Thorax and Lung Assessment

Thorax

Thorax

Portion of the body extending from the base of the neck superiorly to the level of the diaphragm inferiorly.

Lower respiratory system

Composed of the lungs, distal portion of the trachea, and the bronchi.

Thoracic cage

Outer structure of the thorax.

Thoracic cavity

Contains the respiratory components.

Thoracic cage

Provides support and protection for many important organs including those of the lower respiratory system.

Sternum, 12 pairs of ribs, 12 thoracic vertebrae, muscles, cartilages

The thoracic cage is constructed of the…

Purpose of Respiration

Maintain an adequate oxygen level in the blood to support cellular life.

External respiration or ventilation

Is the mechanical act of breathing and is accomplished by expansion of the chest, both vertically and horizontally.

Vertical expansion

Is accomplished through contraction of the diaphragm.

Horizontal expansion

Occurs as intercostal muscles lift the sternum and elevate the ribs, resulting in an increase in anteroposterior diameter.

Breathing patterns

Change according to cellular demands. Often without awareness on the part of the individual.

Medulla and pons located in the brain stem

Such involuntary control of respiration is the work of the…

Subjective data related to the thoracic and lung assessment

Provide many clues about underlying respiratory problems and associated nursing diagnoses as well as clues about risk for the development of lung disorders.

Information about the client’s level of functioning

Is also important because certain respiratory problems greatly impact a person’s ability to perform activities of daily living.

Subjective data

When collecting __________, remember to follow up on the client’s related signs and symptoms to determine specific respiratory problems and associated nursing diagnoses.

Judgmental approaches

Be careful to avoid ___________ to poor health practices.

Breathing difficulties

Examination of the thorax and lungs begins when the nurse first meets the client and observes any obvious __________.

Inspection, palpation, percussion, and auscultation

Complete examination of the thorax and lungs consists of ________________ of the posterior and anterior thorax to evaluate functioning of the lungs.

Gown and drape, Gloves, Stethoscope, Light source, Mask, Skin marker, Metric ruler

Equipment used in Thorax and Lungs Assessment

Key points

• Provide privacy for the client.

• Keep your hands warm to promote the client’s comfort during examination.

• Remain nonjudgmental regarding client’s habits and lifestyle, particularly smoking.

• Educate and inform about risks, such as lung cancer and COPD, related to habits.

Analysis of data

After collecting subjective and objective data pertaining to the thorax and lung assessment, identify abnormal findings and client strengths.

Cluster

__________ the data to reveal any significant patterns or abnormalities. Data may then be used to make clinical judgments about the status of the client’s thorax and lungs.

Medical problems

Development of RC and/or other signs and symptoms may clearly require medical treatment and referral to a primary care provider.

Risk for Complications (RC)

• Atelectasis

• Pneumonia

• Chronic obstructive pulmonary disease

• Asthma

• Bronchitis

• Pleural effusion

• Pneumothorax

• Pulmonary edema

• Tuberculosis

Wellness diagnoses

• Readiness for Enhanced Breathing Patterns

• Health-Seeking Behaviors: Requests information on TB skin testing, how to quit smoking, or on exercises to improve respiratory status

Risk diagnoses

• Risk for Respiratory Infection related to exposure to environmental pollutants and lack of knowledge of precautionary measures

• Risk for Activity Intolerance related to imbalance between oxygen supply and demand

• Risk for Imbalanced Nutrition: Less Than Body Requirements related to fatigue secondary to dyspnea

• Risk for Ineffective Health Maintenance related to lack of knowledge of condition, infection transmission, and prevention of recurrence

• Risk for Impaired Oral Mucous Membranes related to mouth breathing

Actual diagnoses

• Anxiety related to dyspnea and fear of suffocation

• Activity Intolerance related to fatigue secondary to inadequate oxygenation

• Ineffective Airway Clearance related to inability to clear thick, mucous secretions secondary to pain and fatigue

• Impaired Gas Exchange related to chronic lung tissue damage secondary to chronic smoking

• Ineffective Airway Clearance related to bronchospasm and increased pulmonary secretions

• Ineffective Breathing Pattern: Hyperventilation related to hypoxia and lack of knowledge of controlled breathing techniques

• Disturbed Sleep Pattern related to excessive coughing

• Impaired Gas Exchange related to poor muscle tone and decreased ability to remove secretions secondary to the aging process