ASSESSMENT OF CHEST AND

LUNGS

Respiratory assessment landmarks

Auscultation assessment landmarks

 Respiratory rate and pattern
 Count the number of breaths for a full minute.
Adults normally breathe at a rate of 12 to 20
breaths/minute. An infant’s breathing rate may
reach 40 breaths/minute. The respiratory pattern
should be even, coordinated, and regular, with
occasional sighs (long, deep breaths).

Accessory muscle use

 Observe the diaphragm and the intercostal
muscles with breathing. Frequent use of
accessory muscles may indicate a respiratory
problem, particularly when the patient purses his
lips and flares his nostrils when breathing.

Men, children, While Memory board

infants, inspecting the Chest-wall
athletes, and chest, look asymmetry
singers usually for these Respiratory rate
use characteristic and
abdominal, or s pattern(abnormal)
diaphragmatic that may put Accessory muscle
, breathing. a CRAMP in use
ASSESSMENT your Masses or scars
 Begin your respiratory assessment by first Most women, patient’s Paradoxical
observing the patient’s general appearance. however, respiratory movement
 Then use inspection, palpation, percussion, and usually use system.
auscultation to perform a physical examination. chest, or
 Examine the back of the chest first, comparing intercostal,
one side with the other. breathing.
 Then examine the front of the chest using the
same sequence. Palpating the chest
 Observe the chest from the side as well.  The chest wall should feel smooth, warm, and
 The diameter of the thorax should be greater dry. Gentle palpation shouldn’t cause the patient
from side-to-side than from front-to-back. pain. Pain may be caused by costochondritis, rib
or vertebral fractures, or sore muscles as a result
of protracted coughing.
 Crepitus Inspecting the
, which feels like chest cereal
puffed-rice
crackling under the skin, indicates that air is
Inspect for chest-wall
leaking from the airways or lungs.
 Alsosymmetry. Note
palpate for tactile masses
fremitus, or
palpable
vibrations caused by the transmission of air
scars that indicate trauma
through the bronchopulmonary system. Then
or surgery
evaluate chest-wall symmetry and expansion.

LANDMARK LINE KEYS

Axillary line
Midclavicular line
Midsternal line
Scapular line
Vertebral line

Assessing voice sounds
Check the patient for vocal fremitus — voice sounds
resulting from chest vibrations that occur as the patient
speaks. Abnormal
transmission of voice sounds may occur over
consolidated areas. The most common abnormal voice
sounds are bronchophony,
egophony, and whispered pectoriloquy.
Assessing vocal fremitus
■ Ask the patient to repeat the words below while you
listen.
■ Auscultate over an area where you heard abnormally
located bronchial breath sounds to check for abnormal
voice sounds.
“ninety-nine”
Bronchophony
■ Ask the patient to say, “ninety-nine.”
■ Over normal lung tissue, the words sound muffled.
■ Over consolidated areas, the words sound unusually
loud
Egophony
■ Ask the patient to say, “E.”
■ Over normal lung tissue, the sound is muffled.
■ Over consolidated lung tissue, it will sound like the
letter a.
Whispered pectoriloquy
■ Ask the patient to whisper, “1, 2, 3.”
■ Over normal lung tissue, the numbers will be almost
indistinguishable.
■ Over consolidated lung tissue, the numbers will be
loud and clear.
Evaluating chest-wall symmetry and expansion
 Place your hands on the front of the chest wall
with your thumbs touching each other at the
second intercostal space. As the patient inhales
deeply, watch your thumbs. They should
separate simultaneously and equally to a
distance several centimeters away from the
sternum.
 Repeat the measurement at the fifth intercostal
space. The same measurement may be made on
the back of the chest near the tenth rib. The
patient’s chest may expand asymmetrically if he
has pleural effusion, atelectasis, pneumonia, or
pneumothorax.
What the results mean
 Vibrations that feel more intense on one side
than the other indicate tissue consolidation on
that side. Less intense vibrations may indicate
emphysema, pneumothorax, or pleural effusion.
 Faint or no vibrations in the upper posterior
thorax may indicate bronchial obstruction or a
fluid-filled pleural space.
Percussing the chest
Chest percussion reveals the boundaries of the lungs and
helps to determine whether the lungs are filled with air
or fluid or solid material.
■ Place your nondominant hand over the chest wall,
pressing firmly with your middle finger.
■ Position your dominant hand over your other hand.
■ By flexing the wrist (not the elbow
or upper arm) of your dominant hand, tap the middle
finger of your nondominant hand with the middle finger
of your dominant hand (as shown).
■ Follow the standard percussion sequence over the
front and back chest walls.
 intensity and lobar pneumonia
pitch, moderate
length, thud
like, as
found over the
liver

Resonant Long, loud, low Normal lung

pitched, hollow tissue;
bronchitis

Hyper resonant Very loud, Hyperinflated

lower pitched, lung, as in
as found emphysema or
over the pneumothorax
stomach

Tympanic Loud, high- Air collection, as

pitched, in
moderate a large
length, musical, pneumothorax
drum-like,
as found over a
puffed-out
cheek

AUSCULTATING THE CHEST

As air moves through the bronchi, it creates sound waves
that travel to the chest wall. The sounds produced by
breathing change as air moves from larger airways to
smaller airways. Sounds also change if they pass through
fluid, mucus, or narrowed airways. Auscultation of these
sounds helps you to determine the condition of the
alveoli and surrounding pleura. Classify each sound you
hear according to its intensity, location, pitch, duration,
and characteristic. Note whether the sound occurs when
the patient inhales, exhales, or both.

Percussion sounds
Sound Description Clinical
significance
flat Short, soft, Consolidation, as
high-pitched, in
extremely atelectasis and
dull, as found extensive pleural
over effusion
the thigh

dull Medium in Solid area, as in


To distinguish between normal and adventitious breath
sounds in the patient’s lungs, press the diaphragm of the
stethoscope firmly against the skin. Listen to a full
inspiration and a full expiration at each site in the
sequence shown. Remember to compare sound
variations from one side to the other. Document
adventitious sounds that you hear and include their
locations.
Auscultation sequence
Listen to these auscultation tips
■ Have the patient breathe through his
mouth; nose breathing alters the pitch of
breath sounds.
■ If the patient has abundant chest hair,
mat it down with a damp washcloth so the
hair doesn’t make sounds like crackles.
Assessment: NORMAL FINDINGS
 The thorax is normally symmetric, it moves
easily and without impairment on respiration.
There are no bulges or retractions of the
intercostal spaces.
 The anteroposterior diameter of the thorax in
relation to the lateral diameter is approximately
1:2 (the lateral diameter is wider than the AP
diameter.
 On palpation of the posterior chest, there should
be no tenderness; chest movement should be
symmetric and without lag or impairment.
 Percussion normally reveals resonance over
symmetric areas of the lungs
 On auscultation, breath sounds are louder and
coarse near the large rhonchi and over the
anterior chest. softer and much finer (vesicular)
at the periphery over the alveoli.
 The Normal breaths sounds are as follows:
VESICULAR- heard in most areas of the lungs
BRONCHOVESICULAR – heard near the main stem
bronchi
BRONCHIAL- Heard over the trachea
ABNORMAL FINDINGS
 Cough
 Hemoptysis- coughing out of blood
 Orthopnea- difficulty breathing when supine
 Paroxysmal Nocturnal Dyspnea (PND) – Is
awakening from sleep with shortness of breath
(SOB) and needing to be upright to achieve
comfort
 Unequal chest expansion
 Decreased fremitus – occurs when anything
obstructs transmission of vibrations
 Increased fremitus- occurs with compression
or consolidation of lung tissue
 Crepitus- is a coarse crackling sensation
palpable over the skin surface, it occurs when air
escapes from the lung and enters the
subcutaneous tissue.
 Hyperresonance- a low pitched, booming
sound on percussion of the chest, when too
much air is present in the lungs
 Dullness- soft, muffled thud, which signals
abnormal density in the lungs
 Atelectasis- collapse lungs
 Unequal chest expansion- occurs when part of
the lung is obstructed or collapsed
 Retractions- indentions at the intercostal
spaces, these suggest obstruction of respiratory
tract.
  Tachypnea- rapid, shallow breathing
 Hyperventilation- deep rapid breathing, also
called Kussmaul’s breathing
 Hypoventilation- slow, shallow breathing
 Barrel chest – alteration in thoracic anatomy
it’s a result of hyperinflation of the lungs
 Pectus Excavatum- the sternum is markedly
sunken
 Pectus carinatum (Pigeon's chest)- there is
forward protrusion of the sternum
 Scoliosis – a lateral S shaped curvature of the
thoracic and lumbar spine
 Kyphosis- an exaggerated posterior curvature of
the thoracic spine
 Chest pain with breathing
Mammogram
 Decreased or absent breath sounds

THE BREAST

Breast self-examination (males)

Breast self-examination

What is breast self-examination?

- breast self-examination is an examination done at
home to look for changes or problems in the breast
tissue.

When is the best time to do BSE?

3 days to 5 days after a woman’s period starts
Menopause – do exam on the same day every
month
How to do BSE?

Examining the nipples

BSE lying down

Assessment of the client’s breast

How to do BSE?  Remove clothing from waist up and provide
examination gown/drape
 Client sits in an upright position with arms
relaxed at the sides.
  Observe and inspect breasts and axillae for
color and skin surface
 Observe areola and nipples
 Palpate the axillae

Bimanual examination of the breast

 Let the patient lie down, arm overhead and
place a rolled towel / pillow under the breast B. Superficial Vascular Patterns;
to be palpated,
 Palpate the breast for temperature, elasticity,
tenderness and presence of masses using the
flat pads of the fingers.
 Palpate every square inch of the breast, from
the areola, nipples to the periphery of the
breast up to the tail of spence following a
circular, vertical strip pattern, and wedge.

C. Peau d’orange;

D. Asymmetry of Breasts with Deviation.

Abnormal Breast Findings:

A. Striae;
Take note of all findings, temperature,
elasticity, tenderness, and presence of
masses.
*Press the nipples for discharges
*Document findings
Assessment of the abdomen

Quadrants of the abdomen

the abdomen

Inspection of the abdomen

regions of the abdomen
 Inspect the abdomen for skin integrity,
contour and symmetry
Normal findings Abnormal findings
May be paler than the Purple discoloration
general skin tone at the flanks
Jaundice
Pale taut skin may be
due to ascites
 Auscultate the abdomen for bowel sounds, vascular
sounds, and peritoneal friction rubs

Flat, rounded, Generalized

scaphoid in thin protuberant or
adults. distended may be due
to obesity, gas, or
Should be evenly accumulation
rounded
symmetrical Asymmetry due to
organ enlargement,
masses, hernia or
bowel obstruction Intermittent soft clicks Hypoactive sound –
and gurgles at a rate of abdominal surgery or
 Observe abdominal movements associated 5 to 30 per minute bowel obstruction
with respiration, peristalsis, or aortic Hyperactive bowel
pulsations sounds loud, prolonged Hyperactive –
 Observe the vascular pattern gurgles, stomach increased bowel
 Abdominal movement associated with growling motility may be due to
respiration, peristalsis, or aortic pulsations “Borborygmi” diarrhea, gastroenteritis
Abdominal Diminished or bowel obstruction
respiration seen in abdominal resp or Bowel sounds normally
thin client especially thoracic breathing in occur every 5 to 15 Blood flow in an artery
males male may be due to seconds is turbulent or
peritoneal irritation obstructed may be due
Slight pulsation Bruits are not normally to aneurysm or arterial
Vigorous, wide, heard over abdominal, stenosis
Peristalsis is not seen exaggerated renal, iliac or femoral
normally, although arteries.
seen in thin client Peristaltic wave
increased and
progress in a ripple
like fashion may due Percussion of the abdomen
to intestinal • Percuss several areas of the four quadrants
obstruction to determine presence of tympany and
dullness
Auscultation of the abdomen • Percuss the liver to determine its size
 Palpation of the abdomen
(light palpation- identify tenderness and
muscular resistance)
Abdomen is soft and Involuntary reflex
non-tender, no muscle guarding is serious
guarding and reflects peritoneal
irritation

Abdomen is rigid and

rectus muscle failed to
relax when client
exhales.

Usually seen on the

right side because of
nerve tract pattern.
Right sided guarding
may be due to
cholecystitis
Normal mild Severe tenderness or
tenderness is possible pain may be due to
over xiphoid, aorta, trauma, peritonitis,
cecum, sigmoid colon, infection, tumors, or
and ovaries enlarge or diseased
organs
No palpable masses

Generalized tympany Accentuated tympany

because of air in the or hyper resonance
stomach and over a gaseous
intestines distended abdomen

Dullness over the liver Large area of dullness

and spleen is heard over an
enlarged liver or
Dullness over non spleen
evacuated descending
colon

Palpation of the abdomen

• Perform light palpation to detect areas of
tenderness and or muscle guarding.
• Perform deep palpation over all four
quadrants
• Palpate the bladder above the symphysis
pubis.

• The musculoskeletal system provides
shape and support to the body, allows
movement, protects the internal organs,
produces red blood cells in the bone marrow
(hematopoiesis), and stores calcium and
phosphorus in the bones. Although
examining this system is usually only a
small part of the overall physical
assessment, everything we do depends on an
intact musculoskeletal system.
• How extensive an assessment you perform
depends largely on each patient’s
problems and needs.
The goal of a complete musculoskeletal
assessment
-To detect risk factors, potential problems, or
musculoskeletal dysfunction early and then to plan
appropriate interventions, including teaching health
promotion and disease prevention and
implementing treatment measures.
3 Major Components of the Musculoskeletal
System
1. Bones
 The 206 bones of the skeleton form
the body’s framework, supporting
and protecting organs and tissues.
 Serve as storage sites for minerals
such as calcium
 Contain bone marrow, which
produces red blood cells.
2. Muscles
 Muscles are groups of contractile
cells or fibers that affect movement
of an organ or another part of the
body.
 Skeletal muscles contract and
produce skeletal movement when
they receive a stimulus from the
central nervous system (CNS). The
CNS is responsible for involuntary
and voluntary muscle function.
 Tendons are tough fibrous portions
of muscle that attach the muscles to
bone.
 Bursae are sacs filled with friction-
reducing synovial fluid that are
located in areas of high friction such
as the knee. Bursae allow adjacent
muscles or muscles and tendons to
glide smoothly over each other
during movement.
3. Joints
 The joint or articulation is the place
where two or more bones meet.
Joints provide range of motion
(ROM) for the body parts.
Classified in three ways:
a. The degree of movement they permit.
b. The connecting tissues that hold them together.
c. The type of motion the structure permits.
  Note the size and shape of joints, limbs, and
body regions. Whenever possible, observe
how the patient stands and moves.
 Watch him walk into the room or, if he’s
already in, ask him to walk to the door, turn
around, and walk back toward you.
 Then systematically assess the whole body,
working from head to toe and from proximal
to distal structures.

TESTING MUSCLE STRENGTH

-To test specific muscle groups, ask the patient to
move the muscles while you apply resistance; then
compare the contralateral muscle groups.
- Use the techniques to test the muscle strength of
your patient’s arm and ankle muscles.

• Muscle Strength Test strength by having

the patient move against your resistance.
Always compare one side to the other.
Grade strength on a scale from 0 to 5
"out of five":
Grading Motor Strength
Grade Description
0/5 No muscle movement
1/5 Visible muscle movement, but no
movement at the joint
ASSESSMENT 2/5 Movement at the joint, but not
 Begin your examination with a general against gravity
observation of the patient. 3/5 Movement against gravity, but not
against added resistance
4/5 Movement against resistance, but
 less than normal
5/5 Normal strength

Shoulders and elbows

- With the patient sitting or standing, observe
the shoulders, noting asymmetry, muscle
atrophy, or deformity.
- Palpate the shoulders with the palmar
surfaces of your fingers to locate bony
landmarks; note crepitus or tenderness.
MUSCLE TONE
Using your entire hand, palpate the shoulder
- Muscle tone describes muscular resistance to
muscles for firmness and symmetry.
passive stretching.
- Assess ROM.
- To test the patient’s arm muscle tone, move his
shoulder through passive ROM exercises. You
Shoulder abduction and adduction
should feel a slight resistance. Then let his arm
■ To assess abduction, ask the patient to move his
drop. It should fall easily to his side.
arm from the neutral position laterally as far as
- Test leg muscle tone by putting the patient’s hip
possible. Normal range of motion (ROM) is 180
through passive ROM exercises and then letting the
degrees.
leg fall to the examination table or bed. Like the
■ To assess adduction, have the patient move his
arm, the leg should fall easily. Abnormal findings
arm from the neutral position across the front of his
include muscle rigidity and flaccidity.
body as far as possible. Normal ROM is 50 degrees.
MUSCLE STRENGTH
- Observe the patient’s gait and movements to
form an idea of his general muscle strength.
- Grade muscle strength on a scale of 0 to 5.
- Document the results as a fraction, with the
score as the numerator and maximum
strength as the denominator.
- Then test specific muscle groups.

COMMON MUSCULOSKELETAL
ABNORMALITIES
1. Foot drop
—plantar flexion of the foot with the toes bent
toward the instep
—is a characteristic sign of certain
peripheral nerve or motor neuron
disorders. It results from weakness or
 paralysis of the dorsiflexor muscles
of the foot and ankle. Foot drop may
also stem from prolonged immobility.

2. Crepitus
- is an abnormal crunching or grating you
can hear and feel when a joint with
roughened articular surfaces moves. It occurs in
patients with rheumatoid arthritis or osteoarthritis or
when broken pieces of bone rub together.

3. Muscle spasms, or cramps

-are strong, painful contractions. They can
occur in virtually any muscle but are most common
in the calf and foot. Muscle spasms typically result
from simple muscle fatigue, exercise, electrolyte
imbalances, neuromuscular disorders, and
pregnancies.

4. Muscle weakness
-can result from a malfunction in the
cerebral hemispheres, brain stem, spinal cord, nerve
roots, peripheral nerves, or myoneural junctions and
within the muscle itself.

5. Muscle atrophy, or muscle wasting - results

from denervation or prolonged muscle disuse. Some
muscle atrophy also occurs with aging.

6. Traumatic injuries -include fractures,

dislocations, amputations, crush injuries, and
serious lacerations. To swiftly assess a
musculoskeletal injury, remember the 5 P’s: pain,
paresthesia, paralysis, pallor, and pulse.
Assignment: Read on the meaning and
indication of the following.
1. Muscular Dystrophy
2. Duchenne’s
3. Gower’s sign