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02.07 Thorax and Lungs Assessment

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Overview

  1. The thorax and lungs should be assessed anteriorly, posteriorly, and laterally

Nursing Points

General

  1. Supplies needed
    1. Stethoscope

Assessment

  1. Anterior
    1. Inspect
      1. Size and shape of thorax
        1. Anterior-Posterior diameter should be approximately ½ the lateral diameter
        2. Barrel Chest – COPD
      2. Symmetry
        1. Expansion should be symmetrical on inspiration
      3. Ribs should slope downward from the sternum outward
      4. Observe for signs of distress
        1. Tachypnea
        2. Retractions
        3. Cyanosis
      5. Observe the overall rate and rhythm of respirations
      6. Inspect skin color and condition on thorax
    2. Palpate
      1. Using 2 fingers, press lightly on skin over anterior chest, feeling for crepitus – feels like “rice crispies” under skin
        1. Indicates subcutaneous air
    3. Percuss
      1. Starting at the Apex, percuss in the intercostal spaces moving left to right and downward
      2. Should hear resonance
      3. May hear dullness over heart and liver
    4. Auscultate
      1. Listen for audible cough, wheezing, or stridor
      2. Lung sounds
        1. Bronchial
          1. Upper areas
          2. High pitch
          3. Insp < Exp
        2. Bronchovesicular
          1. Middle areas
          2. Moderate pitch
          3. Insp = Exp
        3. Vesicular
          1. Outer areas
          2. Low pitch
          3. Insp > Exp
      3. Listen from left to right starting at the apex and moving downward, including the lateral areas.
        1. The only way to hear the right middle lobe is to listen near the axilla on the right side.
      4. Should listen in 10-12 areas on the front
      5. BEST heard with stethoscope directly on skin
      6. Listen to one full respiration in each area
      7. Make note of any adventitious sounds
        1. Crackles
        2. Rhonchi
        3. Wheezes
        4. Stridor
        5. *See Lung Sounds lesson in Respiratory Course for details
  2. Posterior
    1. Inspect – same as anterior
    2. Palpate – same as anterior, plus:
      1. Tactile fremitus
        1. Use the palm of your hands to palpate from the apex down in 5 places as the patient says the word “ninety-nine”
        2. Should feel vibrations equally bilaterally
          1. Decreased vibration = fluid consolidation
      2. Expansion
        1. Place hands on lower rib cage with thumbs touching, ask patient to inhale deeply
        2. Should see hands expand and return symmetrically
    3. Percuss – same as anterior,
      1. Avoid scapula
    4. Auscultate – same as anterior
      1. Avoid scapula
      2. 8-10 locations

Nursing Concepts

  1. Make note of any abnormal findings. New or significant findings should be reported to the provider
  2. Remember there are nursing interventions you can perform without a provider order to improve respirations:
    1. Incentive Spirometry
    2. Turn, Cough, Deep breathe
  3. Request oxygen and chest x-ray from provider if you feel they are necessary
    1. Should have an SpO2 from when you did your vital signs

Patient Education

  1. For efficiency-sake – ask the patient to take a deep breath every time they feel your stethoscope on their chest/back
    1. Same for tactile fremitus – “Say the word “ninety nine” when you feel my hands move

Reference Links

Study Tools

Video Transcript

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!

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