Assessment of The Thorax and Lungs 2014
Assessment of The Thorax and Lungs 2014
Assessment of The Thorax and Lungs 2014
Assessment of the
Thorax and Lungs
Myung-Hee Pak, RN, MSN, CNS
Organs of respiration
Located in thoracic cavity
Right lung-3 lobes
Left lung- 2 lobes
Important to know landmarks of
thorax
Composed of trachea, bronchioles &
alveoli
Figure 6-7.
Pneumonia Diagram
Figure 6-9.
Pneumothorax Diagram
Figure 6-11.
Figure 6-8.
Atelectasis Diagram
Anatomical Landmarks
Anteriorly: Apex of lung -1 and
(2-4cm) above clavicle.
Anteriorly: Base to 6th rib
midclavicular, 8th rib midaxillary.
Posterior: Apex- first thoracic
vertebrae.
Posterior: Base T-10 expiration and T
-12 deep inspiration.
Figure 6-13.
Figure 6-15.
Chest Landmarks
Figure 6-17.
Subjective Data
Cough
Sputum
Shortness of Breath (SOB)
Smoking
Past Hx respiratory disorders
Environmental factors
Self-care behaviors
Figure 6-21.
Normal Anteroposterior-to-Transverse
Chest Diameter Ratio
Kyphosis
Figure 6-22.
Increased Anteroposterior Diameter
Scoliosis
Figure 6-27.
Figure 6-29.
Chest
expansion/
excursion
Chest excursion
How to Assess Posterior Chest Expansion
or Excursion
Diaphragmatic Excursion
Figure 6-34.
Percussion of the Chest
Diaphragmatic excursion
Auscultation
Beginning at apices to base, compare
bilaterally.
Listen for full cycle, note quality and
intensity
Instruct patient to breathe through
mouth, a little deeper (but not faster)
than usual
Use stethoscope diaphragm firmly vs
chest wall
Figure 6-41.
Breath Sounds Anterior View
Figure 6-38.
Figure 6-40.
Normal Breath Sounds
Figure 6-42.
Breath Sounds Posterior View
Adventitious sounds
Figure 6-44.
Assess Lungs
Further Assessment
Sample Charting
SUBJECTIVE
No cough, shortness of breath, or chest pain
with breathing. No history of respiratory
diseases. Has one or no colds per year.
Has never smoked. Works in well-ventilated
office-smoking coworkers are restricted to
smoke in lounge. Last TB skin test 4 years
PTA, negative. Never had chest x-ray.
Summary:
Respiratory Assessment
Respiratory rate and rhythm
Lung sounds
Use of accessory muscles?
Nasal flaring?
Color- skin, nail beds, lips.
Clubbing of nails.
Pulse Ox +/or ABG
Orthopnea?, SOB?, Dyspnea?