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E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Compare assessment findings to normal
● Refer patient to an internist or endocrinologist for evaluation of
abnormal findings if warranted

KEY POINTS FOR REPORTING AND RECORDING

● Abnormal observations of the neck including lesions, nodules,
swelling, asymmetry, or tenderness.
● If nodes are palpated, note their location, size, shape, delimita-
tion (discrete or matted together), mobility, consistency, and
tenderness.
● Position of the trachea (midline or direction of deviation) and
direction of tracheal deviation if present.
● Ability to palpate thyroid, tenderness; if enlarged, which lobes
are palpable, auscultation of a bruit.
● Presence of jugular-vein distention noting the degree of eleva-
tion of the head.
● Limitation of range of motion and in which position.

PROCEDURE 4.6
Assessing the Thorax and Lungs
OVERVIEW
● To determine functional status and to detect any alteration in physi-
ologic process.
● A complete physical assessment of the chest and lungs, together

with the history, will provide the examiner with important clues to
diagnose and treat various pathologic conditions.

P R E PA R AT I O N
● Provide privacy during assessment.
● Interview patient prior to assessment focusing on any history of
cough, sputum production, allergies, dyspnea at rest or on exertion,
chest pain, asthma, bronchitis, emphysema, tuberculosis, cyanosis,
pallor, exposure to environmental irritants, or smoking.
● A specific sequence should be used when assessing the chest and

lungs—inspection, palpation, percussion, and auscultation.

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Special Considerations
Pediatric Patient
• There are special considerations when assessing the thorax and
lungs of an infant. The anterior-posterior diameter noted on inspec-
tion of an infant is equal to the lateral or transverse diameter (1:1).
The lateral diameter increases in proportion to the anteroposterior
diameter.
• The chest wall is thin, and the rib cage is soft and pliant.
• Respiratory rate will vary with age.
• Hyperresonance will be demonstrated upon auscultation throughout
the lungs owing to the thin chest wall.
• The bell of the stethoscope or small diaphragm should be used to
localize findings.
• Wheezes and rhonchi occur more frequently in infants and young
children.
• See Table 4.6A for respiratory rates for children.

TABLE 4.6 Respiratory Rates for Children

AGE RATE
Newborn–5 months 30–50
5–23 months 20–30
24 months–12 years 20–30
12 years–19 years 12–20

Elderly Patient
• Chest expansion is often decreased owing to muscle weakness,
physical disability, or calcification of the rib articulations.
• Bony prominences are marked, and there is a loss of subcutaneous
tissue.
• The dorsal curve of the thoracic spine may be pronounced (kypho-
sis), along with flattening of the lumbar curve.
• The anterior-posterior diameter is increased in relation to the lateral
diameter.
• The pace of the physical examination should be adapted to the indi-
vidual need.

R E L E VA N T N U R S I N G D I A G N O S E S
● Possible impaired tissue perfusion due to disease
● Impaired gas exchange related to infection
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80 C h a p t e r 4 Physical Assessment

EXPECTED OUTCOMES
The outcome of assessing the thorax and lungs will include the
following:
● Inspection of symmetry of movement on expansion, anterior-

posterior to lateral diameter, and the use of accessory muscles

● Palpation of tactile fremitus

● Percussion for diaphragmatic excursion, resonance notes

● Auscultation of vesicular, bronchovesicular, bronchial, and adventi-

tious breath sounds

EQUIPMENT/SUPPLIES
Stethoscope
Tape measure
Drapes
Marking pencil

I M P L E M E N TAT I O N
➧ Wash hands.
Reduces transmission of microorganisms.

➧ Organize equipment.
Organizing equipment before beginning an assessment enhances efficiency.

➧ Explain assessment to patient.

Careful explanation reduces the patient’s anxiety.

➧ Expose anterior, posterior, and lateral chest with patient in sitting

position.
Exposure of the chest in the sitting position facilitates easy access for inspec-
tion, palpation, percussion, and auscultation of the area.
Inspection
➧ Inspect anterior, posterior, and lateral thorax for the following:
Inspection will enable the examiner to assess the general appearance of the
thorax. Inspection is important before palpation, percussion, and ausculta-
tion as the latter are more invasive.
● Color
Color should be pink without pallor or cyanosis.
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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 81

● Intercostal spaces
The intercostal spaces should be even and relaxed, without bulging or
retracting.
● Chest symmetry
Both sides of the chest should be equal.
● Costal angle
The costal angle is formed by the blending together of the costal margins at
the sternum. It is usually no more than 90 degrees, with the ribs inserted at
approximately 45-degree angles.
● Respirations
Respirations should be even, 12–20/min, unlabored.
● Anterior-posterior to lateral diameter
Normal is a 1:2 ratio (anterior-posterior diameter is approximately one half
the lateral diameter). This information will provide the examiner with shape
and symmetry of the chest. A barrel chest, which results from compromised
respiration, chronic obstructive pulmonary disease (COPD), for example, will
demonstrate an increase in the anteroposterior diameter.
● Shape and position of sternum
Sternum should be level with the ribs. Two structural variations of the ster-
num are pigeon chest (pectus carinatum), a prominent sternal protrusion,
and funnel chest (pectus excavatum), which is an indentation of the lower
sternum above the xiphoid process.
● Position of trachea
Trachea should be midline without deviation to either side.
● Chest expansion
Chest should expand approximately 3 inches upon inspiration.
Palpation
➧ Drape anterior chest. Use finger pads or palm of hands to palpate
posterior chest. Have patient lean forward and fold arms across chest.
Palpation of the chest will enable the examiner to assess the thoracic mus-
cles and skeleton, and to feel for pulsations, areas of tenderness, bulges,
depressions, and unusual movements. The anterior chest should be draped
while you are assessing the posterior chest to ensure privacy. Leaning for-
ward increases the area of the lungs. Palpation, percussion, and auscultation
of the posterior lungs will be done while the patient remains in the sitting
position.
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82 C h a p t e r 4 Physical Assessment

➧ Palpate upper, middle, and lower thorax for sensation.

No pain or tenderness should be present.

Palpating anterior chest excursion Palpating anterior chest excursion

at apex at base

FIGURE 4.6A Example of chest palpation.

➧ Palpate upper, middle, and lower thorax for vocal fremitus. Have the
patient say “99” while palpating.
Vibration should be decreased over the periphery of the lungs and increased
over the major airways. Vibration will be increased over areas of consolida-
tion and decreased over airway with obstruction.

➧ Palpate the thorax for expansion. Place hands at level of 10th rib on
the posterior thorax, and have patient take a deep breath. Observe
thumb movement.
2- to 3-inch symmetric expansion should be noted upon inspiration.

➧ Place hands on the lower sternum anteriorly and have patient take
a deep breath. Observe thumb movement.
Symmetric expansion of 2 to 3 inches should be noted.
Percussion
➧ Percuss over shoulder apices and at posterior, anterior, and lateral
intercostal spaces moving from apex to base of lungs.
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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 83

Percussion will provide the examiner with information concerning areas of

the thorax and lungs that are air-filled or that may have consolidation (fluid-
filled). The impact of the examiner’s finger produces a vibration against the
underlying tissue, and percussion tones can be heard (resonance). Resonance,
a loud, low-pitched, hollow sound is percussed in healthy lungs. The more
dense the medium, as in fluid or masses, for example, the quieter (dullness)
the percussion tone. The percussion tone over air-filled lungs is loud, low-
pitched, and has a boomlike quality (hyperresonance), as in emphysema.

FIGURE 4.6B Percussion sequence.

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84 C h a p t e r 4 Physical Assessment

➧ Percuss for diaphragmatic excursions bilaterally.

● Ask patient to inhale deeply and hold.
● Percuss along the scapular line until you locate the lower border
(noted by a change from resonance to dullness).
● Mark the point with a pencil and have the patient breathe.

● Ask the patient to exhale as much as possible and hold.

● Percuss up from the marked point and mark where the change

from dullness to resonance occurred. Have the patient breathe.

● Measure and record the distance in centimeters.

The excursion distance of the diaphragm is usually 3 to 5 cm. The descent

of the diaphragm may be limited by emphysema, ascites, tumor, or pain.
Auscultation
➧ Instruct patient to take slow, deep breaths through his mouth while
you auscultate the intercostal spaces with the diaphragm of the
stethoscope. Auscultate over the following areas:

FIGURE 4.6C Auscultation sequence.

Auscultation of the chest provides the examiner with important clues to the
condition of the lungs. Listen for two full breaths while comparing each side
of the thorax moving the stethoscope from the apex of the lungs to the base.
● Trachea
Bronchial (tubular)/ tracheal breath sounds are heard over the trachea.
They are high-pitched, loud, with the expiratory phase of respiration often
longer than the inspiratory phase.
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● Bronchial airway, including below clavicles and between scapulae

Bronchovesicular breath sounds, medium in pitch, are heard over the main
bronchus area and over the upper-right posterior lung field. The inspiratory
phase should equal expiratory phase.
● Lung periphery
Vesicular (soft, breezy) breath sounds, low in pitch, are heard over lung
periphery. The inspiratory phase should be longer than the expiratory
phase.

➧ Auscultate breath sounds for adventitious sounds, including

wheezes, rales, and rhonchi.
Lungs should be clear to auscultation on inspiration and expiration. If abnor-
mal sounds are heard, ask patient to cough and note if adventitious sound is
still present.

➧ Auscultate for altered voice sounds over lung periphery where any
previous lung abnormality was noted.
● Bronchophony patient says “99” while examiner auscultates.

● Whispered pectoriloquy patient whispers “one, two, three” while

examiner auscultates.
● Egophony patient says “eee” while examiner auscultates.

Auscultation for altered voice sounds will provide the examiner with clues
regarding the presence of consolidation in the lung tissue. The voice
vibrates and transmits sounds through the lung fields. The sounds should
be muffled in healthy lungs, but may be loud and clear in any condition
that consolidates lung tissue.

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Compare assessment findings to normal findings
● Record and report normal and abnormal findings

KEY POINTS FOR REPORTING AND RECORDING

●A history of any condition reported in the interview (subjec-
tive data) such as a history of cough, sputum production, aller-
gies, dyspnea at rest or on exertion, chest pain, asthma,
bronchitis, emphysema, tuberculosis, cyanosis, pallor, exposure
to environmental irritants, or smoking.
● Assessment findings (objective data) to include
• Size and shape of chest, anteroposterior versus lateral diame-
ter, symmetry of movement with respiration
• Presence of retractions or use of accessory muscles
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86 C h a p t e r 4 Physical Assessment

• Diaphragmatic excursion
• Respiratory rate, depth, regularity, and ease of respiration
• Symmetry and quality of tactile fremitus
• Symmetry and quality of percussion notes
• Characteristics of breath sounds including location and
phase of respiration where abnormal sounds are auscultated
• Characteristics of cough
• Presence of vocal resonance

PROCEDURE 4.7
Assessing the Heart and Vascular System
OVERVIEW
● The heart and the blood vessels are complex, integrated systems.
● Findings from examinations of other systems, besides the cardiovas-
cular, have a significant impact on judgments that will be made
about the cardiovascular system.
● Performing a successful examination requires an ability to integrate

and interpret findings in relation to the cardiac events they reflect.

P R E PA R AT I O N
● The parts of the physical examination should be performed in a
sequence that is comfortable for the examiner, with assessment of
the heart following the traditional inspection, palpation, percussion,
and then auscultation.
● These systems cannot be appropriately evaluated unless a complete

examination is performed.
● Interview the patient for any history of the following: chest pain,

irregular heartbeats, hypertension, diabetes, rheumatic fever, stroke,

or smoking. Ask about pain in calves, feet, buttocks, or legs, including
the type of pain and what aggravates or relieves the pain. Is there a
history of coldness, cyanosis, edema, varicosities, paresthesia, or tin-
gling in the extremities?

Special Considerations
Pediatric Patient
• There are a few variations that occur normally in children.
• The presence of an S3 and S4 in children and young adults is com-
mon, but an increase in the intensity should be suspect.