Introduction

Assessment of the Lungs and Thorax

Mental Status Assessment

Neurological Assessment
Cardiovascular Assessment

Recording the Physical Assessment

Special Nursing Situations Finding

The EKG Paper

Post Examination

ASSESSMENT OF THE LUNGS AND THORAX CONTINUED

ADDITIONAL BREATH SOUNDS

If you are unsure of what you are hearing through the stethoscope, or if breath sounds are diminished, ask him/her to breathe deeper and/or open the mouth wider.  Perhaps ask him to breath faster; that may enhance the quality of the sounds you are hearing.

Bronchophony

This term represents a test to perform on the patient which may indicate that there is consolidation of the lung.  Consolidation refers to increased density of the lung tissue, due to it being filled with fluid and/or blood or mucus.  Ask the patient to say the words:  “ninety-nine” while you listen through the stethoscope.  Normally the sound of “ninety-nine” will sound very faint and muffled.  When you listen through normal lung tissue, sounds are normally muffled.  If it sounds clear through the stethoscope, there is probably consolidation of the lung and Bronchophony is present.  This occurs because sound transmission through consolidated tissues will be greater and clearer because dense tissue transmits sound better than normal “fluffy” lung tissue.

Egophony

This is a term that indicates that there is consolidation of the lung or possible collapse of the lung.  Ask the patient to repeatedly say the sound “ee” while you listen with the stethoscope.  Normally, it will sound muffled, but it will remain with the long sound of “ee” when you listen over most of the lung field.  If the sound changes to “ay” sound, while the patient is saying “ee” then egophony is present.  This indicates consolidation, or that there is fluid in the lungs.

Whispered Pectoriloquy

This is another term to determine the presence of consolidation of the lungs.  You will ask the patient to whisper a number or short phrase and repeat it; such as counting, “1, 2, 3”  “1, 2, 3”, etc. and listen through the stethoscope.  Normally the whispered voice will be distant and very muffled through the stethoscope.  If consolidation is present in a section of the lung field, the whispered voice will sound unusually clear and loud, instead of muffled and distant.  Consolidation of the lung tissue causes filling of the air spaces of the alveoli and voice transmission through that part of the lung will be unusually clear and louder than normal.  Thus if pectoriloquy is present, it indicates consolidation of some portion of the lung field.

COMMON PULMONARY DISORDERS AND PHYSICAL ASSESSMENT FINDINGS USUALLY PRESENT

hyperinflation of lungs, impaired expansion, use of accessory muscles of respiration, prolonged expiration and wheezes present.

decreased expansion on affected side, hyper resonant or tympanic sounds or even absent sounds in affected areas.

decreased expansion of affected side, trachea & heart shifted away from affected side, dullness or flatness or absent breath sounds.

decreased expansion on affected side, dull or flat sound or absent breath sounds, trachea and heart shifted toward affected side.

bronchial breath sounds, bronchophony, pectoriloquy, possible splinting on the (pneumonia) affected side.

Summary of Assessment factors:

Look for the slope of the ribs, bilateral and symmetrical chest wall expansion, abnormal breathing patterns, thoracic or abdominal breathing.

Look for the shape of the thorax; evaluate anteroposterior diameter relative to lateral diameter of chest wall, pectus carinatum (pigeon breast), pectus excavatum (funnel chest), kyphosis (spine curvature), scoliosis (lateral spine curvature), kyphoscoliosis, and note tracheal position.

Look for breathlessness wheezing, sputum, cough, cyanosis, pallor, eruptions, nodules, scars, neck vein distention, fingers for tobacco stains, finger and toes for clubbing, which can be a sign of chronic respiratory disease.

Feel for masses, nodules, pain, tenderness, examine the:  neck, axillae, supraclavicular fossae for lymph nodes, palpate trachea for midline placement.

Feel for skin temperature and moisture

Feel for other mentioned in the text.

Listen for symmetry of sounds from each side.

Listen to patient to tell you of pain or tenderness when percussing.

Listen for intensity of sounds one each side of the thorax (symmetry)

Listen for normal and abnormal breath sounds.

Following, we will present detailed outlines of the method for assessment.  Today, nurses are taking increased responsibility for assessment of lungs, including auscultation.  However, there are still many differences in levels of responsibilities among nurses in different hospitals.  Some hospitals do not allow any nurses to chart any breath sounds at all.  Other facilities want all nurses to listen and record all patients’ breath sounds.  There is also every situation in between these two extremes.

We will present guidelines for those nurses who will have this responsibility of listening and charting breath sounds.  If you are in a facility that does not allow you to record breath sounds, you may still listen to the lungs and at least chart that you notified someone that the patient sounds “congested.”  In most facilities around the country, you may at least chart “congested” lungs if you are not allowed to chart terms like:  “rales,” “rhonchi,” etc.

CHARTING THE EXAMINATION FINDINGS

When charting the normal exam, most nurses, for brevity, will chart only that respirations are “normal” and there is no “SOB.”  In most cases, that is acceptable for a routine or normal examination.  However, it is very possible to be brief and thorough.

  1. Inspection  observe:  shape of chest; include deformities width or costal angle, movements of intercostal spaces during respirations use of accessory muscles of respirations local impairment of respiratory movements rate and rhythm of respirations.

Charting of these normal findings might be:
resp rate-20/min, regular, no SOB1

  1. Palpation       a.         identify areas of tenderness

b.         assess any observed areas of abnormality
c.         assess respiratory excursion (expansive movements of the  
chest during breathing)
d.         assess skin condition (temperature, etc.)

  1. Percussion    a.         assess any areas of dullness, flatness, tympany

b.         assess areas found to be abnormal from previous examinations.

  1. Auscultation a.         assess quality and intensity of breath sounds

b.         assess patient for abnormal breath sounds
c.         assess patient for areas of consolidation

When charting your findings, you may not be sure as to exactly what you are hearing.  Most hospitals do not require that palpation and percussion results be charted.  If the nurse carefully assesses the breath sounds, those others may not need to be charted, but are still used to confirm the nurse’s assessment of the patient’s problem.  If the nurse is unfamiliar with naming the individual breath sounds, you should be very descriptive when charting.

For example:  chart the location and sound that you hear…..
moist respirations in LLL and RLL……or
fine rales in LLL and RLL  (either is correct)

Do not feel that you must always tag a name to the type of abnormal respirations that you hear.  It is sufficient to accurately describe the abnormal breathing.  Another important function is to follow up the results of your exam if there is an abnormality.  Your nursing diagnosis will include nursing orders to turn the patient more frequently or to suggest that respiratory therapy be performed on the patient.  Therefore, communications is important, but so is the nursing follow-up on your findings.

GUIDE TO ASSESSMENT OF LUNGS AND THORAX

  1. Assemble Equipment
  2. History-taking
  3. Explains Procedure to the patient
  4. Washes hands
  5. Gowns or drapes patient to prevent unnecessary exposure
  6. Provides a quiet place for patient comfort and for auscultation
  7. Provide adequate lighting
  8. Use of proper Techniques:
    1. inspection, palpation, percussion, auscultation
    2. compares symmetry of thorax (each hemothorax)
    3. starts at neck, then posterior, right and left lateral, then anterior thorax
    4. Respiratory rate determination
    5. Rhythm determination
    6. Depth determination
    7. Abnormalities:
      1. defines boundaries of abnormality is found; describes accurately
      2. do not allow patient to hyperventilate during the exam.
      3. avoids bony prominences during the exam (poor sound conduction)
      4. records findings accurately

POSTERIOR THORAX EXAMINATION

  1. Patient seated with arms folded across chest
  2. Inspects symmetry, contour, color, skin condition
  3. Palpates posterior interspaces for masses, lesions, etc.
  4. Palpates ribs and scapulae for masses, breaks, etc.
  5. Evaluates tactile fremitus
  6. Evaluates respiratory excursion
  7. Percussion – 5 cm intervals from apex to base contra laterally
  8. Diaphragmatic excursion
  9. Ausculate breath sound
  10. Ausculate voice and whispered sounds

RIGHT AND LEFT LATERAL THORAX

  1. Patient seated with arms on head
  2. Begin in the axillae and proceed downward contra laterally using at least 4 or 5 sites for comparison
  3. Inspects for symmetry, color, condition of skin
  4. Palpate ribs for masses or bulges
  5. Palpates tactile fremitus
  6. Percusses lateral thoraces
  7. Auscultates breath sounds
  8. Auscultates voice and whispered sounds

ANTERIOR THORAX

  1. Patient is supine with arms abducted; child is placed totally flat and head is not allowed to turn.
  2. Inspect anterior chest for symmetry, contour, color, skin condition
  3. Palpate ribs and interspaces for bulges and masses
  4. Palpate for tactile fremitus
  5. Palpate trachea
  6. Percuss anterior chest at 5 cm intervals
  7. Auscultate for breath sounds
  8. Auscultate for voice and whispered sounds.

CHARTING EXERCISE:  This is not part of Posttest for this course:  for practice only.

  1. Chart a brief narrative of a “normal” lung assessment
  2. Chart on a patient who has COPD with an acute attack.
  3. General - - - - - -
  4. Rate, rhythm, depth (difficulty) - - - - -
  1. Auscultation results - - - - - -

S-        (subjective)
O-        (objective)
A-        (assessment)
P-        (plan - -nursing orders)

ADVENTITIOUS SOUNDS:

RALES:         (or crackles)

Definition:

  1. Clusters or showers of sounds
  2. Produced by bubbling air through the alveoli, bronchioles bronchi
  3. Non-continuous
  4. Variable quality:

Types:

Fine rales:  terminal bronchioles and alveoli, sounds like hair being rubbed between fingers.
Medium rales:  larger air passages, bubbling sound of opening a carbonated beverage.
Coarse rales:  louder and lower-pitched from larger passages

RHONCHI:

Definition:

  1. Produced by air travelling through narrowed passages or through mucus in the passages.
  2. Varying sound quality
  3. Continuous sound

Types:      Fine rhonchi
Coarse rhonchi (sonorous)
Sibilant rhonchi (wheezes)

FRICTION RUB:

Definition:

  1. Coarse grating sound
  2. Inflamed surfaces of the pleura rub together during respirations
  3. Usually over anterolateral thorax

Next: PART II  MENTAL STATUS ASSESSMENT