Assessing Thorax

and Lungs
Chapter 19 Health Assessment in Nursing
Presented by: Chloe Williams, RN, BSN

Objectives:
Describe the structures and functions of the thorax and lungs
Differentiate between normal and abnormal findings of the thorax and

lungs
Discuss risk factors for lung cancer across cultures and way to reduce
ones risk
Interview patient for accurate nursing history of the thorax and lungs
Perform physical assessment using inspection, auscultation, palpation,
and percussion
Describe teaching opportunities to reduce risk and promote health of the
thorax and lungs

Thorax and Lung Assessment

Thorax

Extends from the base of the

neck superiorly to the level of
the diaphragm inferiorly

Lungs, distal portion of the

trachea, bronchi

Sternum has three parts

Manubrium, the body, xiphoid

process

12 pairs of ribs - thoracic cage

Thorax and Lung Assessment

Mediastinum: central area
in the thoracic cavity
Lungs: two cone-shaped,
elastic structures
Pleura: thin, doublelayered serous membrane
that lines the thoracic
cavity

Thorax and Lung Assessment

Anterior vertical lines

Lateral vertical lines

Thorax and Lung Assessment

Posterior Vertical Lines

Lung Cancer
Leading cause of cancer in the US.
158,040 deaths (American Cancer Society, 2015)

Risk Factors
Cigarette smoke/secondhand smoke
Exposure to asbestos or radon
Personal history of radiation exposure
Family history

Effects of Smoking
https://
youtu.be/gwuwrRK-I2Y?list=PL63ZDAxBLAEt8d56sG5bF
X9gDCT3lzmmY

Lung Cancer Prevention

Avoid smoking/tobacco cessation program
Have residence or office checked for asbestos or radon (if
older residence)
Avoid secondhand smoke
Healthy diet (low-cholesterol)
Manage weight
Seek medical assistance with a prolonged cough or chest pain
***Patient teaching opportunity***

Lung Cancer Prevalence

African American men have higher incidence and
mortality rates
U.S. Hispanics have lower rates than non-Hispanic whites
***Why is this? ***

Subjective Data Collection

History of present health concern - COLDSPA
Character
Onset
Location
Duration
Severity
Pattern
Associated factors/How it Affects the client
Past health history
Family history
Lifestyle and health practices

Subjective Data Collection

Case study: Mr. Jones presents the following symptoms in clinic:
chest pain, productive cough with yellow phlegm, and a
temperature of 102 degrees Fahrenheit. He admits to smoking 1
pack of cigarettes per day for the last 30 years. His mother died
at age 70 with CHF and his father suffered with emphysema and
died of lung cancer at age 72.
Questions:
What type of screening is recommended for Mr. Jones?
What information will you provide for pt education?

Collecting Objective Data

https://youtu.be/9yvbsSRlAyY

Explain procedure to client

Have the client remove all clothing from the waist up

Ask the client to sit in an upright position

Examination gown and drape

Gloves; stethoscope

Light source

Mask; skin marker and metric ruler

Inspection
Inspect for nasal flaring and pursed lip breathing
Labored respiration may indicate hypoxia
Observe color of the face, lips, and chest.
Ruddy to purple (COPD, CHF)
Cyanosis (cultural considerations)
White skin-blue-tinged in perioral, nailbed, and conjunctival area
Dark skin-blue, dull, lifeless in same areas

Inspect color and shape of nails

Pale/cyanotic may indicate hypoxia, also clubbing

Inspection

Tripod position seen in COPD

Client leans forward

Uses arms to support weight
Lifts chest to increase
breathing capacity
Pursed lip breathing

Barrel chest

Inspection
Anterior Thorax: Spaces and Muscles
Inspect intercostal spaces.
Ask the client to breathe normally and observe the intercostal
spaces.
Observe for use of accessory muscles.

Palpation of the Thorax

Tenderness and sensation
Crepitus: crackling
sensation, inflammation or
infection of small bronchi,
bronchioles, and alveoli
Surface characteristics

Palpation: Fremitus and Chest

Expansion
Palpate for fremitus:
vibrations of air in the
bronchial tubes
transmitted to the chest
wall.
Assess chest expansion.

Auscultation
Do not attempt to listen through clothing/materials
Ask pt to take deep breaths (be alert to older patients or if
fatigue is an issue)
Normal breath sounds include:
Bronchial (high pitched)-trachea and thorax
Bronchovesicular (moderate)-upper sternum and 2 nd intercostal
spaces
Vesicular (low)-peripheral lung fields

Auscultation
Auscultate for adventitious (abnormal) breath sounds.
Crackles (fine)-high pitched, heard on inspiration, coughing does not help, associated
with bronchitis, asthma, or emphysema.

Crackles (low)-early inspiration to early expiration, may indicate PNA, pulmonary

edema, and PF.

Pleural friction rub (low)-similar to crackles but sound is superficial, inspiration and
expiration, d/t rubbing two inflamed pleural surfaces, cause is pleuritic

Wheeze (sibilant)- high, musical, expiration and sometimes inspiration, d/t acute
asthma or chronic emphysema

Wheeze (sonorous)-low, expiration, cleared w/coughing, d/t bronchitis, single

obstructions, and snoring before sleep apnea, stridor-harsh, honking wheeze (needs
immediate attention)

Auscultation
Respiration Patterns

Normal Breath
Sounds

Auscultation

http://www.easyauscultation.com/cases?
coursecaseorder=2&courseid=201

QUESTION
Which symptom is indicative of COPD?
A. Increased breath sounds
B. Nose breathing
C. Barrel chest
D. Comfortable laying down

Percussion
Tone- start at scapulae and
percuss across and down
in intercostal spaces
Resonance-normal lung
tissue
Hyperresonance-trapped
air, in
emphysema/pneumothorax

Abnormal Findings
Position of scapulae and the shape and configuration of the
chest wall
Spinal configurations and deformities p.393
Scoliosis-sideways curvature of the spine
Barrel chest- over inflation of the lungs
Pectus excavatum (funnel chest)-breastbone sunken into chest, affects
lungs and heart, surgery can fix deformity

Kyphosis- forward rounding of the back, commonly seen in older

women, symptoms pain/back stiffness

Special Considerations
Older adults may experience dyspnea with certain
activities related to aging changes of the lungs (loss of
elasticity, fewer functional capillaries, and loss of lung
resiliency).
Chest pain related to pleuritis may be absent in older
clients because of age-related alterations in pain
perception.
The ability to cough effectively may be decreased in the
older client because of weaker muscles and increased
rigidity of the thoracic wall.

Special Considerations
Deep breathing may be especially difficult for the older client,
who may fatigue easily. Thus offer rest as needed.
Kyphosis (an increased curve of the thoracic spine) is common in
older adults.
Because of calcification of the costal cartilages and loss of the
accessory musculature, the older clients thoracic expansion may
be decreased, although it should still be symmetric.
The sternum and ribs may be more prominent in the older client
because of loss of subcutaneous fat.

Case Study
Mr. White was admitted for fever, chills, fatigue,
tachypnea, use of accessory muscles, and purulent
sputum. He also states he has been unable to complete a
full meal. What is an actual nursing diagnosis for Mr.
White? Also a risk for nursing diagnosis?

Case study (Nursing

interventions)

References
Weber, J. R. (2014). Health Assessment in Nursing. Philadelphia:
Wolter Kluwer Health| Lippincott Williams & Wilkins.
Weber, J. R. (2015, September 17). The Point. Retrieved from
The Point: http://thepoint.lww.com/Book/Show/474186?
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