SHERPATH | Findings for Chests and Lungs

Use this for reviewing the normal and abnormal findings for the chest and lungs!

what are the expected findings for the following places of the chest via palpation (chest symmetry, rib cage, clavicles, sternum, anterior-posterior and transverse diameter, trachea, spine, and thoracic muscles/skeleton) in adult?

1. the chest is symmetric

2. rib cage is elastic

3. clavicles prominent superiorly (we can see them raised)

4. sternum is flat and inflexible with no abundance of overlying tissue

5. anterior-posterior diameter about half the transverse diameter

6. trachea midline with ‘equal’ space in each side (slight deviation can be expected) with no pulsation or significant tug (meaning no large mass that require tugging)

7. spine midline with normal curvature with rigid thoracic spine

8. nontender sensation

9. variable fremitus

10. no pulsation on the thoracic muscles and skeleton

what is the expected finding for the skin, mouth, and nail?

1. skin: dry, warm, and intact

2. mouth: oral mucosa moist

3. nail: pink nail beds

what is the expected finding for respiration?

1. breathing without difficulty

2. even, regular pattern

3. rate of (can be low as 10) 12-20 respiration per minute

4. rate of respiration to heartbeats = 1:4

what is the expected findings for chest movement?

bilateral & symmetric chest expansion

what is the expected quality of percussion tone over these areas: lungs, heart, liver, spleen, heavy muscles or bones, stomach, and viscera (other internal organs)?

1. lungs: resonance

2. heart: dull

3. liver: dull

4. spleen: dull

5. heavy muscles or bone: flat

6. stomach: tympany

diagrammatic excursion, what it measures, and how a student nurse can measure it?

1. movement of the diaphragm during breathing

2. to measure how far the diaphragm contract (how flat and obtuse it gets) during inhalation and exhalation

what is the expected finding for a diagrammatic excursion?

1. 3-5 cm

2. higher on the right side due to placement over the liver

3. locate diagram by looking for area of the lower chest with dull sounds

4. DE after full exhalation: patient take deep breath and fully exhale and the student nurse mark the top areas of the diaphragm and marked it

5. DE after full inhalation: patient take deep breath and hold and the student nurse mark the top area of the diaphragm and marked it

review all of the expected finding when performing an inspection of the infant chest…

1. chest circumference is about 30-36 cm (usually 2-3 cm smaller than the head circumference)

2. breathing pattern varies with feeding, sleep, and maturity

3. 30-80 (normal 40-60) breaths/min (expect higher in newborn from C-section)

4. obligate nose breather (baby can only breath through their nose and only do through mouth when crying)

5. periodic breathing and brief period of apnea lasting from 10-15 seconds

6. frequent hiccuping

7. paradoxical breathing (especially during sleep)

8. symmetric chest expansion

9. diaphragmatic breathing

10. sneezing

intrauterine growth retardation

smaller chest circumference than expected

gestational diabetes

bigger chest circumference than expected

what is the expected finding when performing palpation of the infant chest?

1. symmetric clavicles, rib cage, sternum

2. no masses

3. no crepitus (a crackling, popping, clicking, or grinding sound or sensation that occurs when you move a joint)

4. xiphoid is more mobile and more prominent than adult

what is the expected finding when auscultating the infant chest?

1. localization of breath sounds is more difficult

2. breath sounds easily transmitted from one area to another

3. gastrointestinal gurgling may be heard

4. mucus in the upper airway is normal

5. (immediately after birth) crackles and rhonchi can be heard immediately after birth due to fetal fluid in lung

true or false: percussion may be unreliable on infant as the examiner’s finger may be too large

true

what is the normal breathing rate for a 3 years old?

20-30 breaths/min

what is the normal breathing rate for newborn?

30-80 (normal 40-60) breaths/min

what is the normal breathing rate for a 3 year old?

20-30 breaths/min

what is the normal breathing rate for 10 year olds?

16-20 breaths/min

what is the normal breathing rate for 17 years and most adult excluding the elderly?

12-20 breaths/min

breaths sounds in adult vs pediatric

pediatric breathing sounds is usually more resonant, harsher, louder and more bronchial and bronchovesicular breaths sound can be heard throughout the chest

review the possible causes of decreased chest expansion in the elderly population…

1. respiratory muscle weakness

2. physical disability

3. sedentary lifestyle

4. calcification of rib articulation

5. increased use of accessory muscles

6. decline in lung elasticity

7. illness

what are some of the common finding when inspecting the chest of an elderly individual?

1. increased anteroposterior diameter (caused by calcification of rib articulation and kyphosis

2. kyphosis with flattening lumbar curse

3. hyperresonance

which is considered a normal finding during respiratory assessment of a newborn?

• grunting

• bradypnea

• central cyanosis

• acrocyanosis

acrocyanosis (blue color to the hand and feet and should disappear within a few hours or days) - a type of cyanosis

barrel chest

1. abnormal configurations of the thorax

2. increased anteroposterior diameter

kyphosis

1. abnormal configurations of the thorax

2. excessive outward curvature of the thoracic spine, leading to a hunched posture

scoliosis

1. abnormal configurations of the thorax

2. lateral curvature of the spine, causing uneven shoulders or hips

pigeon chest (pectus carinatum)

1. abnormal configurations of the thorax

2. forward protrusion of the sternum (pigeon chest)

funnel chest (pectus excavatum)

1. abnormal configurations of the thorax

2. sunken sternum and adjacent ribs (funnel chest)

review the possible causes of asymmetrical chest movement during breathing…

1. pneumothorax (collapsed lung)

2. pleural effusion (fluid in the pleural space)

3. fractured ribs or chest trauma

4. unilateral lung diseases (e.g., pneumonia, atelectasis)

unilateral or bilateral bulging

protrusion of the chest wall on one or both sides of the chest

• unilateral: localized pleural effusion, pneumothorax, or mass

• bilateral: COPD or obesity

bulging on expiration

conditions of the lungs like hyperinflated lungs, tracheal collapse, intercostal bulging, neck bulging, and palatal prolapse that cause bulging when exhaling

review the abnormal palpation findings of the thoracic muscles and skeleton/thoracic expansion..

1. pulsation

2. tenderness

3. bulges

4. depressions

5. unusual movement

6. unusual positions

7. asymmetric expansion

8. rib rigidity

review the abnormal palpation sensation and fremitus for the chest and lung…

1. crepitus - crackly, crinkly sensation with gentle, bubbly feeling

2. grating - palpable and coarse feeling/sound

3. decreased or absent fremitus - coarser and rougher

4. gentle or tremulous (significantly increased vibration) fremitus

5. variation between similar positions on right and left thorax

true or false: it is not abnormal for the trachea to have significant deviation or tug and can have present pulsation

FALSE; trachea with pulsation and positions with significant deviation or tug are ABNORMAL

true or false: a diaphragmatic excursion less than 3 cm indicates an abnormality

true

what one cause may dullness over the lung tissues indicates?

denser than normal lung tissues which can ultimately cause diminished air exchange

hyperresonance and absent breath sounds may indicate _________________ due to ____________

hyperinflation; pneumothorax; (the lung tries to push against the air but the lung can still inflate even hyperinflate not like atelectasis)

dullness and absent breath sounds may indicate ___________ due to _____________

hypoinflation; atelectasis (the lung cannot inflate properly due to blockage)

true or false: the student nurse should always note an abnormality when hearing vesicular, bronchial, or bronchovesicular sounds out of their expected lung area

true

vesicular breath sounds (description, expected area)

1. description: soft and low pitched

2. expected area: over most of the peripheral lung fields (the smaller airways and alveoli)

bronchial breath sounds (description, expected area)

1. description: loud and high-pitched

2. expected area: over the trachea and large airways (e.g., near the sternum or over the manubrium)

3. indicate con

bronchovesicular breath sounds (description, expected area)

1. description: medium-pitched and moderate

2. expected area: heard over the mid-chest anteriorly (around the 1st and 2nd intercostal spaces) and between the scapulae posteriorly

what does the diminished or absent bronchial, bronchovesicular, and/or vesicular lung sounds possibly indicates?

1. obstruction of the airway

2. pleural effusion

3. pneumothorax

4. ateletacsis (collapsed lung)

5. severe emphysema (loss of lung tissues and overinflation of alveoli)

6. thickened pleura

basically conditions that limits breathing

adventitious lung sounds and the types

abnormal lung sounds

• crackles (rales): short, popping sounds commonly heard in pt with pneumonia or heart failures

• wheezes (rhonchi): high-pitched whistling sounds or low-pitched snoring sounds common heard in pt with narrowed airways (e.g., asthma, bronchitis, etc)

• atelectatic crackles: temporary crackling sounds - fine crackles that are not caused by a disease and go away after the person take a few deep breath

fine crackles (discontinuous/continuous. cause, what it sounds like, and significance)

1. discontinuous

2. cause: usually due to fluid in the alveoli or small airway (e.g., pneumonia, heart failure)

3. what it sounds like: short, high-pitched popping sounds (e.g., rubbing hair between fingers near the ear)

4. significance: common in pulmonary edema or atelectasis

5. using youtube to review the sound

course crackles (discontinuous/continuous, cause, what it sounds like, and significance)

1. discontinuous

2. cause: larger airways or more significant fluid (e.g., chronic bronchitis, COPD)

3. what it sounds like: low-pitched, moist, bubbling sounds

4. significance: indicates excess mucus or secretions in the airway

5. use youtube to review the sound

atelectatic crackles (discontinuous/continuous, cause, what it sounds like, anf significance)

1. discontinuous

2. cause: collapse of small airway in the lungs (e..g., after sleep or in bedridden)

3. what it sounds like: short, fine crackles similar to normal crackles but resolve after a few deep breath

4. significance: typically not pathologic and resolves after a few deep breath

5. use youtube to review sound (go to 0:50)

wheeze (sibilant) (discontinuous/continuous, cause, what it sounds like, anf significance)

1. continuous

2. cause: narrowing of the smaller airways (e.g., asthma, bronchitis)

3. what it sounds like: high-pitched, whistling sounds

4. significance: indicates airway constriction and obstruction

wheeze (sonorous - how is rhonchi similar?) (discontinuous/continuous, cause, what it sounds like, anf significance)

1. continuous

2. cause: larger airway obstruction (e.g., secretions or bronchitis) - rhonchi is similar as it also affect larger airway but instead of inflammation it is secretion accumulation causing gurgling sounds

3. what it sounds like: low-pitched, snoring or gurgling sounds, often heard during exhalation

4. significance: suggests mucus in larger airways or obstruction

5. use youtube to review the sound

pleural friction rub (discontinuous/continuous, cause, what it sounds like, anf significance)

1. discontinuous

2. cause: inflammation of the pleural surfaces rubbing together (e.g., pleuritis)

3. what it sounds like: a dry, grating sound, like walking on fresh snow

4. significance: suggest pleural inflammation or pleuritis

5. use youtube to review the sound (go to 0:32)

malodorous breath is an indication of a ________________

pulmonary infection

flaring of the alae nasi is an indication of __________________

air hunger

which terms identifies a fast, deep breathing pattern?

• bradypnea

• sighing

• air trapping

• kussmaul breathing

kussmaul breathin

Which breath sounds would be classified as abnormal on auscultation of the peripheral lung tissue in a healthy adult?

Select all that apply.

• Tracheal

• Bronchial

• Vesicular

• Wheezing

• Bronchovesicular

tracheal, bronchial, wheezing, and bronchovesicular (any other breaths sounds heard besides from vesicular in the peripheral lung tissues ARE ABNORMAL)

During the respiratory assessment, the nurse percusses hyperresonance over the lungs and notes absent breath sounds, precordial clicks, and crackling. Of which condition are these abnormal findings indicative?

• Atelectasis

• Bronchiectasis

• Pneumothorax

• Pneumonia consolidation

pneumothorax

which finding regarding the quality of tactile fremitus is considered normal on palpation of the chest?

• absent

• coarse/rough

• bilateral symmetry

• tremulous and gentle

bilateral symmetry

which is a normal finding on palpation of the ribs?

• elasticity

• crepitus

• rigidity

• tenderness

elasticity

what is a normal finding on palpation of the sternum?

inflexibility

Which tone would the nurse expect to hear when percussing the indicated area?

• Dullness

• Flatness

• Resonance

• Tympany

dullness

which tone would the nurse expect to hear when percussing the indicated area?

• dullness

• flatness

• resonance

• tympany

resonance

When comparing the diaphragmatic excursion of the left and right sides of the body, what is the expected finding?

• Equal distance on left and right sides

• Diaphragm higher on left side

• Diaphragm higher on right side

• Excursion typically not measurable on right side

higher on the right side due to the placement of the liver

which breath sounds would be expected on auscultation of the bronchi?

• vesicular

• bronchovesicular

• bronchial/tracheal

• tubular

bronchovesicular