02.07 Thorax and Lungs Assessment

In this lesson we’re going to look at assessment of the thorax and lungs, so specifically we’re looking at things related to the respiratory system. It’s important to note here that you have to assess the lungs and thorax front AND back, so we’ll show you both the anterior assessment and posterior assessment. We’ll speed it up a bit for time-sake.

So starting with the anterior thorax, you’re going to start with inspection. In order to do that, you have to move the patient’s gown - so make sure you’re protecting their dignity and privacy at all times.
Start by just watching the patient breathe normally for a few breaths - you want to make sure there are no signs of distress, that their chest is expanding equally, and make note of the general rate and rhythm of their breaths - are they rapid? Shallow? Deep?
You also want to look at the shape and symmetry of their thorax - the diameter from front to back - or the AP diameter - should be about half the length from left to right. If they’re closer to being equal, that’s called a barrel chest - we see that a lot in COPD.
And you of course also want to look at the skin color and condition on the chest - making note of any redness, lesions, or cyanosis. If they have any lines or chest tubes, you’d assess those at this point as well.
Now you want to palpate over the chest to feel for any crepitus or crackling under the skin - this could indicate subcutaneous air - sometimes caused by trauma to the lungs.
Next we move on to percussion. Using two fingers from each hand, tap in the intercostal spaces from the apex down, moving from left to right - you should hear resonance. Any dullness could indicate fluid in the lungs, or you could be over the heart, the liver, or a bone.
And now we can move on to auscultation - make sure you listen with the naked ear first to make sure you don’t hear any audible wheezes, a cough, or stridor. Then you will use your stethoscope to listen in 10-12 places on the front. You’ll start at the apex and work your way down, moving left to right to compare the two sides. Usually I’ll ask the patient to take a breath in and out every time they feel my stethoscope move - that keeps me from having to say “take a deep breath” over and over and over again. Make sure that you also listen in the midaxillary region, especially on the right side to hear that middle lobe.
Now that we’ve finished the anterior, we want to move on to posterior. The easiest way to do this is to have the patient sit up. For efficiency's-sake, you can go ahead and auscultate the posterior while you still have your stethoscope in place. You’ll use the same technique as anterior, avoiding the shoulder-blades and working your way down. You should hear bronchial, then bronchovesicular, then vesicular sounds. Make sure you’re making note of any adventitious sounds like crackles or wheezes. Check out the Lung Sounds lesson in the Respiratory course to learn more!
Now we can circle back to inspection. We are looking for the same things we did on the anterior. Symmetry, skin color and condition, expansion.
When we palpate on the posterior, we are going to feel for crepitus, just like on the front, but there are a couple other things we feel for as well. The first is expansion. Place your hands on the lower ribcage with your thumbs touching and ask the patient to breathe deeply - you should see your thumbs move away and back equally.
Then we’re going to check for what’s called tactile fremitus. It’s a vibration in the chest when the patient talks. Use the palms of your hands to feel in 4 or 5 places from the apex downward on both sides while the patient says the words “ninety nine”. Again, I usually just tell them to repeat the words whenever they feel my hands move. The vibrations should be equal on both sides. Any decrease in vibrations could mean there’s some fluid consolidation.
And finally you’re going to percuss the posterior thorax in the same way as anterior, listening for resonance, and making sure you avoid the scapula.

Remember that any adventitious sounds mean that the client could be having difficulty breathing or oxygenating, so make sure you intervene appropriately and notify the provider if necessary.

Now, go out and be your best selves today. And, as always, happy nursing!