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Assessment of the Chest and Lungs
• Equipment needed:
Tape measure
Stethoscope
Blanket or drape
Ruler
A & P
• Position of the Patient:
Sitting = best; Allows for inspection of both the back and the chest for: the 3 S’s
Size
Shape
Symmetry
Anterior Chest
• Lungs:
Right upper lobe Left upper lobe
Right middle lobe Left lower lobe
Right lower lobe
Assesessment
• Anteroposterior Diameter = half of the transverse diameter
• Unexpected findings:
Barrel chest
Pigeon chest
Funnel chest
Deviations
Assessment
• Assess the patient’s;
Lips: color, pursed lips
Nails: clubbing, cyanosis
Nares: flaring
Oxygen saturation
Breath: odor
Patients overall color
Respirations
• Expected:
Rhythm and pattern: even & easy with no distress
Repiration rate: 12-20 breaths per minute
Ratio of HR/RR: 1 to 4
Respirations
• Unexpected:
Shortness of Breath (SOB)
Tachypnea
Orthopnea
Use of accessory muscles
Retractions
Patterns of Respirations
• Normal: regular 12-20 per minute
• Bradypnea: slow, < 12
• Tachypena: fast, > 20
• Hyperpnea (hyperventilation) faster, >20 and deep
• Sighing: sigh/deep breath
Patterns of Respirations
• Air trapping: increase difference in the air getting out
• Cheyne Stokes: increase in depth with periods of apnea
• Kussmauls: rapid, deep, and labored
• Biots: apnea and disorganized breathing
Listening
• Two types of breath sounds; normal and abnormal
• Normal are called; bronchial, bronchial vesicular, and vesicular
• Abnormal are also called; adventitious
Normal Breath Sounds
• Bronchial: trachea, anterior only, and high pitch
• Bronchovesicular: main bronchus, anterior and posterior, medium pitch
• Vesicular: heard over most of the lung fields, bases, low pitch
Adventicious Breath Sounds
• Crackles: fine, medium, and coarse
Fine: not cleared by coughing, heard at the end of inspiration
Medium: lower, moist, heard during inspiration, not cleared by cough
Coarse: loud, bubbly, heard on inspiration, can be cleared by coughing
Adventicious Breath Sounds
• Wheezes: musical note, squeaky, heard on inspiration or expiration
• Rhonci: sunorous wheeze, loud, low, inspiration or expiration, coughing may clear, due to mucous accumulation
• Stridor: bark, no air exchange
• Pleural friction rub: rubbing, dry, grating sound, inspiration or expiration, anterior
Abnormalities
• Pulsations
• Tenderness
• Bulges
• Depressions
• Unusual movement
• Unusual positions
Thoracic Expansion
• Stand behind the patient
• Place palms lightly on patient’s back with thumbs at the 10th rib
• Have patient breathe & watch thumbs with each breath
• Symmetric expantions should be seen
• Repeat anteriorly under the xiphoid process
Trachea
• Midline
• Palpate gently with index finger about suprasternal notch
• A slight deviation to the right is normal
• Should be non-tender
• Pulsations = abnormal
Percussion Tones
• Resonant: low pitch, hollow, loud, long
• Flat: soft, extremely dull, short, high pitch
• Dull: medium, medium-high pitch, thudlike
• Tympanic: loud, high pitch, drumlike
• Hyperresonant: very loud, very low pitch, long, booming sound
Vocal Resonance
• Have patient recite numbers or words as you listen to all lung fields (99)
• Muffled sound should be heard
Abnormalities
• Cancer
• Infections: upper respiratory, sputum production
• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
Abnormalities Continued
• Emphysema
• Pneumonai
• Barrel Chest
• Productive (sputum)/non-productive coughing
• Long expirations
Cough Descriptions
• Dry
• Moist
• Non-productive
• Productive: assess sputum color; yellow, green, rust, clear, purrulent, blood streaked, thick(viscous) or thin
Coughs
• Assess:
Onset
Frequency
Regularity; certain time of day or activities
Postural changes
Smoker/non-smoker
Environmental/work related issues