Thorax and Lungs

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Thorax and Lungs
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Health History

• Tobacco use (amount, duration, Pack year index)
  http//www.coquitline.org/
• 2nd hand smoke exposure
• Occupation/Exposure to pulmonary irritants
• Chemicals, vapors, dust, allergens, animals,
  smoke, asbestos, arsenic, coal dust, radiation)
• PMH/FH of respiratory illness/disease/cancer or
  allergies
• Pneumonia, TB, COPD, asthma, lung cancer
• Pneumonia or influenza vaccine received?
• Risk factors for TB
• HIV, substance abuse, low income or homeless,
  resident of nursing home, shelter or prison,
  immigrant from country with high TB rate

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Health History

• Do you have any shortness of breath? (Dyspnea)
• Occurs _at_ rest, with exercise, lying flat?
• Have you heard any wheezing?
• Do you have a cough?
• Dry, productive, barking, etc..
• http//www.youtube.com/watch?vmXAxnZ4JJ6A
• Amount, color, consistency of sputum. Presence
  of odor.
• Hemoptysis- coughing up blood (varies from blood
  streaked phlegm to frank blood)
• Do you have chest pain with breathing?
• Have you recently had any pain in calves or been
  on any long car or plane rides?

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Sample Charting
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Sample Electronic Charting

• Respiratory Symptoms
• Difficulty breathing
• Dyspnea with exertion
• Dyspnea at rest
• Unable to lie flat
• Difficulty coughing
• Difficulty clearing secretions

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Inspection

• Observe symmetry, rate, rhythm, depth and effort
  of breathing
• Symmetry Chest wall movement equal bilaterally
• Rate Adult 12-20 resp/min is normal
• Bradypnea Slow (lt12 per minute)
• Tachypnea Rapid (gt20 per minute)
• Rhythm Regular vs. irregular
• Cheyne-Stokes, Kussmauls respirations, Biots
• Depth
• Hypoventilationrate slow, depth
• Hyperventilationrate rapid, depth deep
• Respirations 16/min, symmetrical,relaxed and even

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Inspection

• Effort
• Unlabored vs. labored
• Presence of retractions
• Suprasternal above clavicle sternum
• Intercostal between ribs
• Subcostal below lower costal margin
• Substernal Below Xiphoid process
• Presence of nasal flaring (inhalation) or
  grunting (exhalation)
• Infants/children
• Use of accessory muscles
• Neck/shoulders (ie Sternocleidomastoid
  trapezius)
• Abdominal (exhalation)
• Respirations nonlabored.
• http//www.youtube.com/watch?vHv68EQ3tCBI
• http//www.youtube.com/watch?vJ2R8MOoQtd8

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Inspection

• Body position
• Relaxed vs. Upright/Tripod position
• Color of skin, lips, nail beds
• Even skin tone vs. cyanotic
• Presence of clubbing
• Patient relaxed. Skin and mucous membrane pink.
  Nail beds pink without clubbing in upper and
  lower extremities.

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Inspect/Palpate Trachea Position

• Inspect
• Should be midline
• Palpate
• For tracheal shift
• Place finger in sternal notch and slip to each
  side.
• Trachea midline.

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Inspection

• Wounds, scars, drains, tubes, dressings
• Documentation must include location, size, amount
  of drainage and discharge if present, and signs
  of inflammation.
• Additional terms to describe location
• Supraclavicular- Above the clavicles
• Infraclavicular- Below clavicles
• Interscapular- Between scapula
• Infrascapular- Below scapula
• Midaxillary line- Along line of armpit
• Midclavicular- Along line in middle of clavicle
• No wounds, scars, drains, tubes, or dressings.
• Or- No lesions.

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Inspection

• Shape of Chest
• Symmetrical vs. asymmetrical
• Deformities
• Pectus carniatum, Pectus excavatum, Spinal
  deformitiies
• Normal AP diameter vs.. increased AP diameter
• Oval vs. barrel chest
• Ribs slope downward vs. more horizontal
• Barrel chest appears as if patient in continuous
  inspiratory position
• Chest symmetrical without deformities. AP lt
  transverse diameter

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Kyphosis

• Scoliosis

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Palpation

• Assess for masses, tenderness, or crepitus
• Subcutaneous emphysema- air escapes form lungs
  into subcutaneous tissue
• Assess chest expansion
• Posteriorly place thumbs at level of 10th rib
  place palms on posterolateral chest.
• Approx 2 inches apart before inspiration. Feel
  thoracic expansion during quiet deep
  inspiration. Look for symmetry.
• Chest expansion symmetrical. No masses or
  tenderness.
• http//www.youtube.com/watch?vygD93IKorEw

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Palpation

• Tactile Fremitus
• Palpable vibrations transmitted through
  bronchopulmonary tree to chest when patient
  speaks
• Have patient repeat 99 or 1, 1, 1 while palpate
  with ulnar surface or ball of hand
• Decreased or absent when vibration impeded by
  obstructed bronchus, tumor, or separation of
  pleural surfaces by fluid (pleural effusion),
  fibrosis (pleural thickening), or air
  (pneumothorax)
• Increased with gross compression or consolidation
  (lobular pneumonia) without bronchus obstruction
• Tactile fremitus equal bilaterally.

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Palpation
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Percussion

• Tapping of an chest to set chest wall and
  underlying tissues into motion
• Helps to establish if underlying tissue
  air-filled, fluid-filled, or solid
• Normal sound is resonance
• Resonant to percussion over all lung fields.

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Percussion

• http//www.youtube.com/watch?vPlUejZE6c_w

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Auscultation

• Use diaphragm of stethoscope and
• have patient breath out of their mouth.
• Peds- use smaller pediatric diaphragm or adult
  bell
• Place stethoscope firmly on skin. Avoid movement
  because it may produce confusing sounds (i.e.
  clothing)
• Auscultate at least one complete respiration
• Move from one side to the other
• Observe for hyperventilation, allow to rest if
  needed
• Peds- transmission of sounds enhanced, harder to
  localize sounds

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Auscultation- Anterior Chest
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Auscultation- Lateral Chest
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Auscultation- Posterior Chest
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Anatomy Review

• Air Mouth/Nose? respiratory portion of larynx ?
  trachea ? right left bronchus ? smaller bronchi
  ? smaller bronchioles ? alveolar duct ?
  individual alveoli

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Auscultation

• Breath Sounds
• Bronchial (Tracheal)
• Heard over trachea
• Exp gt insp
• Loud, High pitch
• Hollow quality
• Bronchovesicular
• Heard over major bronchi
• Insp exp
• Medium, Medium pitch
• Blowing sound
• Peds in periphery
• Vesicular
• Heard over lung parenchyma/periphery
• Insp gt exp
• Soft, Low pitch
• Breezy quality
• Diminished

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Auscultation

• Adventitious Breath Sounds
• Wheezes (Sibilant wheeze)
• High pitched, musical sound heard during
  inhalation or exhalation
• Mild, moderate, severe
• Rhonchi (Sonorous wheeze)
• Low pitch snoring sound during inspiration or
  exhalation, but louder on exhalation
• May clear with coughing

Asthma
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Auscultation

Bronchitis
Emphysema
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Auscultation

• Crackles/Rales
• Popping sounds heard on inhalation
• Fine
• High pitched fine, short, interrupted crackling
  sounds heard during end of inspiration
• Medium
• Lower, more moist sounds heard during middle of
  inspiration
• Course
• Loud, bubbly sounds heard during inspiration

• http//www.med.ucla.edu/wilkes/intro.html

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Auscultation

Pneumonia
Atelectasis
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Auscultation

• Pleural friction rub
• Dry, low pitched rubbing or grating sound on
  inhalation and exhalation
• Heard loudest over lower lateral anterior surface
• Occurs with pleurisy or pleuritis
• http//www.merckmanuals.com/professional/resources
  /multimedia/name/audio.html

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Auscultation

• Stridor
• High pitched, harsh sound heard on inspiration
  when trachea or larynx is obstructed
• Croup, foreign body, large airway tumor
• http//www.youtube.com/watch?vQkaX83H31QYfeature
  PlayListp0C59700763AFDD1Eplaynext1index8
• http//www.youtube.com/watch?vZ1_uKqmPyLAfeature
  related

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Auscultation

• Breath sounds vesicular without adventitious
  sounds.
• Or- Lungs sounds CTA in all lung fields without
  wheezes, rales, rhonchi, or rubs

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Auscultation

• Voice Sounds
• Bronchophony
• 99 or 1-2-3
• Normal- Muffled
• Abnormal- Clear
• Whispered Pectoriloquy
• Whisper 1,2,3
• Normal- faint and indistinct
• Abnormal- clear and distinct
• Egophony
• eeeeeeee
• Normal
• Abnormal aaaaaa

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Bringing it all together
http//www.youtube.com/watch?vygD93IKorEw
http//www.youtube.com/watch?vnUJQvFXmTxQfeature
related
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Case Study
Juan Pablo comes to the Urgent Care Clinic for
complaint of a cough that started about a week
ago. He is accompanied by his friends who work at
the local chicken processing plant with him. He
is from Mexico and has lived in the United States
now for 2 years. He speaks English hesitantly.
His family still lives in Mexico. He is 38 years
old and states that he has been in good health.
He smokes one pack of cigarettes daily and
occasionally drinks alcohol. Polly Curtis is a
student nurse assigned to do a health assessment
and physical exam with the registered nurse.
Polly is 25 years old and is in her second year
of nursing school.  
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Sample Charting
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Sample Electronic Charting

• Normal Parameters Met
• Breath sounds clear through all lung fields.
• Respirations unlabored, symmetrical, regular
  rhythm and depth.
• No shortness of breath
• Cough effective
• Skin color within pts norm
• Sputum clear or white

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Sample Electronic Charting

• Sputum Amount
• Scant
• Small
• Moderate
• Large
• Copious
• Swallowed

• Sputum Color
• Yellow
• Tan
• Green
• Pink
• Brown
• Bloody

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Sample Electronic Charting

• Sputum Consistency
• Thin
• Mucoid
• Thick
• Mucus plug
• Frothy
• Small
• Tenacious
• Clots

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Sample Electronic Charting

• Effort
• Labored
• Shallow
• Stridor
• Agonal
• Accessory muscle use
• Gasping labored
• Grunting

• Mechanical ventilated
• Moderate labored
• Slightly labored
• Nasal flaring
• Pursed lip
• Splinting

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Sample Electronic Charting

• Retraction Type
• Substernal
• Intercostal
• Supraclavicular
• Subclavicular
• Abdominal

• Depth
• Deep
• Shallow
• Mediastinal Shift?
• Yes
• No

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Sample Electronic Charting

• Pattern
• Irregular
• Bradypnea
• Tachypnea
• Gasping
• Grunting
• Kussmaul
• Cheyne-stokes

• Irregular or periodic
• Paradoxical
• Agona
• Apnea
• Respiratory Pattern Comment _______

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Sample Electronic Charting

• Auscultation
• Clear throughout
• Absent
• Diminished
• Inspiratory wheeze
• Expiratory wheeze
• Rales
• Rhonchi
• Rub

• Lung Characteristics
• Audible
• Decreased
• Diffuse
• Increased
• Slightly decreased
• Tight
• Difference between anterior and posterior breath
  sounds _______
• Lung sound comments___________

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