONAL RESPIRATIONS GENERAL PALPATION
- irregularly irregular respirations. They are of varying A. ANTERIOR
depths and pattern. • Stand in front of the patient.
DEPTH OF RESPIRATION • Place the finger pads of the dominant hand on the
NORMAL: nonexaggerated and effortless apex of the right lung (above the clavicle)
Hyperpnea - the breath that is greater in volume • Using light palpation, assess the integument of the
Kussmaul’s respiration - characterized by extreme thorax in that area.
depth and rate of respiration • Move the finger pads down to the clavicle
SYMMETRY OF RESPIRATION  Proceed the palpation, moving down to each rib and
NORMAL: ICS
 The thorax rise and fall in union of the respiratory  Repeat the procedure on the left anterior thorax
cycle. B. POSTERIOR
 There's no paradoxical movement  Stand behind the patient
AUDIBLITY OF RESPIRATION  Place the finger pads of the dominant hand on the
NORMAL: apex of the right lung (approximately on the level of T1.
A patient’s respiration is normally heard by the unaided  Using light palpation, assess the integument of the
ear a few centimeters from the patient's nose and
thorax on that area.
mouth.
PATIENT POSTTION IN RESPIRATION  Move the finger pads down to the first thoracic
NORMAL: vertebra and palpate.
The healthy adult breathes comfortably in a supine,  Move down to each thoracic vertebra and ICS of the
prone or upright position. right posterior thorax
ORTHOPNEA - is a difficulty breathing in positions other  Repeat the procedure on the left posterior thorax.
than upright.
C. LATERAL
MODE OF BREATHING
 Stand on the patients right side
NORMAL: Normal findings vary among individuals but
generally, most patients inhale and exhale through the  Have the patient lift the arms overhead
nose.  Place the finger pads of the dominant hand beneath
I. SPUTUM the right axilliary fold.
 Ask the patient to expectorate a sputum sample.  Using light palpation, assess the integument of the
 Note the color, odor, amount, and consistency of the thorax in that area.
sputum  Move the finger pads down to the first rib beneath
NORMAL: the axilliary fold.
 Color is light yellow or clear  Proceed with the palpation, moving dorm to each rib
 Odorless and ICS of the right lateral thorax.
 Thick or thin depending on the hydration status of  Repeat for the left lateral thorax.
the patient. THORACIC EXPANSION

ENRIQUEZ | BSN 1G UNIVERSITY OF CEBU-BANILAD

 ASSESSMENT OF THE THORAX

Assess the extent of chest expansion and the symmetry

of chest wall expansion.
PROCEDURE:
• Stand directly in front of the patient, Place line
thumbs of both hands on the costal margin and
pointing towards the xiphoid process.
 Lay your outstretched palms on the anterolateral
thorax
 Instruct the patient to take a deep breath.
 Observe the movement of the thumbs, both in
direction and in distance.
• Ask the patient to exhale.
SEQUENCE FOR PALPATING POSTERIOR THORAX
 Observe the movement of the thumbs as they return
to the midline.
NORMAL: 3 - 5 CM.

GENERAL PERCUSSION
TACTILE OR VOCAL FREMITUS
A. ANTERIOR
 Is the palpable-vibration of the chest wall that is • Patient is in upright position
produced by the spoken word. • Percuss 2-3 strikes in the lung apex
 The technique is useful in assessing the underlying • Repeat in the left lung apex
lung tissue and pleura. • Note the percussion sound
PALMAR BASES OF THE FINGERS SEQUENCE FOR PERCUSSING THE ANTERIOR THORAX
ULNAR ASPECT OF THE HANDS
ULNAR ASPECT OF A CLOSED FIST
PROCEDURE
 Firmly place the ulnar aspect of an open hand or
palmar base of the fingers or ulnar aspect of a closed
fist) on the patient's right anterior apex.
 Instruct the patient to say the word “99” or “blue
balloons”
 Feel any vibration on the ulnar aspect of the hand as
the patient phonates.
 Move your hand to the same location on the left B. POSTERIOR
anterior thorax •Patient in upright sitting
 Repeat steps 2 and 3 •Have the patient bend down his head and fold the
SEQUENCE FOR PALPATING ANTERIOR THORAX arms around his waist
•Percuss the right lung apex located at the top of the
shoulder.
•Repeat on the left lung.
•Note the sound produces
SEQUENCE FOR PERCUSSING TE POSTERIOR THORAX

ENRIQUEZ | BSN 1G UNIVERSITY OF CEBU-BANILAD

 ASSESSMENT OF THE THORAX

 It is a "soft" sound that has been compared to the

sound of wind blowing through the leaves of a ties,
 This is the most common sound heard in the absence
of lung disease.
BRONCHOVESICULAR SOUNDS
 Location:
Over the major bronchi – posterior
Between the scapula
Around the upper sternum in the first and second
intercostal spaces - anterior
C. LATERAL ADVENTITIOUS/ AB LUNG SOUNDS
•Patient is in upright sitting position. FINE CRACKLES (RALES)
•Start to percuss the ICS directly below the axilla  These are "discontinuous" i.e., intermittent,
•Note the sound produced. "explosive sounds
AUSCULTATION
 Laennec described them as sounding like the
The aim is to identify the presence of normal breath
sounds, abnormal lung sounds, adventitious (added) crackling noise made when salt is heated on a frying
lung sound and adventitious pleural sound pan.
AUSCULTATION OF THE THORAX  They are caused by airway opening.
SEQUENCE FOR AUSCULTATING THE ANTERIOR & COARSE CRACKLES
POSTERIOR THORAX  These are intermittent "bubbling” sound.
 Laennec compared these sounds to the sound of
water being poured from a bottle.
 They are caused by airway opening and secretions in
airways
WHEEZES (RONCHI)
• These are high pitched, whistling or sibilant sounds
• Musical and continuous
• They are caused by airway narrowing secretions
EQUIPMENTS
3 DISTINCT TYPES OF NORMAL BREATH SOUNDS Examination gown and drape
• BRONCHIAL (TUBULAR) I < E Gloves
• BRONCHOVESICULAR I = E Stethoscope
• VESICULAR I > E Light source
BRONCHIAL LUNG SOUNDS Mask
 Bronchial or tracheal sounds are heard on the chest Skin Marker
at sites which are close to large airways. Metric ruler
 They are relatively louder in expiration than KEY POINTS
 Provide privacy for the client
inspiration
 Keep your hand warm to promote the client’s
 They have a tubular or blowing quality similar to air
comfort during the examination
being blown through a tube.
 Remain nonjudgmental regarding the client's habits
 Heard on the back between the scapulae and at the
and lifestyle and at the same time educate and inform
lung apices especially on the right
about risks such as lung cancer, COPD or related habits.
 They may also be heard in the axillae
 It has a "tubular" quality - it has been compared to
the sound of air blowing through a cardboard tube
VESICULAR LUNG SOUNDS
 This is the sound heard over the chest at a distance
from large airways.

ENRIQUEZ | BSN 1G UNIVERSITY OF CEBU-BANILAD