Respiratory System: Assessment

 
Objectives
1.     Identify the anatomy and physiology of the respiratory system.
2.     Distinguish landmarks that guide assessment of the respiratory system.
3.     Develop questions to be used when completing the focused interview.
4.     Explain client preparation for assessment of the respiratory system.
5.     Describe the techniques required for assessment of the respiratory system.
6.     Differentiate normal from abnormal findings in physical assessment.
7.     Describe developmental, psychosocial, cultural, and environmental
variations in assessment techniques and findings.
8.     Discuss the focus areas related to the overall health of the respiratory system
as presented in Healthy People 2010.
9.     Apply critical thinking in selected simulations related to physical assessment
of the respiratory system.

Overview

 The primary responsibility of the respiratory system is the exchange of gases

in the body.
 The intake of oxygen and release of carbon dioxide take place with each
respiratory cycle.
 The central nervous system regulates the rate and depth of each respiratory
cycle.
 The respiratory system helps maintain acid-base balance, helps maintain
body fluids, and assists with speech.

Anatomy and physiology review

 The thorax is a closed cavity containing the structures needed for respiration.
 The thorax extends from the base of the neck to the diaphragm and is
surrounded by muscles and ribs.
 The thorax is divided into the mediastinum in which the heart, trachea,
esophagus, and major blood vessels are located, and the right and left pleural
cavities.
  External respiration refers to the exchange of oxygen and carbon dioxide at
the alveolar level of the lung.
 Internal respiration refers to the exchange of oxygen and carbon dioxide at
the cellular level.
 The upper respiratory tract consists of the nose, mouth, sinuses, pharynx,
larynx, and part of the trachea.
 The lower respiratory tract includes the distal trachea, bronchi and lungs, the
pleural membranes, muscles of respiration, and the mediastinum.
 The lungs are elastic, spongy, cone-shaped, and air-filled structures on the
left and right of the mediastinum.
 The left lung has two lobes and the right lung has three lobes.
 The intercostal muscles and diaphragm are muscles that assist the breathing
process.
 The respiratory cycle consists of the active process of inhalation and the
passive process of exhalation.

Landmarks

 Landmarks for assessment of the thorax include bony structures, horizontal

and vertical lines, and the division of the thorax.
 The thorax is divided into anterior and posterior sections or anterior,
posterior, and lateral sections.
 The sternum, the first bony landmark, is the flat line in the midline of the
thoracic cavity.
 The angle of Louis is a bony ridge of the location where the manubrium and
the body of the sternum join.
 The clavicles are long, slender bones that articulate with the manubrium
medially and laterally form the acromion of the shoulder joint.
 The 12 pairs of ribs form horizontal reference points.
 The vertebral column is located at the midline of the posterior thoracic cage.
 Five imaginary vertical lines are identified on the anterior thorax. These are
the sternal, midclavicular, and anterior axillary lines.
 The posterior aspect of the thorax contains the following imaginary vertical
lines: the vertebral, scapular, and posterior axillary lines.
 The landmarks serve as reference points for internal structures of the
respiratory system.
Special considerations

 During fetal development, breathing movements occur that strengthen

muscles for respiration after birth, but gas exchange occurs at the placenta.
At birth, gas exchange becomes an extrauterine function as fluid in the lungs
is absorbed by the pulmonary capillary bed and lymphatic system, is
expelled or suctioned from the trachea, and is replaced with air.
 During infancy and early childhood, breathing involves the use of abdominal
muscles.
 Pregnancy produces changes in the respiratory system. The muscles and
cartilage of the ribs relax, allowing an increase in tidal volume. Inspiratory
capacity increases, but expiratory reserve volume is decreased. The total
lung capacity remains the same. The mild respiratory alkalosis that occurs is
necessary for placental gas exchange.
 Stress, anxiety, fatigue, and pain may exacerbate respiratory problems.
 Race, ethnicity, and socioeconomic status are significant factors in
respiratory health. The incidence of respiratory diseases such as asthma,
tuberculosis, chronic obstructive pulmonary disease, and obstructive sleep
apnea is greater in non-Caucasians, in poor rural populations, and in recent
immigrant groups.
 Geography and environment influence respiratory health.

Gathering the data

 Respiratory health assessment includes gathering subjective and objective

data.
 Subjective data is gathered during the client interview and includes data
about illness, symptoms, family history, treatment, developmental
considerations, behaviors, and the environment.
 The focused interview guides physical assessment of the respiratory system.

Physical assessment

 Age, gender, and culture must be considered when preparing for physical
assessment of the respiratory system.
 Equipment required for physical assessment of the respiratory system
includes an examination gown and drape, examination gloves, an
 examination light, a stethoscope, a skin marker, a metric ruler, tissues, and a
face mask.
 Physical assessment of the respiratory system includes the techniques of
inspection, palpation, percussion, and auscultation.
 Physical assessment of the respiratory system proceeds in an organized
fashion. It begins with a client survey, followed by inspection of the anterior
thorax. The entire assessment of the posterior thorax follows. The
assessment is completed with palpation, percussion, and auscultation of the
anterior thorax.
 Skin color is assessed to determine the client's oxygenation status.
 The nurse visualizes landmarks prior to assessment of the thorax to form
reference points for underlying structures.
 Auscultation of lung sounds includes classification according to intensity,
location, pitch, duration, and characteristics.
 Four normal breath sounds are tracheal, bronchial, bronchovesicular, and
vesicular.

Abnormal Findings

 Eupnea is normal adult breathing characterized by a regular pattern of

respirations of even depth.
 Inspiration equals expiration, and sighs are occasionally interspersed.
 Abnormal breathing patterns include tachypnea (rapid shallow breathing),
bradypnea (slow regular respirations), hyperventilation, hypoventilation,
Cheyne-Stokes, Biot’s, frequent sighs, and obstructive breathing.
 The normal chest configuration for the adult is elliptical with a lateral
diameter twice as large as the anteroposterior diameter.
 Abnormalities in chest configuration include barrel chest, pectus excavatum,
and pectus carinatum. Kyphosis and scoliosis are alterations in spinal
alignment that impact chest configuration.
 Respiratory disorders include asthma, atelectasis, bronchitis, emphysema,
pneumonia, pleural effusion, pneumothorax, and congestive heart failure.
Glossary
adventitious sounds    Added sounds superimposed on normal breath sounds and
often indicative of underlying airway problems or diseases of the cardiovascular or
respiratory systems.

angle of Louis   (Sternal angle) A horizontal ridge formed at the point where the
manubrium joins the body of the sternum.

bronchial sounds   Loud, high-pitched sounds heard next to the trachea and are
longer on exhalation.

bronchophony   Auscultation of voice sounds, patient says "ninety-nine" and

normal lung sound will be muffled.

bronchovesicular sounds   Sounds that are medium in loudness and pitch, heard

between the scapula, posteriorly and next to the sternum, and anteriorly upon
inhalation and exhalation.

dullness   The level of the diaphragm during quiet respiration.

dyspnea    A change in normal breathing pattern, producing shortness of breath or

difficulty in breathing.

egophony   Ausculation of voice sounds, patient says "E", normal lungs sound like
"eeeeee".

eupnea   The regular, even-depth, rhythmic pattern of inspiration and expiration;

normal breathing.

fremitus   The palpable vibration on the chest wall when the client speaks.

landmarks   Thoracic reference points and specific anatomical structures used to

help provide an exact location for the assessment findings and an accurate
orientation for documentation of findings.

manubrium   The superior portion of the sternum.

mediastinum   Part of the thorax, or thoracic cavity, that contains the heart, trachea,
esophagus, and major blood vessels of the body.
rales/crackles   Discontinuous sounds which are intermittent, nonmusical, and
brief.

resonance   The usual sound in the thorax, a long, low-pitched hollow sound.

respiratory cycle   Consists of an inspiratory phase and an expiratory phase of

breathing.

rhonchi   (Sonorous Wheezes) Sounds that are low-pitched with a snoring quality.

tracheal sounds   Harsh, high-pitched sounds heard over the trachea when the client
inhales and exhales.

vesicular sounds   Sounds are soft and low-pitched and heard over the remainder of
the lungs, longer on inhalation than exhalation.

wheezes    (Sibilant) Sounds that are high-pitched with a shrill quality.

whispered pectoriloquy   Auscultation of voice sounds, patient whispers "one, two,

three", normal lung sounds will be faint, almost indistinquishable.

History
Obtaining accurate information from the client is important in determining the type
and severity of pulmonary problems.
 
DEMOGRAPHIC DATA
Age, gender, and race can affect the physical and diagnostic findings related to
respiratory function. Many of the diagnostic studies relevant to respiratory disorders
(e.g., pulmonary function tests) use these demographic data for determining
predicted normal values.
 
PERSONAL AND FAMILY HISTORY
Medical History
The nurse asks clients about their own respiratory history and that of their family
members. The family history is obtained to consider respiratory disorders with a
geneticcomponent, such as cystic fibrosis, some lung cancers, and alpha,-antitrypsin
deficiency (one risk factor for emphysema). Clients with asthma often have a family
history of allergic symptoms and reactive airways. The nurse assesses for a history
of infectious disease, such as tuberculosis, and considers that family members may
have similar environmental or occupational exposures.
Smoking History
The nurse questions the client about the use of cigarettes, cigars, pipe tobacco,
marijuana, and other controlled substances, and he or she notes whether the client
has passive exposure to smoke in the home or workplace. If the client smokes, the
nurse asks for how long, how many packs a day, and whether the client has quit
smoking (and how longago). The smoking history is documented in pack-
years (number of packs smoked per day multiplied by number of years). Because
the client may have guilt or denial aboutthis habit, the nurse assumes a
nonjudgmental attitude during the interview.
 
Smoking induces anatomic changes in the large and peripheral airways, and these
changes lead to varying degrees of airway obstruction. Men who continue to smoke
experience a more rapid decline in their pulmonary function than do non-smokers.
The pulmonary function of clients who have quit smoking for 2 or more years
appears to decline less rapidly than in clients who continue to smoke.
 
Medication Use
The nurse asks about medications taken for breathing problems and about drugs
taken for other conditions. For example, a cough can be a side effect of the
angiotensin-converting enzyme (ACE) inhibitors. The nurse determines which over-
the-counter medications (e.g., cough syrups, antihistamines, decongestants,
inhalants, and nasal sprays) the client is using.
 
The use of home remedies also is assessed. The client is asked about past medication
use and the reason for its discontinuation. For example, he or she may have used
numerous bronchodilator metered dose inhalers but may prefer one particular drug
for relieving breathlessness. In addition, some medications for other conditions
can cause permanentchanges in pulmonary function. For example, clients
may have residual pulmonary fibrosis if they received bleomycin (Blenoxane) as
chemotherapy for cancer or amiodarone (Cordarone) for cardiac problems.
Allergies
Information about allergies is important to the respiratory history. The nurse
determines whether the client has any known allergies to environmental substances
 such as foods, dust,molds, pollen, bee stings, trees, grass, animal dander
and saliva, or medications. The client is asked to explain a specific allergic response.
For example, does he or she wheeze, have trouble breathing, cough, sneeze, or
experience rhinitis after exposure to the allergen? Has he or she ever been treated
for an allergic response? If the client has received treatment for allergies, the nurse
asks about the circumstances leading up to the need for treatment, the type of
treatment, and the response to treatment.
 
Travel and Area of Residence
Travel and area of residence may be relevant for a history of exposure to certain
diseases. For example, histoplasmosis, a fungal disease caused by inhalation of
contaminated dust, is found in the central United States, the Mississippi and Mis-
souri river valleys, and Central America. Coccidioidomycosis, another fungal
disease, is found predominantly in the western and southwestern United States,
Mexico, and portions of Central America.
 
DIET HISTORY
An evaluation of the client's diet history may reveal allergic reactions to certain
foods or preservatives. Signs and symptoms range from rhinitis, chest tightness,
weakness, shortness of breath, urticaria, and severe wheezing to loss of conscious-
ness. The nurse documents in a prominent location of the client's record any known
allergies and the specific type of allergic response experienced. The client is asked
about his or her usual food intake and whether any symptoms occur with eating.
Malnutrition may occur if he or she has difficulty breathing during eating or the
food preparation process.
 
OCCUPATIONAL HISTORY AND SOCIOECONOMIC STATUS
The nurse considers the home, community, and workplace for environmental factors
that could cause or contribute to lung disease. Occupational pulmonary diseases
include pneumoconiosis, which results from the inhalation of dust (e.g., coal
dust, stone dust, silicone dust); toxic lung injury; and hypersensitivity disease (e.g.,
hypersensitivity to latex). The occupational history includes the exact dates of
employment and a brief job description. Exposure to industrial dusts of any type or to
the noxious chemicals found in smoke and fumes may cause respiratory disease. Coal
miners, stone masons, cotton handlers, welders, potters, plastic and rubber
manufacturers, printers, farm workers, and steel foundry workers are among the most
susceptible.
The nurse obtains information about the home and living conditions, such as the
type of heat used (e.g., gas heater, wood-burning stove, fireplace, and kerosene
heater) and exposure to environmental irritants (e.g., noxious fumes, chemicals,
animals, birds, and air pollutants). The client is asked about hobbies and leisure
activities. Pastimes such as painting, working with ceramics, model airplane
building, furniture refinishing, or woodworking may have exposed the client to
harmful chemical irritants.
CURRENT HEALTH PROBLEMS
Whether the pulmonary problem is acute or chronic, the chief complaint is likely to
include cough, sputum production, chest pain, and shortness of breath at rest or on
exertion. During the interview, the nurse explores the history of the present illness,
preferably in chronologic order. This analysis of the problem(s) includes the
following:
•  Onset
•  Duration
•  Location
•  Frequency
•  Progressing and radiating patterns
•  Quality and number of symptoms
•  Aggravating and relieving factors
•  Associated signs and symptoms
•  Treatments
 
Cough
Cough is the cardinal sign of respiratory disease. The nurse asks the client how long
the cough has persisted (e.g., 1 week, 3 months) and whether it occurs at a specific
time of day (e.g., on awakening in the morning, which is common in smokers) or in
relation to any physical activity. The nurse determines whether the cough is
productive or nonproductive, congested, dry, tickling, or hacking.
 
Sputum Production
Sputum production is an important symptom associated with coughing. The nurse
notes the duration, color, consistency, odor, and amount of sputum. Sputum may be
clear, white, tan, gray or, if infection is present, yellow or green.
 The nurse describes the consistency of sputum as thin, thick, watery, or frothy.
Smokers with chronic bronchitis have mucoid sputum because of chronic stimulation
and hypertrophy of the bronchial glands. Voluminous, pink, frothy sputum is
characteristic of pulmonary edema. Pneumococcal pneumonia is often associated
with rust-colored sputum, and foul-smelling sputum is often found in anaerobic
infections such as a lung abscess. Blood in the sputum (hemoptysis) is most
commonly noted in clients with chronic bronchitis or bronchogenic carcinoma.
Clients with tuberculosis, pulmonary infarction, bronchial adenoma, or lung abscess
may expectorate grossly bloody sputum.
Sputum can be quantified by describing its production in terms of measurements
such as teaspoon, tablespoon, and cups or fractions of cups. Normally, the
tracheobronchial treecan produce up to 3 ounces (90 mL) of sputum per day. The
nurse determines whether sputum production is increasing, possibly from external
stimuli (e.g., an irritant in the work setting) or an internal cause (e.g., chronic
bronchitis or a pulmonary abscess).
Chest Pain
A detailed description of chest pain helps the nurse differentiate pleural,
musculoskeletal, cardiac, and gastrointestinal pain. Because the perception of pain
is subjective, pain is analyzed in relation to the characteristics described in the his-
tory of the present illness. Coughing, deep breathing, or swallowing usually worsens
chest wall pain.
Dyspnea
The perception of dyspnea (difficulty in breathing or breathlessness) is subjective
and varies among clients. A client's perception may not be consistent with the
severity of the presenting problem. Therefore the nurse determines the type of onset
(slow or abrupt), the duration (number of hours, time of day), relieving factors
(changes of position, medication use, activity cessation), and evidence of audible
sounds (wheezing, crackles, stridor).
The nurse tries to quantify dyspnea by asking whether this symptom interferes
with activities of daily living (ADLs) and, if so, how severely. For example, is the
client breathless while dressing, showering, shaving, or eating? Does dyspnea on
exertion occur after walking one block or climbing one flight of stairs?
The nurse asks about paroxysmal nocturnal dyspnea (PND), which involves
intermittent dyspnea during sleep, and about orthopnea, which is demonstrated by a
shortness of breath that occurs when lying down but is relieved by sitting up. These
two conditions are commonly associated with chronic pulmonary disease and left
 ventricular failure. InPND, the client has a sudden onset of breathing difficulty
that is severe enough to awaken the client from sleep.
 
Physical Assessment
ASSESSMENT OF THE NOSE AND SINUSES
The nurse inspects the client's external nose for deformities or tumors and inspects
the nostrils for symmetry of size and shape. Nasal flaring may indicate an increased
respiratory effort. To observe the interior nose, the nurse asks the client to tilt the
head back for a penlight examination. The nurse may use a nasal speculum and
nasopharyngeal mirror for a more thorough examination of the nasal cavity.
The nurse inspects for color, swelling, drainage, and bleeding. The mucous
membrane of the nose normally appears redder than the oral mucosa, but it may
appear pale, engorged,and bluish gray in clients with allergic rhinitis. The nasal sep-
tum is checked for evidence of bleeding, perforation, or deviation. Some degree of
septal deviation is common in mostadults and appears as an S shape, inclining
toward one side or the other. A perforated septum is noted if the light
shines through the perforation into the opposite nostril; this condition is often found
in cocaine users. Nasal polyps, a common cause of obstruction, appear as pale,
shiny, gelatinous structures attached to the turbinates.
The nurse occludes one nare at a time to check whether air moves through the
nonoccluded side easily. The nose and paranasal sinuses are palpated to detect
tenderness or swelling. Only the frontal and maxillary sinuses are readily accessible
to clinical examination because the ethmoid and sphenoid sinuses lie deep within
the skull. Using the thumbs, the nurse checks for sinus tenderness by pressing up-
ward on the frontal and maxillary areas; both sides are assessed simultaneously.
Tenderness in these areas suggests inflammation or acute sinusitis. Tenderness in
response to tapping a finger over these areas also indicates inflammation.
Transillumination of the sinuses may be used to detect sinusitis. In a darkened
room, the nurse places the bulb of a penlight on the client's cheek (just under the
corner of theeye) and observes for light penetration through the roof of the mouth.
Normally, a faint glow of light through the bone outlines the sinus.
Transillumination is absent or decreased in sinusitis. However, this test is not
conclusive for sinusitis.
ASSESSMENT OF THE PHARYNX, TRACHEA, AND LARYNX
Examination of the pharynx begins with inspection of the external structures of the
mouth. To examine the structures of the posterior pharynx, the nurse uses a tongue
 depressor topress down one side of the tongue at a time (to avoid stimulating the
gag reflex). As the client says "ah," the nurse notes the rise and fall of the soft
palate and uvula and observes for color and symmetry, evidence of discharge
(postnasal drainage), edema or ulceration, and tonsillar enlargement or
inflammation.
The neck is inspected for symmetry, alignment, masses, swelling, bruises, and the
use of accessory neck muscles in breathing. Lymph nodes are palpated for size,
shape, mobility, consistency, and tenderness. Tender nodes are usually movable and
suggest inflammation. Malignant nodes are often hard and are fixed to the
surrounding tissue.
The nurse gently palpates the trachea for deviation, mobility, tenderness, and
masses. Firm palpation may elicit coughing or gagging. The space on either side of
the trachea should be equal. Many pulmonary disorders cause the trachea to deviate
from the midline. Tension pneumothorax, large pleural effusion, mediastinal mass,
and neck tumors push the trachea away from the affected area, whereas
pneumonectomy, fibrosis, and atelectasis cause a pull toward the affected area. De-
creased tracheal mobility may occur with carcinoma or fibro-sis of the mediastinum.
The larynx is usually examined by a specialist with a laryngoscope. The nurse
may observe an abnormal voice, especially hoarseness, when there are
abnormalities of thelarynx.
 
ASSESSMENT OF THE LUNGS AND THORAX
 
 
Inspection
Inspection of the chest begins with an assessment of the anterior and posterior
thorax. If possible, the client is in a sitting position during the assessment. He or she
should beundressed to the waist and draped for privacy and warmth. The chest is
observed by comparing one side with the other. The nurse works from the top (apex)
and moves downward toward the base while inspecting for discoloration, scars, le-
sions, masses, and spinal deformities such as kyphosis, scoliosis, and lordosis.
The nurse observes the rate, rhythm, and depth of inspirations as well as the
symmetry of chest movement. An impaired movement or unequal expansion may
indicate an underlying disease of the lung or the pleura. The nurse observes the type
of breathing (e.g., pursed-lip or diaphragmatic breathing) and the use of accessory
muscles. In observing respiration, the nurse documents the duration of the
inspiratory (I) and expiratory (E) phases. The ratio of these phases (the I/E ratio) is
normally 1:2. A prolonged expiratory phase indicates an obstruction of air outflow
and is often seen in clients with asthma or chronic obstructive pulmonary disease
(COPD).
The nurse examines the shape of the client's chest and compares the
anteroposterior (AP) diameter with the lateral diameter. This ratio normally ranges
from 1:2 to approximately 5:7, depending on body build. The ratio increases
to 1:1 in clients with emphysema, which results in the typical barrel chest
appearance.
Normally, the ribs slope downward. However, clients with air trapping in the
lungs caused by chronic asthma or emphysema have little or no slope to the ribs
(i.e., the ribs are more horizontal).
The nurse also checks for abnormal retractions of the intercostal spaces during
inspiration, which indicate airflow obstruction. These retractions may be due to
fibrosis of the underlying lung, severe acute asthma, emphysema, or tracheal or
laryngeal obstruction.
 

Palpation
Palpation of the chest occurs after inspection. Palpation allows the nurse to assess
respiratory movement symmetry and observable abnormalities, to identify areas of
tenderness, and to elicit vocal or tactile fremitus (vibration).
The nurse assesses thoracic expansion by placing the thumbs posteriorly on the
spine at the level of the ninth ribs and extending the fingers laterally around the rib
cage. As theclient inhales, both sides of the chest should move upward and
outward together in one symmetric movement, and the nurse's thumbs move apart.
On exhalation, the thumbs should come back together as they return to the midline.
Decreased movement on one side (unilateral or unequal expansion) may be a result
of pain, trauma, or pneumothorax (air in the pleural cavity). Respiratory lag or
slowed movement on one side may indicate the presence of a pulmonary mass,
pleural fibrosis, atelectasis, pneumonia, or a lung abscess.
The nurse palpates any abnormalities found on inspection (e.g., masses, lesions,
bruises, and swelling). The nurse also palpates for tenderness, particularly if the
client has reported pain. Crepitus (subcutaneous emphysema) is felt as a crackling
sensation beneath the fingertips and should be documented, especially if it occurs
around a wound site or if a pneumothorax is suspected. Crepitus indicates that air
is trapped within the tissues.
Tactile (vocal) fremitus is a vibration of the chest wall produced when the client
speaks. This vibration can be palpated on the chest wall. To elicit tactile fremitus,
the nurseplaces the palm or the base of the fingers against the client's chest wall
and instructs him or her to say the number 99. Using the same hand and moving
from the apices to the bases, the nurse compares vibrations from one side of the
chest with those from the other side. Palpable vibrations are transmitted from the
tracheobronchial tree, along the solid surface of chest wall, and to the nurse's
hand.
The nurse notes the symmetry of the vibrations and areas of enhanced,
diminished, or absent fremitus. Fremitus is decreased if the transmission of sound
waves from the larynx to the chest wall is slowed. This situation can occur when
the pleural space is filled with air (pneumothorax) or fluid (pleural effusion) or
when the bronchus is obstructed. Fremitus is increased over large bronchi because
of their proximity to the chest wall. Disease processes such as pneumonia and
abscesses increase the density of the thorax and enhance transmission of the
vibrations.
 
Percussion
The nurse uses percussion to assess for pulmonary resonance, the boundaries of
organs, and diaphragmatic excursion. Percussion involves tapping the chest wall,
which sets the underlying tissues into motion and produces audible sounds. The
nurse places the distal joint of the middle finger of the less dominant hand firmly
over the intercostal space to be percussed. No other part of the nurse's hand touches
the client's chest wall because doing so absorbs the vibrations. The middle finger of
the dominant hand then delivers quick, sharp strikes to the distal joint of the
positioned finger. The nurse maintains a loose, relaxed wrist while delivering the taps
with the tip of the finger, not the finger pad. This technique is repeated two or three
times to determine the intensity, pitch, quality, and duration of the sound produced.
Long fingernails limit the ability to percuss.

Percussion produces five distinguishable notes. These sounds assist the nurse in

determining the density of the underlying structures (i.e., whether the lung tissue
contains air or fluid or is solid). Percussion of the thorax is performed over the
intercostal spaces because percussing the sternum, ribs, or scapulae yields sound
indicating solid bone. Percussion penetrates only 2 to 3 inches (5 to 7 cm), and
therefore deeper lesions are not detected with this technique.
Percussion begins with the client sitting in an upright position. The nurse assesses
the posterior thorax first and proceeds systematically, beginning at the apex and
working toward the base. The apex of the lung extends anteriorly approximately ¾
to 1 ½  inches (2 to 4 cm) above the clavicle. Posteriorly, there is approximately a
2-inch (5-cm) width oflung tissue at the apex.
 The nurse assesses diaphragmatic excursion by instructing the client to "take a
deep breath and hold it" while percussing downward until dullness is noted at the
lower border of the lung. Normal resonance of the lung stops at the diaphragm,
where the sound becomes dull; this site is marked. The nurse repeats the process
after instructing the client to "let out all your breath and hold." The difference
between the two markings or sounds is the diaphragmatic excursion, which may
range from 1 to 2 inches (3 to 5 cm). The diaphragm is normally higher on the right
because of the location of the liver. Diaphragmatic excursion may be decreased or
absent in clients with pleurisy, diaphragm paralysis, or emphysema.
The nurse continues to assess the thorax with percussion of the anterior and lateral
chest. The percussion note changes from resonance of the normal lung to dullness
at the borders of the heart and liver. The presence of fluid or solid material is
indicated by a dull percussion note over lung tissue (as occurs with pneumonia,
pleural effusion, fibrosis, atelectasis, and tumors).

Auscultation
Auscultation includes listening for normal breath sounds, adventitious sounds, and
voice sounds. Auscultation provides information about the flow of air through the
tracheo-bronchial tree and helps the listener to identify fluid, mucus, or obstruction
in the respiratory system. The diaphragm of the stethoscope is designed to detect
high-pitched sounds.
Auscultation begins with the client sitting in an upright position. With the
stethoscope pressed firmly against the client's chest wall (clothing can distort or
muffle sounds), the nurse instructs him or her to breathe slowly and deeply through
an open mouth. (Breathing through the nose would set up turbulent sounds that are
transmitted to the lungs.) A systematic approach is used, beginning at the apices and
moving down through the intercostal spaces to the bases. Listening over bony
structures is avoided while auscultating the thorax posteriorly, laterally, and
anteriorly. The nurse listens to a full respiratory cycle, noting the quality and
intensity of the breath sounds. The client is observed for signs of lightheadedness or
dizziness caused by hyperventilation during auscultation. If these symptoms occur,
the client is told to breathe normally for a few minutes.
NORMAL BREATH SOUNDS
Normal breath sounds are produced as air vibrates while passing through the
respiratory passages from the larynx to the alveoli. Breath sounds are identified by
their location,intensity, pitch, and duration within the respiratory cycle (e.g.,
early or late inspiration and expiration). Normal breath sounds are known
as bronchial or tubular (harshhollow sounds heard over the trachea and
mainstem bronchi), bronchovesicular (heard over the branching bronchi),
and vesicular (a soft rustling sound heard in the periphery over small
bronchioles). The nurse describes these sounds as normal, increased, decreased
(diminished), or absent.
When bronchial breath sounds are heard peripherally, they are abnormal. This
increased sound occurs when centrally generated bronchial sounds are transmitted
to an area of increased density, such as in clients with atelectasis, tumor, or
pneumonia. When audible in an abnormal location, bronchovesicular breath sounds
may indicate normal aging or anabnormality such as pulmonary consolidation and
chronic airway disease.
 
ADVENTITIOUS BREATH SOUNDS
Adventitious sounds are additional breath sounds superimposed on normal
sounds, and they indicate pathologic changes in the tracheobronchial tree.
Table 27-6 classifies anddescribes adventitious sounds: crackle, wheeze,
rhonchus, and pleural friction rub. Adventitious sounds vary in pitch, intensity,
duration, and the phase of the respiratory cycle inwhich they occur. The nurse
documents exactly what is heard on auscultation.
VOICE SOUNDS
If the nurse discovers abnormalities during the physical assessment of the lungs and
thorax, the client is assessed for vocal resonance. Auscultation of voice sounds
through the normally air-filled lung produces a muffled, unclear sound because
sound vibrations travel poorly through air. Vocal resonance is increased when the
sound must travel through asolid or liquid medium, as it does in clients with a
consolidated area of the lung, pneumonia, atelectasis, pleural effusion, tumor, or
abscess.
BRONCHOPHONY. Bronchophony is the abnormally loud and clear
transmission of voice sounds through an area of increased density. For assessment
of bronchophony, the client repeats the number 99 while the nurse systematically
auscultates the thorax.
WHISPERED PECTORILOQUY. Whispered pectoriloquy is the enhanced
voice heard through the chest wall. It is much more sensitive than bronchophony and
is perceived byhaving the client whisper the number sequence one,
two,  three. Whispered words normally sound faint and indistinct. If they are heard
loudly and distinctly, the nurse suspects consolidation of lung tissue.
 EGOPHONY. Egophony is another form of abnormally enhanced vocal
resonance and has a high-pitched, bleating, nasal quality. The nurse auscultates the
thorax while the clientrepeats the letter E. Egophony exists when this letter is heard
as a flat, nasal sound of A through the stethoscope. This abnormal sound indicates
an area of consolidation, pleural effusion, or abscess.
 
OTHER INDICATORS OF RESPIRATORY ADEQUACY
The nurse evaluates additional indicators of respiratory adequacy because gas
exchange affects all body systems. Some indicators (e.g., cyanosis) indicate
immediate oxygenationproblems. Other changes (e.g., clubbing, weight loss, un-
evenly developed muscles) reflect a more long-standing oxygenation problem.