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Assessment of the

Chest and Lungs


Pat Jackson Allen
RN, MS, PNP, FAAN
Professor
Yale University, School of
Nursing
Anatomy of the Chest
Anatomy of the Chest
Anatomy of the Chest
Anatomy of the Chest
 Chest bones
 Sternum
 Manubrium
 Xiphoid process
 Clavicles
 12 Pairs of ribs
 12 Thoracic
vertebrae
 Scalpula
Anatomy of the Chest

 Anatomical
mapping
 Midsternal line
 Midclavicular line
 Anterior axillary
line
 Midaxillary line
 Posterior axillary
line
 Vertebral line
 Scapular line
Anatomy of the Lungs
 Lungs
 Right has 3 lobes
 Left has 2 lobes
 Oblique fissure divides
upper & lower lobes
 Trachea
 Anterior to esophagus
 Branches into right & left
bronchi
 Right wider, shorter,
more vertical (
aspiration)
 Bronchioles
 Alveoli
Anatomy of the Lungs
 Mapping of the lungs
 Anterior chest
primarily upper lobes
 Posterior chest
primarily lower lobes
 RML best heard right
anterior axillary line
History
 Chief complaint / present illness
 Cough
 Shortness of breath / difficulty breathing
 Chest pain
 Congestion
 Sudden onset breathing problem (aspiration)
 Apnea
 Snoring
History
 Past medical history
 Hospitalizations for respiratory
condition
 Chronic pulmonary conditions, i.e.,
asthma, TB, emphysema, cystic fibrosis
 Other chronic conditions, i.e., heart
disease
 Allergies
 Trauma or surgery to thoracic, nose,
mouth
 Medications used
History
 Family history
 TB
 Cystic fibrosis
 Emphysema
 Allergies, asthma, atopic dermatitis
 Bronchitis
 Clotting disorders (risk of pulmonary
emboli)
 Smoking
History
 Personal and social
 Tobacco use / exposure
 Environmental toxin exposure, i.e., air
pollution, pesticides, smoke, mold,
animals
 Exposure to respiratory infections
 Occupation
 Travel
 Exercise tolerance
Assessment of the Chest and
Lungs
 Inspection
 Palpation
 Percussion
 Auscultation
Assessment of the Chest and Lungs

 Inspection
 Sitting or lying with chest fully exposed
 Note shape and symmetry of chest
 Lateral chest > anterior/posterior diameter
 Barrel chest indicates chronic breathing problem
 Kyphosis and scoliosis abnormalities of spine
 Shape and position of sterum
Assessment of the Chest and
Lungs
 Inspection
 Respirations
 Rate
 Per minute
 Rhythm
 Regular
 Irregular
 Regularly irregular
 Effort
Assessment of the Chest and
Lungs
 Inspection
 Respirations
 Effort
 Abdominal breathing normal in children
 Nasal flaring
 Substernal or intercostal retractions
 Ratio of inspiration to expiration
 Normal 2:1
 Expiration prolonged with air trapping i.e.,
asthma, emphysema
 Grunting is attempt to increase thoracic
pressure
 Never normal
Assessment of the Chest and
Lungs
 Inspection
 Color
 Cyanosis is a late sign of respiratory
distress
 Clubbing of fingers is a sign of prolonged
oxygen deficit
Assessment of the Chest and
Lungs
 Palpation
 Areas of tenderness, bulges, masses,
crepitus
 Fremitus (increased airflow turbulence due to
blockage or fluid)
 Compare lung fields for fremitus at rest and while
person speaks
 Thoracic expansion
 Compare symmetry of lung expansion
Palpating for Fremitus Comparing Lung Fields
Palpating for Thoracic Expansion
Assessment of the Chest and
Lungs
 Percussion
 Tap sharply and consistently with wrist
 Compare side to side
 Percuss between ribs
 Resonant tone over unobstructed lung
fields
 Hyperresonance found with hyperinflation
 Dullness with atelectasis, pneumothorax,
effusion
 Flat tone over scapula and spine
 Dull tone over heart, liver, diaphragm
Percussion Technique
Percussion Areas for Chest and Lungs
Assessment of the Chest and
Lungs
 Auscultation
 Place diaphragm of stethoscope firmly on
skin
 Listen to all lung fields, front, back, right
axillary
 Listen for sounds of inspiration &
expiration
 Clarity
 Duration of sound, ratio of inspiration to
expiration
Auscultation

Diaphragm Bell
Auscultation
Auscultation

Anterior Chest Upper Lobes


Auscultation

Right Middle Lobe


Auscultation

Posterior Chest Lower Lobes


Assessment of the Chest and
Lungs
Assessment of the Chest and
Lungs
 Types of breath sounds
 Vesicular
 Low pitch
 Heard over lung fields
 2:1 ratio inspiration:expiration
 Bronchovesicular
 Medium pitch
 Heard over main bronchus
 1:1 ratio inspiration:expiration
 Bronchial (tracheal)
 High pitch, loud
 Heard over trachea
 1:1 ratio, maybe 1:1.25
Anatomy of the Breast
 Mammary glands
 Glandular tisssue
 Milk ducts
 Nipple end of ducts
 Fibrous tissue
 Supports breast
 Muscles
 Pectoralis major,
minor
 Fat
 Amount varies with
age and body type
 Lymphatic system for
drainage
Anatomy of the Breast
 Mapping of the
breast
 4 quadrants
 Position of clock
 Tail of Spence
 High incidence of
malignancy
 Axillary lymph
nodes
 Supraclavicular
lymph nodes
History
 Chief complaint / present illness
 Breast discomfort, pain, relation to
menses
 Breast mass or lump
 Nipple discharge
 Breast size or asymmetry
History
 Past medical history
 Breast disease
 Cancer…breast, ovarian, colorectal
 Mammography history
 Pregnancy
 Hormone therapy, other medications
History
 Family history
 Breast cancer
 Genetic markers for breast cancer
 Personal and Social
 Menses
 Caffeine intake
 Breast self examination
Assessment of the Breast
 Inspection
 Palpation
Assessment of Breast
 Inspection breast and nipple
 Symmetry
 Maybe slightly different in size
 Contour
 At rest and with arms elevated, extended
 Note dimpling of tissue
 Color
 Lesions
Assessment of Breast
 Palpation
 Breast tissue
 Nipple
 Lymph nodes
Abnormalities of Chest and
Lungs

Pectus Carinatum
(pigeon chest)

Pectus Excavatum
(funnel chest)
Abnormalities of Chest and
Lungs

Kyphosis
Abnormalities of Chest and
Lungs
Abnormalities of Chest and
Lungs
 Abnormal lung sounds
 Fine crackles (rales)
 End inspiration, high-pitched, not cleared by cough
 Pneumonia
 Medium crackles (rales)
 Midstage inspiration, lower pitch, moist, not cleared
by cough
 Bronchiolitis (can also have wheeze)
 Coarse crackles (rales)
 Loud bubbly noise during inspiration
 Bronchitis
Abnormalities of Chest and
Lungs
 Abnormal lung sounds
 Rhonchi (bronchial)
 Loud, coarse, heard during inspiration & expiration
 May clear with cough
 URI, bronchitis
 Wheeze
 Musical noise or squeak
 Heard both on inspiration & expiration, louder
expiration
 Asthma
 Pleural friction rub
 Dry, rubbing, grating sound
 Heard both on inspiration & expiration lower lateral
chest
Abnormalities of Chest and
Lungs
Abnormalities of Chest and
Lungs
Abnormalities of Chest and
Lungs

Gynocomastia, male breast


Abnormalities of Chest and
Lungs

Breast Cancer