Physical Health Assessment

Thorax and Lungs

Lecturer/ Hanaa Eisa

1) Identify the anatomic landmarks of the thorax.

2) Describe the characteristics of the most common respiratory chief complaints.

3) Perform inspection, palpation, percussion, and

auscultation on a healthy adult and on a

patient with pulmonary pathology.

Learning out come

4) Explain the pathophysiology for abnormal findings.

5) Document respiratory assessment findings.

6) Describe the changes that occur in the lungs with the aging process.

Learning out come

Anatomyanterior thorax

Sternum Clavicles Nipples Suprasternal notch Angle of Louis Costal angle

Anatomy of posterior thorax

1. Vertebra prominence

2. Spine

Anatomy of the lungs

1. Right lung — three lobes

2. Left lung — two lobes

3. Apex

4. Base

5. Mid clavicular line (MCL)

6. Mid axillary line (MAL)

Location of Lobes of Lungs with in

The Thoracic Cavity

Pleurao Parietalo Visceral

Mediastinum or interpleural space

Bronchio Righto Left

Anatomy of the lungs cont’d

Alveoli Diaphragm External intercostals muscles Accessory muscles

Anatomy of the lungs cont’d

Thoracic anatomic topography

1. Anterior axillary line

2. Midspinal (vertebral) line

3. Midsternal line

4. Posterior axillary line

5. Scapular line

Physiology

1. Ventilation

2. External respiration

3. Internal respiration

4. Control of breathing

Health history

Patient profileAge• Children and young adults: cystic fibrosis• Adults and older adults: chronic bronchitis,

emphysema, pneumonia, lung cancero Gendero Race• African ,American

Common chief complaints

1. Dyspnea

2. Cough

3. Sputum

4. Chest pain

Characteristics of chief complaint

1. Quantity

2. Quality

3. Associated manifestations

4. Aggravating factors

5. Alleviating factors

6. Timing

7. Setting

Past health history• Medical

o Respiratory specifico Nonrespiratory specific

• Surgical• Medications• Communicable diseases• Allergies• Special needs• Childhood illnesses

Family health history

o Allergies?o Asthma?o Cystic Fibrosis?o Emphysema?o Cancer?o Bronchiectasis?o TB?

Social history

o Alcohol, drug, or tobacco useo Travel historyo Work and home environmento Stresso Economic status

Health maintenance activities

Sleep Diet Exercise Use of safety devices Health check-ups

Assessment of the thorax and lungs

Equipment• Stethoscope• Centimeter ruler and measuring tape• Washable marker• Watch with second hand

Inspection

Shape of thorax

1. Diameter -Transverse diameter –Anteroposterior Symmetry of chest wall

2. Presence of superficial veins

3. Costal angle

4. Angle of the ribs

5. Intercostals spaces

6. Muscles of respiration

Respirations

1. Rateo Normal in adult 12 – 20 c/mo Tachypnea > 20 c/mo Bradypnea < 12 c/mo Apnea: no respiration for 10 or more

seconds

2. Pattern

3. Depth

o Patient position• Upright• Supine• Orthopnea

o Mode of breathing

Respirations

Sputum

o Coloro Odoro Amounto Consistency

Assessing patients with respiratory assistive devices

Oxygen therapyo Mode of deliveryo Percentage of oxygeno Flow rateo Humidification

Pulse oximeter

Incentive spirometero Frequency of use; volume achieved;

number of repetitions

Endotracheal tubeo Sizeo Nasal or oral insertion

Assessing patients with respiratory assistive devices

o Length of tube as it exits mouth or noseo Cuff inflated or deflated

Tracheostomy tubeo Sizeo Cuffed or cuff lesso How tube is secured to neck

Assessing patients with respiratory assistive devices

Mechanical ventilationo Type of ventilatoro Modeo Peepo Rateo Tidal volumeo Alarms

Assessing patients with respiratory assistive devices

Palpation

o Anterioro Posterioro Lateralo Pulsationso Masses

o Thoracic tendernesso Crepituso Thoracic expansiono Tactile or vocal fremitus

Palpation

Percussion

o Anterioro Posterioro Lateralo Diaphragmatic excursion

Auscultation fields

o Anterioro Posterioro Lateral

Auscultation—breath sounds

o Pitcho Intensityo Qualityo Durationo Location

Normal breath sounds

o Bronchialo Bronchovesicularo Vesicular

Adventitious breath sounds

Crackle or Rateo Fineo Coarse

Wheezeo Sonorous (Rhonchi)o Sibilant

Pleural friction rub Stridor

Voice sounds

Bronchophony Egophony Whispered pectoriloquy

Normal findings

o AP to transverse diameter is 1:2o Elliptical-shaped thoraxo Shoulders and scapula at same height bilaterally

o No masses or superficial veinso Costal angle < 90 degrees during exhalation and

at resto Ribs articulate at a 45-degree angle with the

sternumo Absence of intercostals retractions

Normal findings

o No accessory muscle useo Respiratory rate 12–20 breaths per minuteo Eupneao Respiratory pattern is regular .o Respiratory depth is nonexaggerated and

effortless

Normal findings

o Symmetrical rise and fall of thoraxo Respirations are quiet, unless a few

centimeters from patient’s nose or moutho Able to breath comfortably in supine, prone,

or upright positiono Usually breathe through nose

Normal findings

Normal findings

o Small amount of sputum may be presento Sputum should be odorless and light

yellow to clear in coloro No pulsations, masses, thoracic

tenderness, crepitus presento Thoracic expansion is 3 to 5 cmo Trachea is midline

o Resonant sound on percussion over lung tissue

o Dull sounds over diaphragm and cardiac o Rib sounds are flato Hyperresonance present if adult is thin

Normal findings

o Diaphragmatic excursion is 3 to 5 cmo Bronchial breath sounds over tracheao Bronchovesicular breath sounds over

scapular areao Vesicular breath sounds over peripheral lung

Normal findings

o Increased work of breathingo Limited chest wall expansiono Muscle atrophy

Alveolar gas exchangeo Decreased surface area for diffusion

Anatomic changes

Regulation of ventilationo Decreased sensitivity to changes in carbon

dioxide and oxygen

Lung defense mechanismso Decreased ciliary actiono Diminished cough reflexo Increased susceptibility for infection

Age-related changes

Thank you