THORAX AND LUNGS
Anatomy and Physiology amount, appearance, color, odor & viscosity (watery vs.
thick)
6. Wheezing or tightness in chest
7. Change in functional ability
OBJECTIVE DATA COLLECTION
GENERAL APPERANCE
•Body positioning & posture – relaxed &
upright, oriented to time, place & person.
•Observe for purse lip breathing & nasal
flaring.
•Evaluate level of consciousness – alert,
cooperative, skin color
•Chest movements, no cough or sputum,
audible sounds, RR, oxygen saturation
POSTERIOR CHEST
•INSPECTION
•Chest expansion
•Use of accessory muscles
•Supraclavicular or intercostal retractions
during respirations.
•PALPATION
•Tender areas, lumps. Lesions, masses,
crepitus.
•Chest expansion
•Tactile fremitus - ↑(denser or inflamed
lung tissue){PNA}
↓ (air or fluid in the pleural spaces or a
SUBJECTIVE DATA COLLECTION decrease in lung tissue density)
{COPD}.
Past Medical History
Dx with respiratory dse., when it occurs, treatment, Decreased fremitus = pleural effusion,
outcomes, allergies, TB ,skintest,influenza/pneumococcal thickened chest wall, Pnuemothorax,
vaccine. emphysema
Increased fremitus= consolidation of
Lifestyle and Personal habits lung tissue, pneumonia, tumor, fibrosis
Smoking, smoke exposure, inhaled recreational drugs, Crepitus = crackling sensation over skin
environmental exposure (dust, etc.) surface = SQ emphysema
Occupational history •PERCUSSION
Exposed to any substances (asbestos, fumes) •Lung resonant – resonance to dull
irritation to throat, any precautions •diaphragmatic excursion
4. Environmental Exposures •AUSCULTATION
Exposed to person with cough, cold or flu •Breath sounds
•Vesicular Breath – sounds are soft, low pitched, and
5. Medications
found over fine airways near site of air exchange (the lung
for respiratory conditions, dosage, frequency, natural periphery)
supplements, OTC/Rx •Bronchial breath sounds – loud, high pitched and found
over the trachea and larynx.
6. Family History •Bronchovesicular breath sounds – found more
centrally, over major bronchi that have fewer alveoli.
COMMON RESPIRATORY SYMPTOMS
1. Chest pain or discomfort
2. Dyspnea
3. Orthopnea or paroxysmal nocturnal dyspnea
4. Cough
5. Sputum or phlegm produced from cough:
HEALTH ASSESSMENT FINALS / AD
THORAX AND LUNGS
Chest Expansion
Tactile Fremitus
•PERCUSSION
Lung resonant (dullness)
•AUSCULTATE
Lung sounds (egophony, bronchophony,
or whispered pectoriloquy)
LABORATORY AND DIAGNOSTIC TESTING
1. Complete Blood Count (CBC)
2. Positron Emission Tomography scans (PET) measures
the metabolic rate of various body tissue to detect
presence & stage of any malignancy
PROBLEMS REGARDING TORAX AND LUNGS
3. Arterial Blood Gas (ABG) – measures blood level of O2,
Co2, & acid balance.
4. Chest X-Ray
5. Sputum Examination
6. CT Scan
7. MRI
8. Pulmonary Function Test (PFT) – measures the patients
ability to move air into and out of the lungs.
DESIRED PATIENT OUTCOMES
•Demonstrate improved ventilation and adequate
oxygenation.
•Maintain clear lung fields.
Barrel chest: Refers to an increase in the anterior posterior •Remain free of signs of respiratory distress.
diameter of the chest wall resembling the shape of a barrel, •Demonstrate correct use of home supplemental
most often associated with COPD and normal aging. O2 equipment.
•Demonstrate effective coughing.
Pectus Carinatum: Genetic disorder w/c makes the chest •Maintain a patent airway at all times.
jut out. This happens because of an unusual growth of rib •Explain methods useful to enhance removal of
and breastbone (sternum) cartilage . The bulging gives the secretions. (Moorhead, 2013)
chest a birdlike appearance. That's why the condition is
sometimes called pigeon breast or pigeon chest. COMMON NURSING DIAGNOSIS
Impaired gas exchanged
Pectus Excavatum: Structural deformity of the anterior Ineffective airway clearance
thoracic wall in which the sternum and rib cage are shaped Ineffective breathing pattern
abnormally, producing a caved-in or sunken appearance of Activity Intolerance
the chest w/c can either be present at birth or develop after
puberty. NURSING INTERVENTIONS
Kyphoscoliosis: Deformity of the spine characterized by
abnormal curvature of the vertebral column in two planes
(coronal and sagittal). It is a combination of kyphosis and
scoliosis.
Flail Chest: fractured segment will sink into the chest with
inspiration and expand out of the chest wall with expiration
opposite to the normal chest wall mechanics
ASSESSMENT OF THORAX AND LUNGS
[Link] supplemental oxygen
ANTERIOR CHEST [Link] breathing exercise
•INSPECTION [Link] fluid intake
Chest symmetry. No barrel chest [Link] the patient to optimize respirations
Observe for accessory muscles use [Link] breath sounds every 2 – 4 hours
CS for retractions or bulging [Link] energy conserving measures
•PALPATION [Link] O2 saturation level (Bulechek, Butcher,
Tenderness, masses or lesions Dochterman &Wagner, 2012)
HEALTH ASSESSMENT FINALS / AD
