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Posterior Thorax
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Normal Findings
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Deviation from Normal
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1.
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Inspect the spinal alignment for deformities.
• Have the client stand. From a lateral position, observe the three normal curvatures: cervical, thoracic, and lumbar.
• To assess for lateral deviation of the spine (scoliosis), observe the standing client from the rear. Have the client bend forward at the waist and observe from behind.
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Spine vertically aligned;
Spinal column is straight, right and left shoulders and hips are at the same height
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Exaggerated spinal curvatures (kyphosis, lordosis, scoliosis);
Spinal column deviates to one side, often accentuated when bending over;
Shoulders or hips not even
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2.
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Palpate the posterior thorax.
• For clients who have no respiratory complaints, rapidly assess the temperature and integrity of all chest skin.
• For clients who do have respiratory complaints, palpate all chest areas for bulges, tenderness, or abnormal movements. Avoid deep palpation for painful areas, especially if a fractured rib is suspected.
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Skin intact; uniform temperature
Chest wall intact; no tenderness; no masses
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Skin lesions; areas of hyperthermia
Lumps; bulges; depressions; areas of tenderness; movable structures
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3.
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Palpate the posterior chest for respiratory excursion.
• Place the palms of both your hands over the lower thorax, with your thumbs adjacent to the spine and your fingers stretched laterally. Ask the client to take a deep breath while you observe the movement of your hands and any lag in movement.
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Full and symmetric chest expansion (that is, when the client takes a deep breath, your thumb should move apart at an equal distance and at the same time; normally the thumb separate 3 to 5 cm during deep inspiration)
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Assymetric and/or decreased chest expansion
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4.
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Palpate the chest for vocal (tactile) fremitus.
• Place the palmar surfaces of your fingertips or the ulnar aspect of your hand or closed fist on the posterior chest, starting near the apex of the lungs.
• Ask the client to repeat such words as “blue moon” or “one, two, three.”
• Repeat the two steps, moving your hands sequentially to the base of the lungs.
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Bilateral symmetry of vocal fremitus;
Fremitus is heard most clearly at the apex of the lungs;
Low-pitched voices of males are more readily palpated than higher pitched voices of females
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Decreased or absent fremitus (pneumothorax);
Increased fremitus (pneumonia)
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5.
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Percuss the thorax.
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Percussion notes resonate, except over scapula;
Lower point of resonance is at the diaphragm (at the level of the 8th to 10th rib posteriorly)
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Assymetry in percussion
Areas of dullness or flatness over lung tissue (associated with consolidation of lung tissue or a mass)
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6.
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Auscultate the chest using the flat-disc diaphragm of the stethoscope.
• Use the systematic zigzag procedure used in percussion.
• Ask the client to take slow, deep breaths through the mouth. Listen at each point to the breath sounds during a complete inspiration and expiration.
• Compare findings at each point with the corresponding point on the opposite side of the chest.
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Vesicular and bronchovesicular breath sounds
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Adventitious breath sounds (e.g., crackles, rhonchi, wheeze, friction rub;
Absence of breath sounds (associated with collapsed and surgically removed lung lobes)
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Anterior Thorax
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Normal Findings
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Deviation from Normal
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7.
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Inspect breathing patterns.
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Quiet, rhythmic, and effortless respirations
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Abnormal breathing patterns and sounds
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8.
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Inspect the costal angle and the angle at which the ribs enter the spine.
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Costal angle is less than 90°, and the ribs insert into the spine at approximately at 45° angle
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Costal angle is widened (associated with COPD)
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9.
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Palpate the anterior chest.
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Skin intact; uniform temperature
Chest wall intact; no tenderness; no masses
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Skin lesions; areas of hyperthermia
Lumps; bulges; depressions; areas of tenderness; movable structures
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10.
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Palpate the anterior chest for respiratory excursion.
• Place the palms of both your hands on the lower thorax, with your fingers laterally along the lower rib cage and your thumbs along the costal margins
• Ask the client to take a deep breath while you observe the movement of your hands.
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Full symmetric excursion; thumb normally separate 3 to 5 cm
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Assymetric and/or decreased respiratory excursion
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11.
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Palpate tactile fremitus in the same manner as for the posterior chest.
• If the breasts are large and cannot be retracted adequately for palpation, this part of the examination usually is omitted.
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Same as posterior femitus;
Fremitus is normally decreased over heart and breast tissue
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Same as posterior fremitus
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12.
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Percuss the anterior chest systematically.
• Begin above the clavicles in the supraclavicular space, and proceed downward to the diaphragm.
• Compare one side of the lung to the other.
• Displace female breasts for proper examination.
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Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach
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Assymetry in percussion notes areas of dullness or flatness over lung tissue
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13.
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Auscultate the trachea.
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Bronchial and tubular breath sounds
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Adventitious breath sounds
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14.
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Auscultate the anterior chest.
• Use the sequence used in percussion, beginning over the bronchi between the sternum and the clavicles.
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Bronchovesicular and vesicular breath sounds
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Adventitious breath sounds
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