HEALTH ASSESSMENT Assessment of the Nose

- Inspect and palpate the external nose for

Learning Outcome
- knowing how to answer and ask logical
questions (communication)
- develop clinical eye (observation)
- develop critical thinking
NOSE AND SINUSES
Collecting Subjective Data
- History of present health concern
- Past health history
- Family history
- Lifestyle and health practices
Equipment for Assessment of the Upper Respiratory
Tract
color, shape, consistency, tenderness, and
patency of airflow.
- Inspect the internal nose for color, swelling,
exudate, bleeding, ulcers, perforated septum,
or polyps.
Clinical Tip
- Position the otoscopes handle to the side to
improve your view of the structure. If an
otoscope is unavailable, use a penlight and
hold the tip of the nose slightly up. A nasal
speculum with a penlight also facilitates
good visualization.
Structure of the Sinus
- Four pairs of paranasal sinuses—frontal,
maxillary, ethmoidal, and sphenoidal are in
the skull.
- Sinuses decrease the weight of the skull and
act as resonance chambers during speech.

- Gloves Assessment of the Sinuses

- Cotton gauze pads - Palpation for tenderness
- Penlight - Percussion and transillumination for air
- Nasal speculum attached to otoscope versus fluid or pus
- Tongue blade (Palpating the frontal sinuses and maxillary
sinuses.)
Physical Assessment Techniques
Clinical Tip
- Inspection
- Palpation - Upper dentures should be removed is that
- Percussion the light is not blocked

Structure of the Nose Abnormal Findings of the Nose and Sinuses

- Nasal Polyp
- Consists of an external portion covered with
- are soft, painless, noncancerous growths on
skin and an internal nasal cavity
the lining of your nasal passages or sinuses.
- External Nose: a bridge, tip, and two ovals’
- Perforated Septum
openings called nares
- A perforated septum is usually caused by
- Internal Nose: nasal cavity; nasal septum;
the loss of blood flow to both sides of the
Kiesselbach area; superior, middle, and
septum. This causes the cartilage to
inferior turbinate’s
deteriorate, which prevents proper airflow
and worsens as air slips through from one
nostril to the other through the hole.
 THORAX AND LUNGS
Structure of the Thorax and Lungs
- Thorax
- Extends from the base of the neck
superiorly to the level of the diaphragm
inferiorly
- Lungs, distal portion of the trachea,
bronchi
- Sternum
- Lies in the center of the chest anteriorly
- Has three parts:
• Manubrium, the body, xiphoid process
- 12 pairs of ribs—thoracic cage
- Mediastinum
- Central area in the thoracic cavity
- Lungs
- two cone-shaped, elastic structures
- Pleura
- thin, double-layered serous membrane that
lines the thoracic cavity
Vertical Reference Lines
- Anterior Chest
• midsternal, right and left midclavicular
lines
- Posterior Thorax
• vertebral line, right and left scapular lines
- Lateral Thorax
• midaxillary line, anterior and posterior
axillary lines
Health History
- Cough
- Onset? Gradual or sudden? Frequency?
- Continuous throughout day – acute illness
(respiratory infection)
- Afternoon/evening – may reflect exposure
to irritants at work
- Night – postnasal drip, sinusitis
- Early morning – chronic bronchial
inflammation of smokers
- Sputum? How much? Characteristics?
• Chronic bronchitis – productive cough for
3 months of the year for 2 years in a row.
Yellow or green – bacterial infection, strep
throat. Rust colored – TB, pneumococcal
pneumonia. Pink, frothy – pulmonary
edema, medications to treat pulmonary
fibrosis.
- Cough up blood?
- Description of cough – dry, hacking
- Associative and Alleviating factors
- Painful?
- Shortness of Breath (SOB)
- Onset, associative factors
• Determine how much activity precipitates
SOB
- Affected by position?
• Orthopnea – difficulty breathing when
supine (heart failure?)
- Time of day/night
• Paroxysmal nocturnal dyspnea –
awakening from sleep with SOB and
needing to be upright to achieve comfort
- Allergies?
• Asthma attacks
- Alleviating factors
- Chest pain with breathing?
• Location, onset, duration, frequency,
intensity, associative and alleviative factors.
- Past history of respiratory infections
- Smoking history
- Environmental exposure
- Self-care behaviors
• Immunizations, TB skin tests, chest X-rays
Assessment-Inspection
- Inspect Thorax
- Symmetry
- AP Diameter
• Normal 1:2
• AP diameter = transverse diameter, “barrel
chest”. Occurs with normal aging, chronic
emphysema, and asthma
- Symmetry and normal development of
trapezius muscle
•Hypertrophied in COPD
- Position person takes to breathe
• COPD – tripod position
Assessing the Anterior Chest
- Symmetric chest expansion
- Abnormally wide costal angle occurs with
emphysema.
Posterior Chest
- Symmetric chest expansion
- Ask person to place warmed hands-on
posterolateral chest wall with thumbs at
level of T9 or T10 and pinch up small fold
of skin between thumbs. As person inhales,
ask person to move thumbs apart
symmetrically and take a deep breath.
Tactile Fremitus
- Fremitus is a palpable vibration transmitted
through the bronchi and lung parenchyma to
the chest wall.
- Abnormalities in fremitus
- Decrease fremitus occurs when anything
obstructs transmission of vibrations
• Obstructed bronchus
• Pleural effusion or thickening
• Pneumothorax
• Emphysema
- Increased fremitus occurs with compression
or consolidation of lung tissue
• Lobar pneumonia
- Rhonchal fremitus palpable with thick
secretions
- Crepitus occurs in subcutaneous
emphysema, when air escapes from the
lungs and enters the body's nervous system
through the skin (subcutaneous), sometimes
called anaphylactic shock.
Percussion
- Start at the apices and percuss across tops of
both shoulders and down the lung region at
approx. 5cm intervals.
- Make a side-to-side comparison
- Avoid damping effect of scapulae and ribs.
- Resonance predominates in healthy lungs.
• Hyperresonance is found when too much
air is present (emphysema or pneumothorax)
• Dullness signals abnormal density
(pneumonia, pleural effusion, atelectasis,
tumor)
- Expected percussion notes
• Resonance
• Flat over scapula
• Visceral dullness
• liver dullness
- Percussion notes
Percussing and Auscultating Anterior Chest
- Begin percussing the apices in
supraclavicular ares, continuing down in
intercostal spaces
- Note cardiac and liver dullness and stomach
tympany
• Chronic emphysema leads to
hyperinflation of lungs, resulting in
hyperresonance where you would expect
cardiac dullness
- Auscultate lung fields down to the 6th rib.
Progress from side to side moving
downward and listen for one full respiration
at each location
Auscultating Posterior Chest
- Breath sounds
- Instruct the person to breathe through the
mouth a little deeper than usual, but to
stop if they feel dizzy. Hyperventilation
may lead to fainting!
- Use the flat diaphragm endpiece of the
stethoscope and listen for at least one full
respiration in each location
- Continue to think:
- What am I hearing?
- What should I expect to be hearing?
• Bronchial
• Bronchovesicular
• Vesicular
- Do not confuse background noise with lung
sounds
• Stethoscope tubing bumping together
• Shivering
• Hairy chest
• Rustling of gown
- Characteristics of normal breath sounds
• High > loud > inspiration\expiration >
harsh, hollow tubular > Trachea and larynx
• Moderate > moderate >
inspiration=expiration > mixed > over major
bronchi where fewer alveoli are located
• low > soft > inspiration/expiration >
rusting like the sound of the wind in the
trees > over peripheral lung fields where air
flows through smaller bronchioles and
alveoli.

Auscultation
- Abnormal findings
- Decreased breath sounds
• Obstruction of bronchial tree (by
secretions, mucous plug, foreign body)
• In emphysema due to loss of elasticity in
the lung fibers and decreased force of
inspired air. The lungs are already
hyperinflated so not much air will be coming
in.
• Obstruction of sound by pleural thickening
• Silent chest – no air moving in or out
- Increased breath sounds louder than normal
- Bronchial sounds
• Heard in abnormal location, such as
periphery
• High pitched, with prolonged expiratory
phase
• Occur in consolidation (pneumonia) or
compression (fluid in intrapleural space).
Dense lung tissue enhances transmission
of sound.
Auscultating Adventitious Sounds
- Adventitious sounds
- Sounds not normally heard in the lungs
- Caused by moving air colliding with
secretions in trachea or bronchi, or from
popping open of previously deflated
airways
- Crackles (fine)
- Description: popping sounds heard during
inspiration. May be stimulated by rolling a
strand of hair between fingers near the ear.
- Mechanism: Inhaled air collides with
previously deflated airway
- Clinical example:
• Early inspiratory – COPD
• Late inspiratory – Pneumonia, heart
failure, interstitial fibrosis
Crackles (coarse)
- Description
- loud, low-pitched, bubbling and gurgling
sounds early in inspiration. Sound like
Velcro.
- Mechanism
- Inhaled air collides with secretions in
trachea and large bronchi
- Clinical example:
- Pulmonary edema, pneumonia, pulmonary
fibrosis, depressed cough reflex
Pleural Friction Rub
- Description
- Coarse and low-pitched superficial sound.
Both inspiratory and expiratory.
- Mechanism
- Caused when pleurae become inflamed and
lose normal lubricating fluid. Pleural
surfaces rub together during respiration.
Heard best in anterolateral wall.
- Clinical example:
- Pleuritis
Wheeze
- Description
- High pitched musical squeaking sound
predominantly during expiration
- Mechanism
- Air squeezed or compressed through
narrowed airways (collapsing, swelling,
secretions, tumors)
- Clinical example:
- Acute asthma or chronic emphysema
Rhonchi (sonorous)
- Description
- Low-pitched, musical snoring
- Mechanism
- Airflow obstruction
- Clinical example:
- Bronchitis, obstruction of bronchus from
obstruction or tumor
Stridor
- Description
- High pitched, inspiratory, crowing sound,
louder in neck than over chest wall
- Mechanism
- Originates in larynx or trachea. Upper
airway obstruction from inflamed tissue or
obstruction
- Clinical example:
- Croup and acute epiglottitis. Obstructed
airway.
Developmental Consideration
- Infants
- While infant is sleeping, can inspect and
auscultate the lungs
- Infants normally have a rounded thorax,
reaching a 1:2 (anteroposterior to transverse)
diameter by age 6
• If a barrel shape persists after age 6,
possible chronic asthma or cystic fibrosis
- If baby begins to cry, it actually enhances
the palpation of tactile fremitus.
- Pregnancy
- Wider thoracic cage
- The enlarging uterus elevates the
diaphragm 4 cm during pregnancy, but the
increased estrogen relaxes thoracic
ligaments allowing compensation by
increasing the transverse diameter
- Mother’s tidal volume increases to meet
demands of fetus
- Aging
- kyphosis
- calcification of costal cartilage
- decreased vital capacity
- decreased number of alveoli
- decreased mucous production