Physical assessment of thorax and lungs

1. PHYSICAL ASSESSMENT
OF THORAX AND LUNGS
Dr. Milka D. Madhale
Associate Professor
Arsi University
Ethiopia
Asella

2. OBJECTIVES
 Discuss brief anatomy and physiology of lung and thorax.
 Demonstrate assessment of lung and thorax.
 Identify normal assessment of lung and thorax.
 Identify abnormal assessment of thorax and lung.
 Apply the caring value during assessment of thorax and
lung.

3. BRIEF ANATOMY AND PHYSIOLOGY OF
LUNGS AND THORAX
THORACIC CAVITY
 It is situated between the
neck and the diaphragm.
 Thoracic cavity has lungs,
heart, oesophagus,
trachea and thymus.

5. IMPORTANT FUNCTIONS OF RESPIRATORY
SYSTEM
 It brings oxygen into our bodies, which we need for our
cells to live and function properly.
 It helps to get rid of carbon dioxide, which is a waste of
product of cellular function.
( Respiration is the movement of oxygen
from the outside environment to the cells
within tissues, and the transport of carbon
dioxide in the opposite direction.)

9. MECHANISM OF RESPIRATION (BRIEF
OVERVIEW)
Air enters the nostrils--------Nose filters the incoming air—
----Air passes in the pharynx to the larynx ( protected by
epiglottis, which prevents food entering in the passage of
lungs)------Air goes into trachea(windpipe)-------Trachea
divides into two bronchi-------Each bronchus divides
bronchioles----Bronchioles enters into alveolar duct ( the
actual exchange of gases occurs in the alveoli)
( Oxygen from air in the alveoli goes into the blood and
carbon dioxide in the blood goes out)

10. INSPECTION
 Patient is asked to sit
upright on the
examination table with
arms aside.
 Ensure adequate lighting.
 Examine the anterior and
posterior chest.
 Before examination , wash
the hands with soap and
water.

11. General observations:
 Fast respiratory rate.
 Cyanosis(blue discoloration on skin)
 Unusual posture.
 Using accessary muscle for breathing.
 Inward movement of intercostal muscles.
 Note if patient is coughing.
 Note if patients voice is hoarse.
 Note wheezing.
 Abnormal breathing pattern.

12. Peripheral examination:
Hand examination:
 Assess the flapping tremor (asterisks):
It is the tremor of hand when the
wrist is extended. It resembles like
bird flapping its wing.( Caused by
CARBON DIOXIDE retention, if they have
received bronchodilator therapy.)

13. Nicotine staining on the
fingers:(sign of identifying
smokers)
Both thumbnails side by side
(Diamond shape is normal)
Abnormalities are seen in pulmonary
fibrosis, cystic fibrosis, bronchogenic
carcinoma)

14. Erythema Nodosum:( Red,
painful, tender lumps)
May be the first sign of a
systemic disease such as
Tuberculosis.

15. Facial flushing (Indication of
carbon dioxide retention-
Dyspnea)
Nasal polyps and epistaxis

16. Pink and healthy tongue Bluish tongue-Central
cyanosis

17. Horner's syndrome
 Observe for Horners
syndrome:
( constricted pupil,
ptosis, decreased
sweating on the face
shows brachial plexus
compression—tumor in
the apex of the lungs)

18. CHEST INSPECTION:
Chest Scars:
Chest scars can be from
previous thoracotomy

19. SHAPES OF THE CHEST:

20. Normal Chest:
The chest cavity is outlined on each side by the white bony
structures that represent the ribs of the chest wall. On the
top portion of the chest is the neck and the collar bones
(clavicles). On the bottom, the chest cavity is bordered by
the diaphragm under which is the abdominal cavity.
No deformity is seen on the chest.

21. Contd……
 Barrel chest: It refers, to an increase in the anterior
posterior diameter of the chest wall resembling the shape
of a barrel, most often associated with emphysema.
 Pectus excavatum: It is a congenital deformity of the
anterior thoracic wall in which the sternum and rib cage
grow abnormally. This produces a caved-in or sunken
appearance of the chest. It can either be present at birth
or not develop until puberty.

22.  Pectus carinatum (L carīnātus, equiv. to carīn(a) keel),
also called pigeon chest, is a malformation of the chest
characterized by a protrusion of the sternum and ribs. It is
distinct from the related malformation Pectus
excavatum.

23. Contd…..

24. PALPATION:
1. Examination with the
hands, feeling for organs,
masses, or infiltration of a
part of the body, feeling the
heart or pulse beat, or
vibrations in the chest. 2.
Touching, feeling, or
perceiving by the sense of
touch.

25. Assessing lymphadenopathy
 Palpate the cervical lymph nodes
with both hands, one on each side of
the patient's face.
 Start at the preauricular glands and
then work down, palpating with the
ends of your fingers: jugulodigastric,
submandibular, submental, anterior
cervical, supraclavicular, posterior
cervical, posterior auricular, occipital
lymph nodes.
 Assess for axillary lymphadenopathy
by holding the patient's arm near the
elbow with one hand and palpating in
the axilla with your other hand.

26. Palpate the trachea
 Palpate the trachea
 Position yourself in front of the
patient.
 Place your right index finger in
the sternal notch.
 Palpate the lateral borders of
the trachea to determine if it is
in normal (midline) position. A
deviated trachea can indicate
lung pathology The trachea will
be deviated away from the side
of an effusion or lung mass, and
towards the side of a
pneumothorax, collapsed lung,
or atelectasis.

27. Palpate the chest wall.
• Use the palm of your right or left hand to assess for any obvious point tenderness,
masses, or rib deformities.
• Palpate the chest anteriorly and posteriorly. Any differences between right and
left can indicate abnormal underlying lung tissue.
• Note any evidence of subcutaneous emphysema.It is observed when air gets into
the subcutaneous tissues, and is associated with lung collapse secondary to trauma
or a ruptured bronchial tube.
Assess chest expansion
• Place your hands, with thumbs touching, in the midline and extend your fingers to
make contact with the lateral edges of the chest anteriorly, just below the level of
the nipples.
• Ask the patient to take a deep breath. The thumbs should separate by
approximately 5 cm or more in normal chest expansion (this technique can also be
utilized posteriorly).

28.  Place your hands at the
lower part of the chest.
 Ask the patient to say 99
or 1-2-1
 The vibration felt against
your hand should be the
same in each hand.

29. PERCUSSION
 The act or technique of
tapping the surface of a
body part to learn the
condition of the parts
beneath by the resultant
sound

30. PERCUSSION
Posterior Chest Anterior Chest

31. PROCEDURE:
 Make sure the patient is undressed till the waist.
 Position the patient on examination table at 30-40 degree
angle and approach from the right side.
 Percuss both posteriorly and anteriorly , starting on the
back.
 Place non-dominant hand with middle finger pressed and
hyperextended firmly. The firmer the finger is pressed to
the chest wall, the harder the percussion note.
 Make sure other fingers and palm are not pressed against
the chest wall.
 It is advisable to keep finger nail short.

32. Contd…..
 Percuss on the chest in the intercostal spaces.
 Resonant percussion note ------ Heard over a normal air
filled lung.
 Dull Percussion note ------ The sound over solid tissues---
Indicates the consolidation.
 Tympanic percussion note ---- ( a drum like sound when
percussing hollow organ) ----- Pleural effusion
 Stony Duller sound than dull sound ---- COPD, Emphysema
or pneumothorax.

33. AUSCULTATION: ( Actions of listening sounds
from the heart, lungs, and other organs ,typically
with stethoscope.)

34. Points for auscultation of the lungs:

35.  Position the patient: ask the patient to lean forward or sit upright in
order to examine posteriorly. Asking the patient to fold arms or place
hands on opposing shoulders also helps to get maximal exposure to
the lung fields.
 Place the diaphragm of the stethoscope on the patient's chest, and
ask the patient to take deep breaths in and out through the mouth.
 Auscultate at five levels posteriorly and anteriorly, comparing side by
side.
 Normal breath sounds are called vesicular breath sounds, which are
low-pitched sounds louder on inspiration and softer on expiration.
They should be symmetrical posteriorly.
 Note the presence and location of abnormal (adventitious) extra
breath sounds, such as crackles, wheezing, rhonchi, stridor, or pleural
friction rub.
Procedure:

36.  Note the characteristics of any abnormal breath sounds (if present):
loudness, quality, duration, and whether they occur during inspiration
or expiration (i.e., timing in the respiratory cycle). Many abnormal
breath sounds are best heard after asking the patient to cough.
 Assess for Broncho phony, an increased sound transmission over the
consolidated lung, when asking the patient to say "99" or "1-2-1
 Assess for whispering sound, While auscultating with the stethoscope,
ask the patient to whisper "99" or "1-2-1." In the consolidated lung,
the sound will actually be heard better and more clearly with the
stethoscope.
Contd……..

37. Breath Sounds
 Bronchial Sound  These are hollow sound,
tubular sounds that are lower
pitched.
 They can be auscultated over
trachea, where they are
considered normal. If it is
heard over the peripheral lung
field, considered as abnormal,
which indicate pneumonia,
atelectasis, pleural effusion.

38. Contd….
 Broncho-vesicular sounds
 Crackles/Crepitations/ Rales
 These are normal sounds
on the mid chest area in
between the scapula,
where inspiration and
expiration periods are
equal.
 These are abnormal
sounds made in
respiratory disease
during inhalation in CCF,
Pulmonary edema

39. Contd……..
 Wheezing
 Ronchi
 It is a high pitched ,
whistling sound made
while breathing often
associated with difficulty
in breathing.Heard in
Bronchial Asthma
 It is continuous low
pitched, rattling sounds,
often resembles snoring.
Heard in COPD, Chronic
Bronchitis, Cystic fibrosis.

40.  Stridor
 Rub
It is high pitched crowing
breath sound heard during
respiration.
Heard in upper airway
narrowing or obstruction
It is the audible medical
sign( a friction sound)
Heard in pleurisy, viral
infection and influenza
Contd…..

41. Application of caring value
 Patient value is a key element in patient care.
 Respect his opinion and decision.
 Allow him/her to communicate.
 Guide him/her in all the steps he has to follow.
Nurse must have professional value to provide safe and high
quality care.