Posterior Thorax with the Beginning of Objective info

Client prep for thorax exam

Remove clothing from waist up, gown opening down the back; explain exposure of the chest and procedures first (reduces anxiety/embarrassment)

Starting position for exam

Sitting upright with arms relaxed at sides

Equipment for thorax exam

Gown and drape, gloves, stethoscope, light source, mask, skin marker, metric ruler

Key points during exam

Provide privacy; warm your hands; stay nonjudgmental about habits like smoking but educate on risks (lung cancer, COPD)

Order of the exam

Inspection, palpation, percussion, auscultation (posterior and anterior)

Some clinicians' approach (clinical tip)

Inspect the whole thorax first, then palpate, percuss, and auscultate anterior and posterior

Routine screening: skills included

Color of face/lips/chest, nails, thorax configuration, accessory muscles and intercostal spaces, positioning, palpation (tenderness, fremitus, crepitus, surface characteristics), chest expansion, percussion for tone, auscultation of normal and adventitious sounds

Focused specialty assessment

Percuss for diaphragmatic excursion; auscultate voice sounds

Who does focused skills most often?

ICU nurses, nurses caring for respiratory clients

Why hospital nurses auscultate routinely

Check ability to ventilate; detect complications like pneumonia

Home health use

Early ventilation complications can be detected with correct lung and thorax assessment

Which techniques take more practice?

Palpation, percussion, and auscultation (inspection is easier to learn) Nasal flaring: normal

Nasal flaring: abnormal

Labored respirations (especially small children); indicates hypoxia

Normal breathing muscles

Diaphragm and external intercostals (outward expansion of abdomen and lower ribs on inspiration)

Pursed lip breathing: seen in

Asthma, emphysema, CHF; slows expiration and keeps alveoli open longer

Normal color of face, lips, chest

Even skin tone, no unusual discoloration

Red blotchy spots

COPD or CHF from polycythemia

Cyanosis cause

Cold or hypoxia

Cyanosis in white skin

Blue-tinged (perioral, nail beds, conjunctiva)

Cyanosis in dark skin

Blue and dull in the same areas

Normal nail beds

Pink tones

Normal nail base angle

160 degrees

Early clubbing

180 degrees

Late clubbing

Greater than 180 degrees

Cause of pale/cyanotic nails and clubbing

Hypoxia Normal scapulae

Normal AP to transverse ratio

1:2

Barrel chest ratio

1:1 (AP equals transverse); often emphysema from lung hyperinflation

Normal rib slope

Downward at about 45 degrees to the spine

Ribs more horizontal (greater than 45 degrees)

Barrel chest

Spinous processes deviating laterally

Scoliosis

Normal spinous processes

Straight, thorax symmetric

Kyphosis in older adults

Can be normal; from loss of lung resiliency and loss of skeletal muscle

Normal accessory muscle use

None; diaphragm is the major muscle (lower chest expands)

Trapezius/shoulder muscle use

Acute or chronic airway obstruction or atelectasis

Tripod position

Leaning forward, arms supporting weight to lift chest; seen in COPD/emphysema

Normal client positioning

Sitting up, relaxed, breathing easily, arms at sides or in lap Palpation sequence

Normal palpation

No tenderness, pain, or unusual sensation; equal temperature bilaterally

Tenderness from muscle soreness

Exercise or excessive work of breathing (COPD)

Increased warmth

Local infection

Pain over intercostal spaces

Inflamed pleurae

Pain over ribs / costal chondral junctions

Fractured ribs

Crepitus (subcutaneous emphysema)

Crackling sensation when air passes through fluid or exudate

Crepitus causes

Air escaping from lung/airways into subcutaneous tissue (open thoracic injury, around chest tube or tracheostomy); extreme congestion or consolidation

If you find crepitus

Mark the margins and monitor for increase or decrease

Surface lesions or masses

Wear gloves; any unusual mass needs provider evaluation

Tactile fremitus

Vibrations of air in bronchial tubes transmitted to the chest wall

Fremitus technique

Ball or ulnar edge of hand; client says "ninety-nine"; compare symmetry and intensity

Best part of the hand for fremitus

The ball of the hand (most sensitive to vibration)

Normal fremitus

Symmetric, easy to feel in upper lungs; decreases toward the bases but stays symmetric

If fremitus is hard to feel

Ask client to speak louder

Fremitus INCREASED by

Consolidation

Fremitus DECREASED by

Bronchial obstruction, air trapping (emphysema), pleural effusion, pneumothorax

Posterior chest expansion technique

Thumbs at T9 or T10 pressing together a skin fold; client takes deep breath

Normal posterior expansion

Thumbs move 5 to 10 cm apart, symmetrically

Older adult chest expansion

May be decreased (calcified costal cartilage, less accessory muscle) but still symmetric

Unequal chest expansion causes

Severe atelectasis, pneumonia, chest trauma, pneumothorax

Decreased basal excursion

COPD (decreased diaphragmatic function) Percussion sequence

Percussion interval (Fig. 19-13)

Symmetrical areas at 5-cm intervals

Normal tone over lung

Resonance

Tone over the scapula

Flat

Hyperresonance

Trapped air (emphysema, pneumothorax)

Dullness

Fluid or solid tissue replacing air (lobar pneumonia, pleural effusion, tumor)

Diaphragmatic excursion start point

Scapular line at T7, after client exhales forcefully and holds breath

Diaphragmatic excursion steps

Percuss down until resonance changes to dullness and mark; client inhales deeply and holds; percuss down again to dullness and mark; measure distance between marks; do both sides

Normal excursion

Equal bilaterally, 3 to 5 cm in adults

Well-conditioned clients

Up to 7 to 8 cm

Why right diaphragm may be higher

Position of the liver

Limited diaphragmatic descent

Lower lobe atelectasis, emphysema (diaphragm stays low), pain, extreme ascites, tumors, pregnancy

Uneven excursion

Unilateral pneumonia, phrenic nerve damage, splenomegaly Where to place the stethoscope

Client breathing during auscultation

Deep breaths through the mouth

Posterior auscultation range

Apices at C7 down to bases at T10; laterally from axilla to 7th or 8th rib

How long at each site

At least one complete respiratory cycle

Three normal breath sounds

Bronchial, bronchovesicular, vesicular

Clinical tip: location of normal sounds

Normal ONLY in their specified area; heard elsewhere they're abnormal (e.g., bronchial sounds over peripheral lung fields)

Why sounds may be hard to hear

Obesity or heavy muscling (greater distance to lung tissue)

Older adult auscultation

Deep breathing is tiring; offer rest as needed

Diminished or absent breath sounds

Little or no air movement: secretions, mucous plug, foreign object, pleural thickening, effusion, pneumothorax

Emphysema breath sounds

Diminished inspiratory sounds (hyperinflation and loss of elasticity)

Increased (louder) breath sounds

Consolidation or compression (denser lung transmits sound better)

Adventitious sounds

Sounds added or superimposed on normal breath sounds

Crackles

Discrete, discontinuous sounds (formerly rales)

Wheezes

Musical, continuous sounds (formerly rhonchi)

If you hear an abnormal sound

Have client cough, then listen again; coughing may clear the lungs

Bronchophony technique

Client repeats "ninety-nine"

Normal bronchophony

Soft, muffled, indistinct; phrase can't be distinguished

Abnormal bronchophony

Words clear and louder over increased density (consolidation, atelectasis, tumor)

Egophony technique

Client says "E"

Normal egophony

Soft and muffled; "eeee"

Abnormal egophony

Louder, bleating "aaaa" over consolidation or compression

Whispered pectoriloquy technique

Client whispers "one-two-three"

Normal whispered pectoriloquy

Very faint and muffled; may be inaudible

Abnormal whispered pectoriloquy

Clear and distinct, as if whispering into the stethoscope