Thoracic Assessment
Unit 6

Thoracic Assessment Overview

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

Anatomy & Physiology

Thoracic cavity

Lungs

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

Breathing

Exhalation

Pulmonary pressures

Intrapulmonic (within lungs)
Intrapleural (around lungs)

    • Boyles law - volume of gas varies inversely with P

Health History

Present health status

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

Other considerations

Thoracic Assessment

  • Privacy
  • Warm
  • Well lit

Assessment

Inspection
Thoracic contour
  • shape, symmetry
  • developmental:

Pigeon chest

Funnel chest

Spinal Deformities

Kyphosis

 

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

Normal rate, rhythm, quality termed eupnea

  • rhythmic
  • effortless
  • quiet
  • symmetrical
Palpation

assess for lesions 
thoracic expansion 
tactile fremitus
tracheal position

Thoracic Expansion Tactile Fremitus

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
Percussion
check underlying area for Percussion sounds -

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

Why would sounds be dull ?

Auscultation

Don’t confuse sounds over chest hair with breath sounds

Auscultate

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

 

  • 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

Caused by inflamed visceral and parietal pleura rubbing together

also heart (pericardial friction rub) (usually heard over anterolateral chest)

Documenting variation from NL breath sounds:

Fine crackles R and L lung bases bilaterally.

Voice sounds

NL sounds muffled

(air-filled lung has become airless)

Tactile fremitus will be …?
Percussion sound will be … ?
Breath sounds - may hear...?

Difference between tactile  fremitus and vocal resonance

Tactile fremitus- sound vibration of spoken or whispered voice through lung fields on palpation

Vocal resonance- sound vibration of spoken or whispered voice through lung fields on auscultation

Corroborate findings with

faculty

colleagues

CXR

ABGs

continued assessment

Developmental Differences

 

Nursing Diagnoses

P: Activity intolerance
E:
̣decreased oxygenation 2 0 emphysema
P: Ineffective airway clearance
E: pulmonary congestion, diminished cough reflex
P: Risk for aspiration
E: diminished cough reflex, impaired swallowing
P: Risk for infection
E: thick sputum,
̣ decreased  resp. function

Nursing Diagnoses

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

Teaching Opportunities