THE COLLEGE OF MAASIN

Nisi Dominus Frustra

College of Nursing and Allied Health
Sciences Maasin City, Southern
Leyte

THORACIC AND LUNG ASSESSMENT

Collecting Objective Data: PHYSICAL EXAMINATION
 Begins when the nurse first meets the client and observes any obvious breathing
difficulties
 Complete examination of the thorax and lungs consists of inspection, palpation,
percussion and auscultation of the posterior and anterior thorax to evaluate the
functioning of the lungs

Preparing the client

 Have the client remove all clothing from the waist up and put on an examination gown or
drape
 The gown should open down the back and is used to limit exposure
 Explain that exposure of the entire chest is necessary during some parts of the
examination
 Explain the procedures before initiating the examination to ease client anxiety
 Ask the client to sit in an upright position with arms relaxed at the sides
 The client should be encourage to ask questions and to inform the examination of any
discomfort or fatigue he experiences during the examination

Equipment
 Examination gown and drape
 Gloves
 Stethoscope
 Light source
 Mask
 Skin marker
 Metric ruler

PHYSICAL ASSESSMENT

Assessment Procedure Normal Findings Abnormal Findings

GENERAL
Inspection
1. inspect for nasal flaring Nasal flaring is not observed Normally Nasal flaring is seen with labored
and pursed lip breathing diaphragm and external intercostal resting respirations
muscles do most of the work of and is indicative of hypoxia
breathing (evidenced by outward Pursed lip breathing may be seen in
expansion of the abdomen and lower asthma, emphysema or
ribs on inspiration and return to CHF as a physiologic response to help
resting position on slow down expiration and keep alveoli
expiration) open
longer

2. observe color of face and Has evenly colored skin tone without Ruddy o purple complexion may be seen
chest unusual or prominent discoloration in clients with COPD or CHF as a result
of polycythemia
Cyanosis may be seen if client hypoxic

3. observe quality and Respiration are relaxed, effortless and Labored and noisy breathing is
pattern of respiration quiet often seen with severe asthma or
a. note breathing Regular rhythm and normal depth at a chronic bronchitis Abnormal
characteristics such as rate, rate of 16-20 per minute in adults breathing
rhythm and depth pattern include:tachypnea,
bradypnea, hyperventilation,
hypoventilation, cheyne- stokes
respiration and Biot’s respiration

College of Nursing and Allied Health
POSTERIOR/ANTERIOR
THORAX
1. inspect Configuration
a. ask client sits with her arms at her
sides
b. stand behind her and observe the
position of scapulae and shape and
configuration of the chest wall
2. inspect intercostal spaces
a. ask the client to breathe normally
and observe the intercostal spaces
3. observe use of accessory muscles
a. watch as the client breathes
and note use
Palpation
1. palpate for tenderness, sensation unusual sensations
and crepitus (cracking sensation – like No palpable crepitus
bones rubbing against each other)
POSTERIOR THORAX
a. used your fingers to palpate for
tenderness, warmth, pain or other
sensations
b. start toward the midline at the level
of the left scapula (over the apex of
the left lung) and move your hand left
to right)
c. compare findings bilaterally
move systematically downward and out
to cover the lateral portions of the
lungs at the bases
ANTERIOR THORAX
a. start with your hand positioned
over the left clavicle (over the apex of
the left lung)
b. move your hand left to right
c. compare findings bilaterally
d. move your hand systematically
downward toward the midline at the
level of the breasts and outward at the
base to include the lateral aspect of
the lung
THE COLLEGE OF MAASIN
Nisi Dominus Frustra
Sciences Maasin City, Southern
Leyte
Scapulae are symmetric and non-
protruding
Shoulders and scapulae are at equal
horizontal positions
Ratio of anteroposterior to transverse
diameter is 1:2
Spinous process appear straight and
thorax appears symmetric with ribs
sloping downward at approximately a
45-degree angle in relation to the
spine
Scoliosis is common in older clients
No retractions or bulging of
intercostal spaces are noted
Does not use accessory
(trapezius/shoulder)/(sternomastoid
and rectus abdominis) muscles to
assist breathing
Client reports no tenderness, pain or
Spinous processes that deviate
laterally in the thoracic area may
indicate scoliosis
Increased ratio between the
anteroposterior-
transvers diameter (barrel chest)
commonly results for emphysema
Retraction of the
intercostal spaces
indicates an increased inspiratory
effort
This may be the result of an
obstruction of the respiratory tract
or atelectasis
Bulging of the intercostal spaces
indicates trapped air such as
emphysema or
asthma
Trapezius, shoulder
muscles/neck muscles
(sternomastoid) are used to
facilitate inspiration in cases of
acute and chronic airway
obstruction or
atelectasis
Tender or painful areas may
indicate inflamed fibrous
connective tissue Pain over the
intercostal spaces may be from
inflamed pleurae
Pain over the ribs is a symptoms
fracture ribs
Crepitus can be palpated if air
escapes from the lung or other
airways into the subcutaneous
tissue resulting from open
thoracic injury, extreme congestion
and consolidation

College of Nursing and Allied Health
2. palpate for fremitus
a. use the ball or ulnar edge
of one hand to assess for
fremitus (vibrations of air in
the bronchial tubes
transmitted to the chest wall)
b. as you move your hand to
each area, ask the client to
say “ninety-nine”
c. assess all areas for
symmetry and intensity of
vibrations
3. assess chest expansion
POSTERIOR THORAX
a. place your hands on the posterior
chest wall with your thumbs at the
level of T9 or T10
b. as the client takes a deep breath,
observe the movement of your
thumbs
THE COLLEGE OF MAASIN
Nisi Dominus Frustra
Sciences Maasin City, Southern
Leyte
Fremitus is symmetric and easily
identified in the upper regions of
the lungs
If fremitus is not palpable on either
side, the client may need to speak
louder
A decrease in the intensity of
fremitus is normal as the examiner
moves toward the base of the
lungs
The examiner’s thumb should
move 5 to 10 cm apart
symmetrically
Unequal fremitus is usually
the result of consolidation
(which increases fremitus)
or bronchial obstruction,
air trapping in
emphysema, pleural
effusion or pneumothorax
(all decrease fremitus)
Diminished fremitus even
with a loud spoken voice
may indicate an
obstruction of the trachea-
bronchial tree
Unequal chest expansion can occur
with severe atelectasis (collapse or
incomplete expansion), pneumonia,
chest trauma, or pneumothorax (air
in the pleural space)

ANTERIOR THORAX
a. place your hands on the client’s
antero-lateral wall with your thumbs
along the costal margins and pointing
toward the xyphoid process
b. ask the client to take a deep
breath
c. observe the movement of
your thumb
Percussion
1. Percuss the tone Resonance is the percussion tone Hyperesonance is elicited in cases
POSTERIOR THORAX elicited over normal lung tissue of trapped air such as in
a. start at the apices of the scapulae emphysema or pneumothorax
and Percuss across the tops of both Dullness is present when fluid or
shoulders solid tissue replaces air in the lung
b. then Percuss the intercostal or occupies the pleural space such
spaces across and down, comparing as pneumonia, pleural effusion or
sides tumor
c. Percuss to the lateral aspects at
the bases of the lungs, comparing
sides

ANTERIOR THORAX
a. Percuss the apices above the
clavicle
b. then Percuss the intercostal
spaces across and down
compare sides
 THE COLLEGE OF MAASIN
Nisi Dominus Frustra
College of Nursing and Allied Health
Sciences Maasin City, Southern
Leyte
2. Percuss for Excursion should be equal Diaphragmatic descent may be
diaphragmatic excursion bilaterally and measure 3-5cm in limited by atelectasis of the lower
POSTERIOR THORAX adults lobes or by emphysema in which
a. ask he client to exhale forcefully diaphragmatic movement and air
and hold the breath, beginning at the trapping are minimal
scapular line (T7)
b. Percuss the intercostal spaces of
the right posterior chest wall
c. Percuss downward until the tone
changes from resonance to dullness
d. mark this level and allow the client
to breath
e. next ask the client to inhale deeply
and hold it
f. Percuss the intercostal spaces
from the mark downward until
resonance changes to dullness
g. mark the level and allow the client
to breathe
h. measure the distance
between the two marks
i. perform on both sides of
the posterior thorax
3. Auscultate for breath sounds Three types of normal breath Adventitious lung sounds such as
POSTERIOR THORAX sounds may be auscultated – crackles (formerly called rales) and
a. place the diaphragm of the bronchial, Bronchovesicular and wheezes (formerly called rhonchi)
stethoscope firmly and directly on the vesicular are evident
posterior chest wall at the apex of the
lung at C7
b. ask the client to breathe deeply
through his or her mouth for each
area of auscultation (each
placement of the
stethoscope) in the auscultation
sequence so you can best hear
inspiratory and expiratory sounds

ANTERIOR THORAX
a. place the diaphragm of the
stethoscope firmly and directly on the
anterior chest wall
b. Auscultate from the apices of the
lungs slightly above the clavicles to
the bases of the lungs at 6th rib
c. ask the client to breathe deeply
through his mouth in an effort to avoid
transmission of sounds may
occur with nasal breathing