Ch 29 Thorax, Heart, and Abdomen

Page 1: Health Promotion - Assessment of Thorax, Heart, and Abdomen

Introduction

  • Focus on examination of the thorax (breast tissue and lungs), heart, and abdomen.

Breast Examination

Important Considerations

  • For clients who have had:

    • Mastectomy

    • Breast augmentation

    • Reconstruction

  • Palpate incisional lines for abnormalities.

  • Look for lymphedema in clients with impaired lymphatic drainage on the affected side.

  • Encourage self-awareness of breast tissue changes.

  • Monthly breast self-examination (BSE) advised:

    • Perform in front of a mirror and during a shower.

    • Pregnant or postmenopausal clients should do it on the same day each month.

    • Optimal timing: 4 to 7 days post-menses.

Examination Techniques

  • Inspect and palpate the breasts.

Equipment Needed

  • Gloves

  • Drape

  • Small pillow or folded towel

Inspection Positions for Women

  1. Arms at the side

  2. Arms overhead

  3. Hands on hips

  4. Leaning forward

Inspection Positions for Men

  • Sitting or lying down with arms at the side only.

What to Inspect For

  • Size & Symmetry: One breast often slightly larger than the other.

  • Shape: Convex, conical, or pendulous.

  • Skin Tone: Symmetric venous patterns, no lesions, edema, or erythema.

  • Areola: Round/oval shape, darker pigmentation; color varies by skin tone (darkens in pregnancy).

  • Nipple Direction: Preferably everted; inversion is unexpected.

  • Discharge: Assess for any bleeding or discharge.

Documentation of Nodules

  • Location (quadrant or clock method).

  • Size (cm).

  • Shape and consistency (soft, firm, hard).

  • Borders, tenderness, erythema, dimpling or retraction, lymphadenopathy, and mobility.

Health History Questions

  • Self-examination frequency?

  • Noticed any tenderness/lumps?

  • For menstruating clients: Any changes during menstrual cycle?

  • History of mammogram and frequency?

Palpation Techniques

  • Axillary & Clavicular Lymph Nodes: Palpate while client is seated with arms at their sides; expect them to be non-palpable and non-tender.

  • Breast Examination Protocol:

    • Spread breast tissue evenly over chest wall by positioning the client lying down with one arm elevated.

    • Palpate in a systematic pattern:

      1. Circular

      2. Wheel (clock spokes)

      3. Vertical strip

    • Compress nipples gently to check for unexpected discharge in non-lactating women.

Page 2: Expected Findings and Thorax Examination

Expected Findings

Females

  • Breasts should feel firm, dense, elastic, and free of lesions or nodules.

  • Bilateral granular/lumpy breast tissue in some women can be normal.

Males

  • No edema, masses, nodules, tenderness; areolae are round and darker pigmented.

Unexpected Findings

Females

  • Fibrocystic Breast Disease: Tender cysts may be more pronounced during menses.

Males

  • Gynecomastia: May appear in adolescents or bilaterally in older males (excluding those undergoing estrogen therapy).

Thorax and Lungs Examination

Examination Techniques

  • Includes inspection, palpation, percussion, and auscultation.

Equipment Required

  • Stethoscope, centimeter ruler, wristwatch.

Positioning

  • Assess posterior thorax while sitting or standing. Assess anterior thorax: sitting, lying, or standing.

Anatomical Landmarks for Lung Assessment

  • Right lung has 3 lobes; left lung has 2 lobes. Check right middle lobe via axillae.

Key Landmarks

  • Midsternal Line: Central sternum.

  • Midclavicular Line: Midpoint of clavicle.

  • Axillary Lines: Anterior, mid & posterior axillary lines.

  • Scapular/Vertebral Lines: Inferior angle of scapula/along spine.

Percussion & Auscultation Sites

  • Found in intercostal spaces, between scapulae & vertebrae, along rib cage. Side-to-side comparisons necessary.

Maximizing Sounds during Auscultation

  • Deep breaths with mouth open, diaphragm against the skin, clear patient directions for optimal positioning.

Page 3: Respiratory Assessment and Findings

Visual Inspection of the Chest

Shape & Symmetry

  • Anteroposterior diameter should be 1/3 to 1/2 of transverse diameter.

  • Chest symmetry with no rib deformities or retractions.

Respiratory Effort

  • Normal rate: 12-20 breaths/min, regular pattern.

  • Assess character of breathing (diaphragmatic, abdominal, thoracic), accessory muscle use, and depth of breaths (should be unlabored).

Cough Assessment

  • If productive, note sputum color/consistency.

Trachea Assessment

  • Should be midline.

Palpation

  • Check for tenderness, lesions, lumps, or deformities; tenderness is unexpected.

  • Chest excursion: use thumbs along spine to assess expansion (should move outward by 5 cm with deep breath).

Vocal Fremitus

  • Use palms, assess side to side; vibration should be symmetric, stronger at the tracheal bifurcation.

Expected Findings

  • Vibration symmetric; increased might indicate pneumonia; decreased may point to pneumothorax.

Percussion

  • Sound comparison:

    • Resonance: normal finding.

    • Dullness: indicates fluid/solid tissue (pneumonia, tumor).

    • Hyperresonance: signals excess air (pneumothorax, emphysema).

Auscultation of Lung Sounds

Expected Sounds

  1. Bronchial: Loud, hollow, longer expiration (trachea).

  2. Bronchovesicular: Medium pitch, equal inspiration/expiration (large airways).

  3. Vesicular: Soft, low-pitched, longer inspiration (peripheral lungs).

Unexpected Sounds

  • Crackles/Rales: Bubbly, non-clearing with cough.

  • Wheezes: High-pitched whistling on expiration.

  • Rhonchi: Low-pitched, rumbling; may clear with cough.

  • Pleural Friction Rub: Dry, grating sound during breathing.

  • Absence of Breath Sounds: May indicate removed/collapsed lobes.

Page 4: Heart Examination and Findings

Heart Examination Techniques

Equipment

  • Stethoscope, blood pressure cuff, wristwatch, rulers.

Cardiac Cycle and Sounds

  • S1: Closure of mitral/tricuspid valves marking ventricular systole.

  • S2: Closure of aortic/pulmonic valves marking ventricular diastole.

  • S3: Rapid ventricular filling (normal in children/young adults).

  • S4: Strong atrial contraction (typically in older adults).

Dysrhythmias & Gallops

  • Dysrhythmias: Irregular heartbeats; gallops sound like "Ken-tuck'-y" for S3, "Ten'-es-see" for S4.

Murmurs & Bruits

  • Murmurs indicate blood flow abnormalities. Systolic occurs after S1; diastolic after S2.

  • Bruits signal obstructed peripheral blood flow.

Auscultation Sites for Heart Sounds

  • Aortic Area: Right 2nd ICS.

  • Pulmonic Area: Left 2nd ICS.

  • Erb's Point: Left 3rd ICS.

  • Tricuspid Area: Left 4th ICS.

  • Mitral Area: Left 5th ICS, midclavicular line.

Health History Review of Systems

Key Questions

  • Any heart issues? Diabetes? Lung diseases?

  • History of hypertension or high cholesterol?

  • Symptoms: Swelling, cough, chest pain?

  • Stress level, lifestyle habits, and family history of heart problems?

Inspection & Palpation

Vital Signs

  • Heart rate, blood pressure for cardiovascular status.

Jugular Vein Inspection

  • Assess for right-sided heart failure with the head elevated at 30-45°. No distention expected; JVP < 2.5 cm (1 in) is normal.

Carotid Artery Examination

  • Assess one artery at a time while preventing loss of consciousness.

Point of Maximal Impulse (PMI)

  • Check left midclavicular line, 4th or 5th ICS; be cautious with clients having large breast tissue.

Heaves & Thrills

  • Heaves: unexpected elevating of chest wall; Thrills: vibrations accompanying murmurs (abnormal findings).

Page 5: Peripheral Vascular System Assessment

Locations for Bruit Assessment

  1. Carotid Arteries: Over the pulses.

  2. Abdominal Aorta: Below the xiphoid.

  3. Renal Arteries: Midclavicular lines above the umbilicus.

  4. Iliac Arteries: Midclavicular lines below the umbilicus.

  5. Femoral Arteries: Over the pulses in the abdomen.

Abdomen Examination Techniques

Examination Overview

  • Inspection, palpation, percussion, and auscultation (technique order modified).

Equipment Required

  • Stethoscope, tape measure/ruler, marking pen.

Client Preparation

  • Instruct the client to urinate; position client supine with arms at the sides and knees bent.

Abdominal Quadrants

  • Examine quadrants: RUQ, LUQ, RLQ, LLQ using xiphoid process and symphysis pubis as boundaries.

Health History Review of Systems Questions

  • Symptoms: nausea, vomiting, dietary intolerances?

  • Recent weight changes? Bowel habits?

  • Abdominal pain history or surgery? Family history of colon cancer?

  • Alcohol consumption and dietary habits?

Inspection of the Abdomen

Expected Findings

  • Check for guarding/splinting, umbilical inspection, skin lesions.

  • Shape/Contour: Flat, convex, concave, or distended.

  • Monitoring abdominal size: measure at umbilicus for fluid retention.

Movements of Abdominal Wall

  • Peristalsis: Visible in thin adults or those with obstructions.

  • Pulsations: Regular was are normal; spotted mass signifies concern.

Auscultation of Bowel Sounds

Timing and Technique

  • Listen between meals. Use diaphragm over all quadrants.

Expected/Unexpected Sounds

  • Expected Sounds: High-pitched clicks/gurgles (5-35 times/min).

  • Absent Sounds: No sounds after 5 mins indicate a blockage.

  • Loud growling (borborygmi) indicates increased gastrointestinal activity.

Percussion

Expected Sounds

  • Most of the abdomen should produce tympany; dullness over liver/distended bladder.

  • Liver span: 6 to 12 cm (2.4 to 4.7 in); outsized indicates hepatomegaly.

Kidney Assessment

  • Assess costovertebral angles for tenderness.

Palpation

Techniques

  • Check tender areas last; light palpatation (1.3 cm depth) for softness, no nodules, pain.

  • Bladder will feel palpable if full.

  • Deep palpation for experienced providers to assess organ size/masses noted.

Rebound Tenderness

  • Blumberg's sign: Indicates inflammation. Apply pressure then release. Observe client response.

  • Deep palpation to be avoided if there are signs of tenderness or prior surgeries.

Expected Changes with Aging

Breasts

  • Glandular tissue atrophies with menopause. Adipose tissue replaces it.

Lungs

  • Chest shape changes, reduced vital capacity, diminished cough reflex.

  • Increased respiratory infection risk; cilia activity reduces.

Cardiovascular System Changes

  • Systolic hypertension from atherosclerosis, heart valves stiffen, decreased cardiac output, and activity tolerance issues.

Abdomen

  • Weaker muscles, more adipose; slower motility in digestive processes.

Sample Documentation of Findings

  • Breast: Symmetrical, without masses or lesions, no palpable lymph nodes, non-tender.

  • Respiratory: Rate 16/min, symmetrical movement, expired sound increased; no adventitious sounds.

  • Heart: Regular rate at 72/min, no murmurs or thrills; JVP 2 cm bilaterally.

  • Abdomen: Flat with active bowel sounds, soft and nontender, no masses or organ enlargement.