Thorax and Lungs

Dyana M. M. Saplan, RN, MAN

Thorax and Lungs

Assessing thorax and lungs is frequently critical to assessing the clients oxygenation status Changes in the respiratory system can come about slowly or quickly
COPD chronic bronchitis, emphysema, asthma = changes are frequently gradual Pneumonia, pulmonary embolus = onset more acute or sudden
Dyana M. M. Saplan, RN, MAN

Chest Landmarks
Before beginning assessment:
nurse must be familiar w/ a series of imaginary lines on the chest wall and be able to locate the position of each rib and some spinous processes

Landmarks help the nurse to identify the position of underlying organs and to record abnormal assessment findings
Dyana M. M. Saplan, RN, MAN

Chest landmarks
Chest wall landmarks
A. Anterior chest
Midsternal line Midclavicular lines (R-L) Anterior axillary lines (R-L)

B. Lateral chest
Posterior axillary line Midaxillary line

C. Posterior chest
Vertebral line Scapular lines

Dyana M. M. Saplan, RN, MAN

Dyana M. M. Saplan, RN, MAN

Posterior chest landmarks and underlying lungs

Dyana M. M. Saplan, RN, MAN

Chest Landmarks
Each lung is divided into upper and lower lobes by an oblique fissure runs from level of spinous process of 3rd thoracic vertebra (T3) to the level of 6th rib @ the midclavicular line
RUL and RLL LUL and LLL
Dyana M. M. Saplan, RN, MAN

Lateral Chest landmarks

Right lung further divided by a minor fissure into the RUL and right middle lobe (RML)
Dyana M. M. Saplan, RN, MAN

Right lung further divided by a minor fissure into the RUL and right middle lobe (RML)
Dyana M. M. Saplan, RN, MAN

Location of ant. Ribs, angle of louis, sternum

Starting point for locating ribs anteriorly is the ANGLE OF LOUIS
Junction bet. body of sternum (breastbone) and manubrium (handlelike superior part of sternum that joins w/ clavicles)

Superior border of the 2nd rib attaches to the sternum at this manubriosternal junction
Dyana M. M. Saplan, RN, MAN

Identifying Manubrium
Nurse can identify this by 1st palpating the clavicle and following its course to its attachment @ the manubrium Nurse palpates and counts distal ribs and ICS from the 2nd rib
An ICS is numbered accdg to the # of the rib immediately above the space
Dyana M. M. Saplan, RN, MAN

Chest Shape and Size

Adult thorax = oval
Anteroposterior diameter is half its transverse diameter

Overall shape = elliptical

Diameter is smaller @ the top than @ the base

Dyana M. M. Saplan, RN, MAN

Deformities of the Chest

Pigeon chest
pectus carinatum
Permanent deformity, may be caused by rickets Narrow transverse diameter ed anteroposterior diameter Protruding sternum
Dyana M. M. Saplan, RN, MAN

Chest deformities
Funnel chest
pectus excavatum
Congenital defect Opposite of pigeon chest sternum is depressed narrowing the anteroposterior diameter Because sternum points posteriorly in clients abnormal pressure on the heart may result in altered fxn
Dyana M. M. Saplan, RN, MAN

Chest deformities
Barrel chest
Ratio of anteroposterior to transverse diameter is 1:1 Seen in clients w/ thoracic kyphosis (excessive convex curvature of the thoracic spine) and emphysema
Dyana M. M. Saplan, RN, MAN

Kyphosis

Dyana M. M. Saplan, RN, MAN

Scoliosis Lateral deviation of the spine

Dyana M. M. Saplan, RN, MAN

Assessing Scoliosis

Dyana M. M. Saplan, RN, MAN

Normal Breath Sounds

Vesicular
Soft-intensity, low-pitched, gentle sighing sounds createdby air moving thru smaller airways (bronchioles and alveoli) Location: over peripheral lung; best heard @ the base of lungs Characteristics: best heard on inspiration, w/c is about 2.5 times longer than the expiratory phase
Dyana M. M. Saplan, RN, MAN

Broncho-vesicular

Normal Breath Sounds

Moderate-intensity and moderate-pitched blowing sounds created by air moving through larger airway (bronchi) Between the scapulae and lateral to the sternum @ the 1st and 2nd ICSs Equal inspiratory and expiratory phases

Dyana M. M. Saplan, RN, MAN

Normal Breath Sounds

Bronchial
High-pitched, loud, harsh sounds created by air moving through the trachea Anteriorly over the trachea; not normally heard over lung tissue Louder than vesicular sounds; have a short inspiratory phase and long expiratory phase

Dyana M. M. Saplan, RN, MAN

Breath Sounds
Abnormal breath sounds are called
Adventitious breath sounds Occur when:
air passes thru narrowed airways or Airways filled w/ fluid or mucus, or When pleural linings are inflamed

4 types:
Crackles (rales, crepitations) Gurgles Pleural friction rubs wheezes
Dyana M. M. Saplan, RN, MAN

Adventitious Breath sounds

Crackles (rales)
Fine, short, interrupted crackling sounds; alveolar rales are high pitched
Can be simulated by rolling a lock of hair near the ear Best heard on inspiration but can be heard on both inspiration and expiration May not be cleared by coughing

Cause: air passing thru fluid or mucus in any air passage Location: most commonly heard in the bases of the lower lung lobes
Dyana M. M. Saplan, RN, MAN

Adventitious breath sounds

Gurgles (rhonchi)
Continuous, low-pitched, coarse, gurgling, harsh, louder sounds with a moaning or snoring quality
Best heard on expiration but can be heard on both inspiration and expiration May be altered by coughing

Air passing through narrowed passages as a result of secretions, swelling, tumors Loud sounds can be heard over most lung areas but predominate over the trachea and bronchi

Dyana M. M. Saplan, RN, MAN

Adventitious Breath sounds

Friction Rub
Superficial grating or creaking sounds heard during inspiration and expiration; not relieved by coughing Rubbing together of inflamed pleural surfaces Heard most often in areas of greatest thoracic expansion
E.g. lower anterior and lateral chest
Dyana M. M. Saplan, RN, MAN

Adventitious Breath sounds

Wheeze
Continuous, high-pitched, squeaky musical sounds
Best heard on expiration; not usually altered by coughing

Air passing through a constricted bronchus as a result of secretions, swelling, tumors Heard over all lung fields

Dyana M. M. Saplan, RN, MAN

Assessing Respiratory Excursion

Thoracic expansion
Place hands over lower thorax w/ thumbs adjacent to the spine and fingers stretched laterally Ask client t take deep breath; observe movement of hands
Normally thumbs separate 3 5 cm (1 to 2 in.) during deep inspiration

Dyana M. M. Saplan, RN, MAN

Assessing respiratory excursion

Dyana M. M. Saplan, RN, MAN

Areas for palpating Tactile Fremitus

Tactile fremitus
Faintly perceptible vibration felt through the chest wall when the client speaks Heard most clearly @ the apex of the lungs 99, blue moon
Dyana M. M. Saplan, RN, MAN

Palpating Tactile Fremitus (Posterior chest)

Dyana M. M. Saplan, RN, MAN

Sequence for Anterior chest percussion

Dyana M. M. Saplan, RN, MAN

Posterior chest Percussion

Dyana M. M. Saplan, RN, MAN

Lifespan Considerations
Dyana M. M. Saplan, RN, MAN

Infants
Thorax rounded
Diameter from the front to the back is equal to the transverse diameter Cylindrical, having nearly equal diameter @ the top and the base
Makes it harder for infants to expand their thoracic space

To assess tactile fremitus place hand over crying infants chest Tend to breathe using diaphragm assess rate and rhythm by watching the abdomen, rather than the thorax, rise and fall
Dyana M. M. Saplan, RN, MAN

Children
By 6 years of age anteroposterior diameter has ed in proportion to the transverse diameter Tend to breathe more abdominally than thoracically
Dyana M. M. Saplan, RN, MAN

Children
During rapid growth spurts of adolescence, spinal curvature and rotation (scoliosis) may appear
Shd be assessed for scoliosis by age 12 and annually until growth slows Curvature greater than 10% shd be referred for further medical evaluation

Dyana M. M. Saplan, RN, MAN

Elders
Thoracic curvature may be accentuated (kyphosis) because of osteoporosis and changes in cartilage, resulting in collapse of the vertebrae
May compromise and effort normal respiratory

Barrel-chested appearance due to loss of skeletal muscle strength in the thorax and diaphragm and constant lung inflation from excessive expiratory pressure on the alveoli
Dyana M. M. Saplan, RN, MAN

Elders
Expiration requires the use of accessory muscles Deflation of the lung is incomplete Cilia in airways in number and are less effective in removing mucus; elderly clients are therefore @ greater risk for pulmonary infections

Dyana M. M. Saplan, RN, MAN

Assessment Video

Dyana M. M. Saplan, RN, MAN