Assessment of the

THORAX and LUNGS

Respiratory Assessment

1. Identify pertinent subjective data related to the

respiratory system.
2. Describe the basic structure and function of the
respiratory system.
3. Follow general guidelines while assessing the respiratory
system.
4. Describe findings to be detected by inspection.
5 .Demonstrate examination technique for the thorax.
6. Demonstrate and document correct assessment of the
respiratory system.
7. Identify nursing diagnoses common to this system
 Overview
• Brief anatomy & physiology
review
– Landmarks
– Thoracic cavity
– Mechanics of respiration
• Respiratory assessment
– History
– Physical examination
– Documentation
Thorax, posterior view of underlying structures
Chest cavity and related anatomic structures
Lobes of the Lung
Pulmonary circulation
Lungs, anterior visualization of from surface
Lungs, posterior visualization of from surface
Lungs, right lateral visualization of from surface
Lungs, left lateral visualization of from surface
Topographic landmarks of the chest
Thoracic landmarks, anterior thorax
Thoracic landmarks, right lateral thorax
Thoracic landmarks, posterior thorax
Reference Lines
• Anterior chest wall
• Midsternal line
• Midclavicular line

• Posterior chest wall

• Vertebral (mid-spinal) line
• Scapular line

• Lateral chest wall

• Anterior Axillary line
• Mid Axillary line
• Posterior Axillary line
 Lung Borders

• The apex of the lung is 3-4 cm above the

inner third of the clavicles

• Base rest on the diaphragm at the 6th rib

• Posteriorly, lungs rest at T9

• During inspiration, the lungs extend to T12

Anterior Location of Lungs

Figure 16-6. p. 451.

 Lobes
• Posteriorly- Primarily lower lobes.
– Upper lobes extend from T1 to T3.
– Lower lobes extend from T3-T10.
• Laterally Right extends from the peak of
the axilla to 7th or 8th rib.
– Upper lobe extends to 4th-5th rib.
– Middle lobe extends forward to 6th rib.
– Lower lobe extend from 3rd rib to 8th rib.
• Laterally Left
– LUL extends from peak axilla to 5th rib.
– LLL extends to 8th rib
Posterior Location of Lungs

Figure 16-7. p. 451.

Right Lateral Location of Lung

Figure 16-8. p. 452.

Left Lateral Location of Lung

Figure 16-9. p. 452.

Mechanics of Respiration

Figure 16-10. p. 454.

 Respiratory muscles
• Inspiration—ACTIVE
– Diaphragm is primary muscle
– Accessory muscles
• Sternocleidomastoid, scalene, external intercostals
• Expiration—PASSIVE
– NO muscles with “normal” expiration
– Accessory muscles
• Abdominal and internal intercostals
• Which accessory muscles are in use when
patient is short of breath??
– “Well, it depends…”
 Lung Volumes

• Measures of ventilation- air in and out

• Tidal Volume (TV)- amount of air during a
normal breath-approx. -Based on client’s
weight
• Inspiratory reserve volume (IRV)-amount of
air in after a normal breath
• Expiratory reserve volume (ERV)-amount of
air out beyond tidal volume
• Residual volume- amount of air left in lungs
after maximum expiration
Developmental Consideration

• Newborn
– Lungs begin to emerge at 4th-5th week of gestation
– Fetal gas exchange occurs at the placenta.
– Chest of the newborn is usually round with
Anterioposterior to transverse diameter being 1:1
• Pregnancy
– Enlarged uterus causes elevation of diaphragm
limiting lung expansion
– Tidal volume increases due to increase oxygen
demands
 Developmental Consideration
• Aging Adult
– Elastic property of thoracic muscles
decreases leading to increased A-P
diameter
– Decrease functioning of alveoli and lung
expansion, increased effort of breathing
– Changes in spinal curvature limiting lung
expansion
 Subjective Data
• Environmental
• Cough exposures
• SOB • Social history
• Orthopnea • Health promotion
• Chest Pain activity
• Past history of • Allergies
respiratory
infection • Exercise tolerance
• Trauma • Assistive devices
• Surgery
• PMH
 Developmental Consideration
• Low birth weight • Family allergies
• Pregnancy history • Home environment
• Difficulty feeding • Activity tolerance
• Apneic episodes • Medication history
• SOB
• Growth and
developmental
changes
• Cyanosis
Equipment

• Stethoscope
• Ruler
• Marking pen
• Warm environment
 Inspection
• Shape and symmetry of chest
• Posture and position of breathing
• Effort of breathing
• Anterio-posterior (AP) to transverse
diameter- A-P less than transverse usually
1:2 ratio
– Documented as A-P: transverse 1:2
• Barrel chest: A-P=transverse
( hyperinflation of lungs)
 Inspection
• Determine respiratory rate
• Note rhythm-page 471-472
• Skin color and condition- lips, nails,
and mucous membranes
• Note lung expansion
• Use of accessory muscles
• Clubbing
Patterns of respiration
 Palpation
• Palpate all areas of anterior and posterior
chest- note tenderness or crepitus
• Note symmetry of lung expansion
• Assess tactile fremitus- palpable
vibrations. Ask client to speak while
palpating lung areas
– Increase vibration occurs with consolidation
– Decreased vibration with air trapping in lungs
pleural effusion or pleural thickening
Thoracic expansion, palpating technique
Evaluation of TACTILE FREMITUS with palmar surface of
both hands
Evaluation of TACTILE FREMITUS with ulnar aspect of
Trachea, palpating to evaluate mid-line position
 Percussion
• Indirect percussion is used to assess for
tones throughout lobes
• Diaphragmatic excursion
– Have client exhale then percuss down on
posterior surface until you hear dullness
(diaphragm): mark
– Have client completely inhale and hold breath:
Percuss down to dullness: mark
– Measure distance between the marks.
– Compare sides: Higher on right than left
because of liver.
– Usually 3-5 cm.
– Used to assess functioning of diaphragm.
Percussion tones throughout chest, anterior view
Percussion tones throughout chest, posterior view
Thorax, direct percussion of using ulnar aspect of fist
Thorax, indirect percussion
Anterior/Posterior Percussion
Sounds
 Auscultation
• Use diaphragm of stethoscope to
assess air movement

• Auscultation should be done over ALL

lobes

• ANTERIORLY & POSTERIORLY

 Breath Sounds
• Bronchial (tracheal)
– Hollow, tubular, high pitched
– Inspiratory sound < Expiratory sound
• Bronchiovesicular
– Heard over main bronchus (between scapulae and
upper sternum
– moderate pitch
– I=E
• Vesicular
– Heard over healthy lung tissue where air flows
through small air passages
– Low-pitched
– Inspiratory sound > expiratory sound
Auscultation Sounds
Anterior/Posterior
 Adventitious Breath Sounds
(Added sounds- considered abnormal)
Discontinuous
– Crackles (rales)- formed by fluid in airway-
heard during inspiration; usually not cleared
by coughing. May be coarse or fine: Sounds
like a velcro fastener (coarse) or like hair rolled
between fingers (fine)

– Friction Rub- Dry, crackly, grating, low-pitched

sound heard during inspiration and expiration
 Adventitious Sounds
Continuous
( heard on inspiration and expiration)
– Sonorous Rhonchi- coarse sounds. May be
cleared with coughing
– Wheezing- musical noise

– Stridor
• high pitched, piercing sound heard during
inspiration
• indicative of upper airway obstruction-
EMERGENCY
http://www.med.ucla.edu/wilkes/lungintro.htm
Systematic percussion and auscultation of the thorax,
suggested sequence for posterior thorax
Systematic percussion and auscultation of the thorax,
suggested sequence for right lateral thorax
Systematic percussion and auscultation of the thorax,
suggested sequence for left lateral thorax
Systematic percussion and auscultation of the thorax,
suggested sequence for anterior thorax
Expected auscultatory sounds, anterior view
Expected auscultatory sounds, posterior view
Schema of breath sounds in the well and ill patient—
on s drive
Adventitious breath sounds, fine, medium, and coarse
crackles
Adventitious breath sounds, rhonchi, wheeze, pleural friction
rub
 Voice Sounds
(Vocal Resonance)
• Auscultation of sound transmission through
lung fields.
– Ask client to recite numbers or sounds while you
are listening to the lungs with your stethoscope
– The transmitted sound should be muffled or
indistinct (air transmission)

• Sound transmits best through solid areas

and less through air.
 Bronchophony
• Ask client to say “ninety-nine” while
listening to all lobes of lungs. Normal
sound is soft, muffled, and
indistinguishable

• Clear sound indicates increased lung

density
 Egophony

• Ask client to say “ee-ee-ee-ee”

• Normally hear eeeeee

• If it sounds like aaaaaa, then you

report
“E A changes” ( indicates
consolidation)
Whispered pectoriloquy

• Ask client to whisper 1, 2, 3

• Normal response faint, muffled,

and almost inaudible

• Clear and distinct sound

indicates consolidation
Respiratory Rate Limits
• Newborn 30-40
• 1 year 20-40
• 3 years 20-30
• 6 years 16-22
• 10 years 16-20
• 17 years 12-20
 Newborn Infant Assessment
Apgar Scoring System

• Begins at birth, uses a scale to look at:

– Heart rate: “absent” to “over 100
beats/min”
– Respiratory effort: “no response” to “Good cry”
– Muscle tone: “limp” to “active motion”
– Color: “blue” or “pale” to “completely
pink”
– Reflex irritability: “no response” to “sneeze,
cough, cry”
• With respiratory inadequacy other systems
will be affected. (heart rate, respiratory
effort, muscle tone, and color)
 Newborns
• Obligate nose breathers-monitor for
grunting and nasal flaring

• Cough is rare in newborn and

considered a problem
• DOCUMENTATION
• S- HPI with ROS, PMH, Allergies & Meds
• O- Inspection: RR=16/min, relaxed and even;
A-P:transverse 1:2; No use of
accessory muscles
Palpation: Chest expansion symmetric;
Tactile fremitus equal bilat;
No tenderness, lumps, or crepitus
Percussion: Lung fields resonant;
Diaphragmatic excursion 5cm
bilat;
Auscultation: Vesicular breath sounds clear
over peripheral lung fields bilat;
No adventitious breath sounds
No E to A changes
 Nursing Diagnosis
• Restlessness R/T____ AEB _____

• Altered gas exchange R/T___ AEB ___

• Ineffective breathing pattern R/T ____ AEB___

• Ineffective airway clearance R/T _____

AEB ____

• Impaired gas exchange R/T _____ AEB _____

• Activity intolerance R/T _____ AEB ____

 Websites to Explore

• Auscultation Assistant - http://

www.med.ucla.edu/wilkes/intro.html 

• Loyola University Chicago Stritch

School of Medicine -
http://www.meddean.luc.edu/lumen/Med
Ed/medicine/pulmonar/pd/b-sounds.htm