Thoracic Assessment
Unit 6

Thoracic Assessment Overview

• Anatomy & Physiology
• History
• IPPA
• Developmental Considerations
• Nursing Diagnoses
• Teaching Opportunities

Oro/naso pharynx and respiratory tree 
respiratory system extends from nares to diaphragm

Anatomy & Physiology

• two distinct pleural cavities
• separated by mediastinum
• Pleural cavities lined by serous membranes
• parietal pleura
• visceral pleura

• parietal pleura lines chest wall and diaphragm
• visceral pleura lines the lungs
• potential space between, small amount of lubricating fluid

Lungs

• R has 3 lobes
• L has 2 lobes

Topography

• 2nd rib articulates with sternum at the Angle of Louis
• Suprasternal notch
• Costal Angle
• Midsternal line
• Midclavicular line
• Anterior Axillary line

Note:
Intercostal space - named for rib above

Lung Borders

• anterior thorax
• apices extend 2-4 cm ABOVE clavicle
• posterior thorax
• apices extend to T1
• lower borders
• T 10 on exhalation
• T12 on deep inspiration

Physiology of respiration

• Specifically ventilation ("breathing")
• inspiration/expiration
  • inspiration- air from atmosphere ® lungs
  • expiration - outflow, passive
  • accomplished by movement of
  • diaphragm
  • muscles - intercostal and neck
  • change in intrathoracic pressure

• Inspiration accomplished by movement of

• diaphragm
• muscles
• change in intrathoracic pressure

• diaphragm moves down, flattens
• intercostal and neck muscles expand
• diameter and length of thoracic cavity ­
• pressure in lungs ¯ below atmospheric
• air rushes in

Breathing

• nearly opposite
• passive event
• diaphragm relaxes
• chest wall and lungs recoil (elastic)
• air is expelled

Pulmonary pressures

Intrapulmonic (within lungs)
Intrapleural (around lungs)

• Boyles law - volume of gas varies inversely with P

• intrapleural pressure ALWAYS NEGATIVE
  (unless chest cavity open)
• essential - creates suction
  holds visceral and parietal pleural tog.

Health History

• Any risk factors for respiratory disease
• smoking
• pack years ppd X # years
• exposure to smoke
• history of attempts to quit, methods, results
• sedentary lifestyle, immobilization
• age
• environmental exposure
  • Dust, chemicals, asbestos, air pollution
• obesity
• family history

Present health status

• URI
• Allergies
• Recent screening or diagnostic assessments, last CXR
• Medications
• Rx or OTC
• Use of aerosols or inhalants for any purpose
• Exercise tolerance

How soon do vital signs return to NL after exercise

HPI - Cough

• Type
  • dry, moist, wet, productive, hoarse, hacking, barking, whooping
• Onset
• Duration
• Pattern
  • activities, time of day, weather
• Severity
  • effect on ADLs
• Wheezing
• Associated symptoms
• Treatment and effectiveness

   

HPI - sputum

• amount
• color
• presence of blood  (hemoptysis)
• odor
• consistency
• pattern of production

HPI - SOB

• Onset - sudden or gradual
• Frequency- intermittent or persistent
• Pattern- when/where condition occurs
• relationship to exercise
• time of day
• eating
• Wheezing
• Severity- effect on activity
• COPD
• Response to treatment

Other terms for SOB

• orthopnea
• "2 pillow"
• paroxysmal nocturnal dyspnea - PND

Past Health History

• Respiratory infections or diseases (URI)
• Trauma
• Surgery
• Chronic conditions of other systems

Family Health History

• Tuberculosis
• Emphysema
• Lung Cancer
• Allergies
• Asthma

Other considerations

• Employment

• place
• exposure

• Current or past residence/travel
• Hobbies

Thoracic Assessment

• Privacy
• Warm
• Well lit

Assessment

Inspection

• Skin
  • color and nutritional state
  • lips - color
  • nail beds - color and shape
• posture

Thoracic contour

• shape, symmetry

• developmental:

Pigeon chest

Funnel chest

Spinal Deformities

Kyphosis

• AP to Lateral diameter
  • till age 6 - 1:1 (equal)
  • 1:2 in normal adult
  • barrel chest - 1:1 in adult
    • presence of chronic pulmonary disease
• Ribs and interspaces
  • retraction of interspaces indicative of obstruction
  • bulging during exhalation result of air outflow obstruction: tumor, aneurysm, cardiac enlargement
  • slope of ribs, costal angle

• Respiratory Pattern
  • Rate
  • Rhythm
  • Depth
  • Effort
  • Respiratory movement

 

• Rate
  • adult NL: 12 - 20 resting
  • tachypnea = > 20
  • bradypnea= <10

Rhythm

 

Depth:   shallow, deep

• Hyperventilation

deep and rapid
2⁰ anxiety
drug OD
CNS disease
acid/base imbalance

• Hypoventilation

2⁰ post op pain
CNS drugs
neuro impairment
obstruction

• Effort/Quality
• unlabored
• labored- dyspnea, orthopnea
• shallow
• grunting

Respiratory movement

• thoracic or abdominal
  • Men & children - abdominal breathers
  • Women- thoracic

Normal rate, rhythm, quality termed eupnea

• rhythmic
• effortless
• quiet
• symmetrical

• Also inspect for
  • cyanosis of
    skin
    MM
    lips, earlobes, nail beds
    soles, palms
  • flaring of nares
  • use of accessory muscles
    • supraclavicular retraction
  • cough

assess for lesions 
thoracic expansion 
tactile fremitus
tracheal position

Thoracic Expansion

• Posteriorly- level of 10th rib
• Thumbs should separate 3 - 5 cm
• Feel during quiet I & E
• Palpate during deep inspiration
• Should be symmetrical
• If not - ? Fx ribs
• atelectasis (lung collapse)

Tactile Fremitus

• palpable vibrations of chest wall over lung fields from speech or sounds
• Use palmar or ulnar surface
• Palpate vocal sounds
• Systematically palpate side to side in same area
• Normal, increased or decreased

Locations for feeling fremitus

What does increased or decreased tactile fremitus mean ?

• Tactile Fremitus Increased- conditions that increase density of thoracic tissue
  • consolidation of pneumonia
  • some lung tumor
• Tactile Fremitus Decreased - obstruction of transmission of vibrations-

• pleural effusion
• pleural thickening (fibrosis)
• pnemothorax
• bronchial obstruction
• COPD/emphysema

check underlying area for

• air
• fluid
• solid

Percussion sounds -

flat
dull - @ heart, liver
resonant - NL
hyperresonant - COPD, hyperinflation
tympany

Why would sounds be dull ?

• Diaphragmatic excursion

• done when breathing is shallow
• when suspect something is limiting diaphragmatic movement
• percuss to mark level of diaphragm at full exhalation, then full inhalation
• should be 3 -6 cm difference

• How is respiratory sx working?
• What lung areas are not working?
• Are secretions, fluid, an obstruction blocking air passages?
• Hold stethoscope firmly but not tightly over ICS
• Use diaphragm or bell ??
• Ask pt to breathe normal/deeply with mouth open (Tell pt to tell you if dizzy, lightheaded)
• Listen for entire cycle inhale/exhale
• Tune out heart sounds
• Systematic

Don’t confuse sounds over chest hair with breath sounds

Auscultate

• Normal breath sounds

• Adventitious breath sounds

• Voice sounds (vocal resonance) (if abnormalities are suspected)

Normal breath sounds

Note

• Pitch

• Intensity

• Quality

• Duration

Vesicular-

heard over most of lung

• I>E

• low pitch

• soft intensity » sigh

 

Bronchovesicular-over bronchi

• I=E
• moderate pitch and intensity, breezy

Bronchial/Tracheal

• I<E
• high pitched, loud, blowing

Documenting NL breath sounds:

Vesicular breath sounds audible all lung fields bilaterally.

Adventitious Breath Sounds

• Abnormal sounds imposed on top of normal

• Crackles
  • due to air passing thru moisture in airway
  • usually heard R and L lung bases
  • best heard during inspiration
    • fine (in small airways, alveoli)
    • medium (in bronchioles)
    • coarse (larger airway, "gurgle", thick secretions, coughing may affect)

• Rhonchi and wheezes

• continuous sounds produced by movement of air thru narrowed areas in larger airways (tracheobronchial tree)

• narrowed 2⁰
          fluid, secretions
          COPD

          mass

• Predominate in exhalation

• wheeze
      high pitched
      suggests COPD or bronchitis

• rhonchi
          lower pitched
          whistle, rumble, snore
          suggests secretions in large airways

Clearing of crackles, wheezes or rhonchi by coughing suggests that they are caused by secretions

• Pleural Friction Rubs

• Creaking, grating, leather-like quality
• Can be heard over lungs (pleurisy)

• Very painful
• not cleared by coughing

Voice sounds

• Vocal Resonance
  • Advanced technique
  • » Tactile fremitus but auscultated
  • Client says or whispers "99",

• Abnormal if increased 2⁰ consolidation (pneumonia)

• THINK! If vocal resonance is increased

Difference between tactile  fremitus and vocal resonance

Corroborate findings with

Developmental Differences

• First thing assessed in neonate is breathing
• Respiratory rate highest in neonate, decreases throughout childhood
• Chest circumference in child same as head circumference until age 2
• Strictly abdominal breathing until age 7
• Breath sounds louder due to thin chest wall

• Elderly-
  • thorax may become more rounded 2 ⁰ kyphosis (osteoporosis)
    • ò Increased muscle tone

      emphysema/ spine changes may increase AP: lateral diameter (barrel chest)
      breath sounds more difficult

  • lung tissue and chest wall less compliant/elastic
  • ò Decreased muscle tone?
  • ò Decreased ability to cough forcefully?

Nursing Diagnoses

Nursing Diagnoses

• Ineffective breathing pattern
• Fatigue
• Impaired gas exchange
• Risk for suffocation
• Inability to sustain spontaneous ventilation
• Ventilatory weaning response dysfunction

Teaching Opportunities

• Immunizations
• TB testing
• Concerns with cold and cough
• Allergies
• Asthma
• When to seek care
• OTC medications