Sherpath- Assessing Chest and Lungs

The expected breath sounds include the following:

-Bronchial sounds (auscultate over the trachea) -Bronchovesicular sounds (auscultate over bronchi) -Vesicular sounds (auscultate over lung fields)

During palpation of the chest, the nurse assesses for the following:

-Chest symmetry and condition -Thoracic muscles and skeleton -Thoracic expansion -Pulsations -Tenderness -Bulges -Symmetry -Depressions -Masses -Unusual movement -Sensations (crepitus, grating vibrations, tactile fremitus) -Tracheal position/location

During inspection of the chest and lungs, the nurse should also observe other body areas for signs of respiratory compromise:

-Cyanosis of lips and nails -Lip pursing -Nasal flaring -Clubbed nails (enlargement of the terminal phalanges of the fingers or toes) -Foul breath -Superficial venous patterns over the chest -Prominence of the ribs and underlying subcutaneous fat -Alae nasi

Auscultation of the patient's lungs is important to identify clues to lung condition...

-During auscultation, the patient should sit upright, when possible, and should breathe slowly and deeply through the mouth, exaggerating normal respiration. -The nurse may need to demonstrate this breathing technique for the patient and should ensure the pace of breathing is comfortable for the patient. -The nurse asks the patient to take a deep breath each time the stethoscope is repositioned. -In addition to assessing lung sounds, this technique allows the nurse to assess the patient's ability to hear and follow commands. --The diaphragm of the stethoscope is preferable for lung auscultation. It is also best to auscultate directly against the skin, when possible. Auscultation through clothes can obscure findings.

Inspection of the Chest: Respiration...

-During inspection, the nurse evaluates the patient's respirations for rate and rhythm by inspecting the chest wall. -Chest movement should be observed during breathing for symmetry and use of accessory muscles. -The nurse should also note any audible sounds with respiration.

To thoroughly assess the chest and lungs:

-It is important for the nurse to inspect and palpate the chest and to auscultate lung sounds. -Careful assessment of the chest and lungs helps the nurse to identify signs of respiratory conditions and is essential to the development of an effective treatment plan.

During inspection of the chest, the nurse should observe the anterior and posterior thorax, noting thoracic landmarks for:

-Size and shape (anteroposterior diameter compared with transverse diameter) -Color -Venous patterns -Symmetry during inhalation and exhalation -Superficial venous patterns -Prominence of ribs

Elements to Assess: Anterior Chest Percussion...

-The nurse percusses the anterior chest to estimate the location, size, and condition of underlying organs. -The nurse should ask the patient to sit with the head bent and arms raised overhead to percuss the lateral and anterior chest. -Moving superior to inferior and medial to lateral, the nurse percusses at 4- to 5-cm intervals over the intercostal spaces. -When assessing female patients, the nurse may need to shift the breast for accurate percussion, as breast tissue may obscure findings. -Areas to avoid during percussion of the chest include the scapula, spine, clavicles, and breast tissue.

Elements to Assess: Palpation for Tactile Fremitus...

-To assess tactile fremitus, the nurse asks the patient to recite numbers or words. -While the patient does this, the nurse systematically palpates the chest with the palmar surfaces of fingers or the ulnar aspect of a clenched fist, using a firm, light touch. -The nurse assesses the area from front to back and side to side and then compares the sides. -Tactile fremitus can be best palpated posteriorly and laterally at the level of the bronchial bifurcation.

Elements to Assess: Posterior Chest Percussion...

-To percuss the posterior chest, the nurse should have the patient lean forward with arms crossed and neck flexed. -Moving superior to inferior and medial to lateral, the nurse percusses at 4- to 5-cm intervals over the intercostal spaces. -Percussion tones over the chest should be compared bilaterally.

Elements to Assess: Auscultation of Chest and Lungs...

-To properly auscultate the lungs, the nurse listens during both inhalation and exhalation, from superior to inferior and from apex toward base at intervals of several centimeters, comparing the two sides. -When a person is speaking, the voice transmits sounds through the lung fields that may be heard with the stethoscope. -The nurse auscultates vocal resonance by asking the patient to recite numbers or words when the stethoscope is against the patient's chest. -The nurse evaluates vocal resonance for the presence of bronchophony (increased loudness of spoken sounds), pectoriloquy (increased resonance, whisper heard clearly through the stethoscope), and egophony (increased intensity of spoken sounds with a nasal quality). -It is especially important to assess vocal resonance when abnormalities have been found during the percussion or tactile fremitus examination.

Elements to Assess: Palpation of the Trachea...

-Using the index finger and the thumb, the nurse gently palpates the neck from the suprasternal notch along the upper edges of each clavicle and in the spaces above the clavicles to the inner border of the sternocleidomastoid muscle. -Palpation of the trachea is often combined with assessment of the thyroid gland. This is discussed in more detail with the head and neck assessment.

Diaphragmatic excursion is the movement of the diaphragm during inhalation and exhalation. The steps to assess diaphragmatic excursion are as follows:

A. Ask the patient to take a deep breath and hold it. B. Percuss along the scapular line until the lower border is found, when resonance turns to dullness. C. Mark the point with a marking pen at the scapular line. Allow patient to breathe, and then repeat procedure on the other side. D. Ask the patient to take several breaths and to exhale as much as possible, then hold his or her breath. E. Percuss up from the marked point and note where dullness changes to resonance. Remind the patient to start breathing. Repeat on the other side. F. Measure and record distance in centimeters between marks on each side.

Elements to Assess: Auscultation of Breath Sounds...

During auscultation of the chest for breath sounds, it is important to assess the duration, vocal resonance, and presence of unexpected breath sounds. The pitch, intensity, quality, and duration should be noted.

Thoracic landmarks are used to help identify the specific underlying structures affected during the physical examination:

Midsternal line --Vertically down the midline of the sternum Right and left midclavicular lines --Parallel to the midsternal line --Begin at the midclavicle --Inferior borders of the lungs generally cross the sixth rib at the midclavicular line Right and left anterior axillary lines --Parallel to midsternal line --Beginning at anterior axillary folds Right and left midaxillary lines --Parallel to midsternal line --Beginning at the midaxilla Right and left posterior axillary lines --Parallel to midsternal line --Beginning at the posterior axillary folds Vertebral line --Vertically down the spinal processes Right and left scapular lines --Parallel to vertebral line --Through the inferior angle of the scapula when patient is erect