THORAX AND LUNGS

Alawi I Capuy I Enriquez I Hanginan I Lacastesantos I Lomboy I Rojas I Teo

 HISTORY OF PRESENT HEALTH
CONCERN

QUESTION RATIONALE/QUESTIONS

Difficulty of Breathing
1.Did you have frequent respiratory infections, 1. May indicate underlying chronic disease
asthma, TB, or pneumonia?
2. Can cause chronic sinus or nasal congestion,
trigger an asthma attack, or progress to COPD.
2.Do you have any allergies (e.g., to pollens, food,
drugs, environmental factors)? What type of reaction
do you have?
 HISTORY OF PRESENT HEALTH
CONCERN

QUESTION RATIONALE/QUESTIONS

Chest Pain
1.Have you had fractured ribs, steering wheel injuries, or 1. May explain physical findings
knife wounds to the chest?
2. May have respiratory manifestations
2.Have you ever had previous respiratory illness?
 HISTORY OF PRESENT HEALTH
CONCERN

QUESTION RATIONALE/QUESTIONS

Cough
1. Do you have postnasal drip, sinus pain, or sore 1. May indicate allergies or acute/chronic URI
throat?
2. May indicate the origin of the symptom.
2. Have you been exposed to people with colds,
flu, or cough?
 PERSONAL HEALTH HISTORY

QUESTION RATIONALE/QUESTIONS

Do you have fatigue or activity intolerance? Chronic lung diseases often cause fatigue and activity
intolerance because so much energy is expended on
breathing.

Have you ever had TB test, chest x-ray, or other respiratory Can be used as baseline data. Also indicates disease
diagnostic testing? when? prevention activities

Did you receive adult boosters against respiratory diseases BCG explains a positive TB test (PPD).
(e.g., pneumovax for pneumonia and bacille Calmette-
Guerin [BCG] for TB)?
 FAMILY HISTORY

QUESTION RATIONALE/QUESTIONS
Does anyone in your family have allergies or Avoid allergens, smoking
asthma?

Does anyone in your family have TB? If so, what Will need follow up PPD (purified protein derivative)
type and how long were you exposed? or chest X-ray

PPD - determines if you have tuberculosis (TB)

 LIFESTYLE AND HEALTH PRACTICES

QUESTION RATIONALE/QUESTIONS
What activities do you usually do in a day? Does it Identifies client activities affecting health. Detects possible
include exercise or taking care of pets? Did these change allergies and progression of diseases.
over the past year?

Have you lost or gained weight? Detects possible catabolic infections, metastasis of lung cancer,
and cardiac failure.

How much uninterrupted sleep do you get per night? Is it Dyspnea, cough, and pain disturbs sleep, causing morning
difficult for you to sleep at night? fatigue
Where do you live? Is it possible to have post hospital Respiratory diseases are more prevalent in some areas.
care in your home? How many people live with you? Identifies home care needs and risk of infectious transmission.
TOOLS NEEDED FOR PHYSICAL
ASSESSMENT

Stethoscope Marking pen Metric tape measure

INSPECTION I
ASSESSMENT
Anterior Chest
● Inspect respiratory rate,
rhythm, depth, and
symmetry of chest
movements.
● Inspect anteroposterior
(AP) to lateral ratio, costal
angle, spinal deformities,
and condition of skin.
NORMAL
Shape and symmetry:
● (For normal adult) AP-to-
lateral ratio is approximately
1:2
● Costal angle less than 90
degrees
● Ribs slope obliquely
● Symmetrical chest (in
appearance)
● Symmetrical rise and fall
when breathing
● Skin intact
ABNORMAL
● Altered chest shape
● AP diameter increased
(results in “barrel chest”)
● Costal angle greater than
90 degrees
● Rib slope is nearly parallel
● Altered chest symmetry
INSPECTION II

ASSESSMENT NORMAL ABNORMAL

Movement with breathing: ● Altered breathing symmetry
● Women
➔ Have more thoracic
respiratory movements
● Men and infants
➔ Have more abdominal
respiratory movements

● No sternal or intercostal ● Sternal and intercostal

retraction or bulging (unless retractions
associated with strenuous ● Intercostal bulging
activity)
INSPECTION III

ASSESSMENT NORMAL ABNORMAL

Condition of chest skin: ● Altered skin color/condition

● Skin color and hair ● Steroids may produce
distribution should be excessive hair in women
consistent with patient’s ● Scars may indicate trauma
gender, ethnicity, and or surgery
exposure to sun ➔ Look for signs of lung
surgery (often on lateral
● Skin intact, no scars thorax) or 1-cm stab wounds
from chest tubes
INSPECTION V

ASSESSMENT NORMAL ABNORMAL

Lateral Chest ● Skin is intact ● Same with anterior and

● Chest expansion is equal posterior chest.
● Inspect respiratory rate, ● Look for scars from
rhythm, depth, and pneumonectomy or
symmetry of chest lobectomy, located laterally
movements. and curving under scapula
● Inspect anteroposterior
(AP) and condition of skin.
INSPECTION VI
ASSESSMENT
Posterior Chest
● Inspect respiratory rate,
rhythm, depth, and
symmetry of chest
movements.
● Inspect anteroposterior
(AP) and condition of skin.
NORMAL ABNORMAL
● Skin should be intact ● Same with anterior and
● Chest expansion equal posterior chest, although
● Spine straight (without spinal curves are more
lateral curves or obvious.
deformities) ● Look for scars from
pneumonectomy or
lobectomy, located laterally
and curving under scapula
PERCUSSION I

ASSESSMENT NORMAL ABNORMAL

Anterior Thorax Resonance to 2nd intercostal Dullness: Seen with exudate,

space on left; slight dullness fluid, tumors, pneumonia,
over 3rd-5th intercostal space pulmonary edema, pleural
over heart. effusion.

Resonance to 4th intercostal Hyperresonance: Noted with air

space on right with dullness trapping of emphysema.
approx. 5th to just above costal
margin over liver.
Lateral Thorax Resonance to eight intercostal “
space.
PERCUSSION II

ASSESSMENT NORMAL ABNORMAL

Posterior Thorax Resonance to T10-T12 with Hyperresonance to T12 level:

deep inspiration. Overinflated lungs.

Diaphragmatic Excursion 3-6 cm diaphragmatic excursion. Decreased diaphragmatic

excursion unilaterally or
bilaterally: Paralyzed
diaphragm, atelectasis, COPD
with overinflated lungs.
 AUSCULTATION I

NORMAL BREATH QUALITY DURATION LOCATION

SOUNDS

Tracheal Harsh, high-pitched I=E Above the supraclavicular

notch, over the trachea

Bronchial Loud, high-pitched I<E Above clavicles on each

side of the sternum, over
the manubrium

Bronchovesicular Medium in loudness and I=E Next to sternum, between

pitch scapulae

Vesicular Soft, low-pitched I>E Remainder of lungs

AUSCULTATION II

ABNORMAL BREATH SOUNDS CHARACTERISTICS

Fine crackles - nonmusical

- soft, high-pitched
- short cracking popping sounds

Coarse crackles - nonmusical

- loud, low-pitched
- bubbling, gurgling sounds

Wheezes - musical
- high-pitched
- squeaky, whistling sounds

Rhonchi - musical
- low-pitched
- snoring, moaning sounds
AUSCULTATION III

ASSESSMENT NORMAL ABNORMAL

Assessing voice sounds or vocal Muffled sounds, almost Bronchophony - unusually loud
fremitus indistinguishable Egophony - sound like letter a
Whispered pectoriloquy - loud
and clear
AUSCULTATION IV

RESPIRATION PATTERN DESCRIPTION CLINICAL INDICATION

Normal 12-20 breaths per minute

Tachypnea Shallow breathing with increased Oxygen shortage

respiratory rate

Bradypnea Decreased rate but regular Respiratory failure

breathing

Hyperventilation Increased depth and rate of Driven by chemoreceptor

breathing stimulation due to metabolic
acidosis

Hypoventilation Decreased depth and rate of Inadequate to maintain a normal

breathing partial pressure of carbon dioxide
 AUSCULTATION V

Kussmaul’s respirations Rapid, deep breathing without pauses; An indication that the body and organs
in adults, more than 20 breaths/minute; have become too acidic
breathing usually sounds labored with
deep breaths that resemble sighs

Cheyne-Stokes respiration Breaths that gradually become faster Usually observed while asleep and is
and deeper than normal, then slower, the result of disordered central control
and alternate with periods of apnea of breathing

Biot’s respiration Rapid, deep breathing with abrupt Damage to the pons due to stroke,
pauses between each breath; equal trauma, or uncal herniation
depth to each breath
PALPATION
ASSESSMENT
Palpating the thorax
Checking for tactile fremitus
Evaluating chest-wall symmetry
and expansion
NORMAL
Smooth, warm, and dry chest
wall
Normal chest vibrations
Symmetrical expansion
ABNORMAL
Pain, crepitus
More than other side, less
intense vibrations, faint, or no
vibrations
Asymmetrical expansion
ABNORMALITIES

NORMAL CHEST
- Symmetrical in shape.
- Distance from the front to the back of the chest is less
than the size of the chest from side to side.
(Anterior-posterior diameter < Transverse diameter)
ABNORMALITIES

BARREL CHEST
- Chest is persistently round, or puffed up
like a barrel.
- Anterior-posterior diameter > Transverse
diameter.
- Caused by chronic hyperinflation.
- A visible symptom of COPD,
emphysema, osteoarthritis, and CF.
ABNORMALITIES

PECTUS EXCAVATUM (FUNNEL CHEST)

- Chest wall with sternum depression at lower end.
- May be symmetrical or may be more prominent on
one side of the chest.
- Speculations of the cause include, post-open heart
surgery effect, genetics, scoliosis.
ABNORMALITIES

PECTUS CARINATUM (PIGEON

CHEST)
- Protrusion abnormality of the anterior
chest wall. (Prominent sternum and flat
chest.)
- Sequel of chronic respiratory disease in
childhood.
ABNORMALITIES

THORACIC SCOLIOSIS
- Scoliosis is the lateral curvature of the spine.
- Thoracic scoliosis affects the region of the spine that
connects to the rib cage.
- Occurs with a ‘C’ shaped curve in the thoracic
vertebrae. May occur in an ‘S’ shape, a product of
development with other types of scoliosis.
- A difference in the rib cage, uneven shoulder blades,
and uneven shoulder height are noticeable.
ABNORMALITIES

KYPHOSIS
- Exaggerated, rounded spine, leading to
forward bending or a hunched back.
- Reduces the amount of space in the chest,
mobility of the rib cage, and expansion of
the lungs.
 REFERENCES

- Dillon, P. (2007). Nursing Health Assessment: A Critical Thinking, Case Studies Approach (2nd ed.) [E-book]. F.A. Davis Company.
- Dresden, D. (2018, October 10). What’s to know about barrel chest? Medical News Today. Retrieved February 6, 2022, from
https://www.medicalnewstoday.com/articles/314967#:%7E:text=Barrel%20chest%20is%20a%20visible,the%20extent%20of%20lung%20damage.
- Kyphosis - Symptoms and causes. (2020, June 12). Mayo Clinic. Retrieved February 6, 2022, from
https://www.mayoclinic.org/diseases-conditions/kyphosis/symptoms-causes/syc-20374205
- Pectus excavatum (funnel chest). (2019, November 20). British Lung Foundation. Retrieved February 7, 2022, from
https://www.blf.org.uk/support-for-you/funnel-chest#:%7E:text=Pectus%20excavatum%20(funnel%20chest)%20is,will%20live%20a%20normal%20life.
- Smith, L. M. (2018, February 6). What is pectus carinatum and can it be treated? Medical News Today. Retrieved February 7, 2022, from
https://www.medicalnewstoday.com/articles/320836#types
- Southwest Scoliosis Institute. (2021, January 15). THE TETHER VERTEBRAL BODY TETHERING SYSTEM. Scoliosis Institute. Retrieved February 7, 2022,
from https://scoliosisinstitute.com/thoracic-scoliosis/
- Whited, L. & Graham, D. (n. d.). Abnormal Respirations. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470309/