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

 Abnormal lung sounds
 Rhonchi (bronchial)

Abnormalities of Chest and Lungs
 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

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