1. INSPECT THE SHAPE AND SYMMETRY OF 7.

PALPATE THE ANTERIOR AND POSTERIOR

THE THORAX FROM ANTERIOR, POSTERIOR THORAX FREMITUS.
AND LATERAL VIEWS.
Anterior:
Compare the left side of the thorax to the right side
of the thorax.

 Clavicles and ribs on each side is symmetrical

 Trachea is in the midline (there is no deviation)
 Scapulae are symmetric and no protruding.
Shoulders and scapulae are at equal horizontal
positions.
 The ratio of antero-posterior to transverse
diameter is 1:2.

2. INSPECT THE CLIENT’S POSITIONING AND

ESTIMATE THE COSTAL ANGLE.
Positioning: Client is sitting up and relaxed, Posterior:
breathing easily with arms at sides or in lap. Client
is not in a tripod position.
Costal angle: 90 degrees.

3. INSPECT THE POSITION OF THE STERNUM

AND THE SLOPE OF THE RIB.

 Thorax appears symmetrical with ribs sloping

downward at approximately 45-degree angle in
relation to the spine.
 Sternum is in the midline (there is no deviation)

4. OBSERVE THE ANTERIOR AND POSTERIOR

THORAX FOR USE OF ACCESSORY MUSCLES.
Watch as the client breathes
 The client does not use accessory
(trapezius/shoulder) muscles to assist breathing.
 The diaphragm is the major muscle at work.
 This is evidenced by the expansion of the lower
chest during inspiration.
5. OBSERVE THE QUALITY AND PATTERN OF
RESPIRATIONS.
 Count the number of breaths for a full minute.
Adults normally breathe at a rate of 12 to 20
breaths/minute (Eupnea)
 Respiratory pattern is even, coordinated, and
regular, with occasional sighs (long, deep
breaths).
6. PALPATE THE ANTERIOR AND POSTERIOR
THORAX FOR TENDERNESS, SENSATION, AND
CREPITUS
a. Warming hands by rubbing
Ask patient to fold arms across chest
b. “ninety nine” -with the balls or ulnar edge
of one hand directly over the posterior
thorax
c. Assess for symmetry and intensity of
vibration
NORMAL:
 Fremitus is symmetric and easily identified
in the upper region the of lungs.
8. PALPATE THE POSTERIOR CHEST FOR
CHEST EXPANSION:
a. Place hands on the posterior chest wall with
thumbs at the level of T9 or T10 and press together
a small skin fold.
b. Ask the client to take a deep breath, and
observe the movement of your thumbs.
Normal:

 chest wall should feel smooth, warm, and dry. When taking deep breath, my thumb should move
5-10cm apart symmetrically.
 Gentle palpation shouldn’t cause pain.
No sign of atelectasis (incomplete expansion)
 Normal:

 Resonance tone is elicited over lung tissues

 Flat over scapula
 Hyperresonance –emphysema or
pneumothorax
 Dullness – fluid or tissue

10. PERCUSS THE POSTERIOR THORAX FOR

DIAPHRAGMATIC EXCURSIONS

 Ask the client to exhale forcefully and hold the

breathe.
 Beginning at the scapular line (T7), percuss the
intercostal spaces of the right posterior chest
wall.
 Percuss downward until the tone changes from
resonance to dullness, mark this level and allow
the client to breathe.
 Ask the client to inhale deeply and hold it.
 Percuss the intercostal spaces from the mark
downward until resonance changes to dullness,
mark the level and allow the client to breathe.
 Measure the distance between the two marks.
 Repeat the procedure with the left posterior
9. PERCUSS THE POSTERIOR THORAX FOR chest wall.
THE TONE
a. Start at the apices of the scapulae and percuss
across the tops of both shoulders.
b. Percuss the intercostal spaces across and
down, comparing sides.
c. Percuss the lateral aspects at the bases of the
lungs, comparing sides




Normal:
 Is 4-6 centimeters between full inspiration
and full expiration.
 No hyperinflation or atelectasis
11. AUSCULTATE ANTERIOR AND POSTERIOR
BREATH SOUNDS, TAKE NOTE OF
ADVENTITIOUS BREATH SOUNDS AND ITS
LOCATION ON THE CHEST WALL.
Place diaphragm of stet firmly and directly on the
posterior chest wall at the apex of the lung at C7 to
the bases of the lungs at T10 and laterally from the
axilla down to the seventh or eighth rib.
Ask client to breathe deeply for each area of
auscultation sequence.
Normal
 Vesicular= Peripheral lung fields
 Bronchovesicular= B/w scapulae and lateral
to the sternum at the 1st and 2nd intercostal
spaces
 Bronchial=Trachea and thorax
-No adventitious sounds, such as crackles or
wheezes
12. ASK THE CLIENT TO LIE SUPINE IN BED.
PLACE A SMALL PILLOW UNDERNEATH THE
CLIENT’S HEAD; MAKE SURE THAT THE HEAD
IS ELEVATED TO 30-45 DEGREES.
13. INSPECT FOR JUGULAR VEIN DISTENTION\
 Stand on the right side of the bed and ask the
client to gently turn their head to the left.
 It is assessed from the right side because the
right jugular vein is more directly attached to
the superior vena cava leading to the right
atrium.
 It is visualized around the sternal notch or
the supraclavicular area
 Use tangential lighting to highlight pulsations.
 Begin by inspecting the right external
jugular pulsation, as it is most visible.
Normal
 Right external jugular vein is flat with no
distension and no bulging
14. SUPRASTERNAL NOTCH (area around the
clavicles for pulsations)
abnormal pulsations or thrills
15. PALPATE CAROTID ARTERIES. NOTE THE
AMPLITUDE AND CONTOUR OF THE PULSE,
ELASTICITY OF THE ARTERY AND THRILLS.
Palpate each carotid artery alternately by placing
the pads of the index and middle fingers medial to
the sternocleidomastoid muscle on the neck
Normal:
 No bounding, firm pulse. Pulses are equally
strong; a 2+ or normal with no variation in
strength from beat to beat.
 Contour is normally smooth and rapid on the
upstroke and slower and less abrupt on the
downstroke
 Arteries are elastic and no thrills are noted.
16. ASK CLIENT TO HOLD THE BREATH FOR A
MOMENT AND AUSCULTATE CAROTID
ARTERY
Place the bell of the stethoscope over the carotid
artery and ask the client to hold his or her breath for
a moment so breath sounds do not conceal any
vascular sounds
Normal:
 No blowing or swishing or other sounds are
heard.
17. AUSCULTATE THE APICAL PULSE AND
NOTE ITS LOCATION RATE AND RYTHM
Remain on the client’s right side and ask the client
to remain supine. Use the palmar surfaces of your
hand to palpate the apical impulse in the mitral area
(fourth or fifth intercostal space at the midclavicular
line) (Fig. 18-9A). After locating the pulse, use one
finger pad for more accurate palpation

Normal:

 The apical impulse is palpated in the mitral area

and may be the size of a nickel (1 to 2 cm).
 Amplitude is usually small—like a gentle tap.
 The duration is brief, lasting through the first
two-thirds of systole and often less

18. Document findings in client’s chart