The Thorax and Lungs

Chest landmarks:

o Anterior imaginary lines: Midsternal, midclavicular, anterior axillary.

o Posterior imaginary lines: L or R scapular, vertebral.
o Lateral: Posterior axillary, midaxillary and anterior axillary.
o 2nd and 5th intercostals space (ICS).
 To identify the 2nd ICS: Palpate the clavicle and follow it to the
sternum; note the suprasternal notch and angle of Louis. Place 3
fingers under the suprasternal notch and palpate the bony ridge below
your fingers (angle of Louis); move finger laterally to find the 2nd rib.
(The 2ndrib is the first one felt since the 1st rib is beneath the clavicle).
The 2nd ICS is the space beneath the 2nd rib.

Posterior Thorax:

 Inspect shape and look for deformities.

 Note the anteroposterior diameter compared with transverse (1:2)- AP
diameter is < transverse diameter. A barrel chest is associated with pulmonary
emphysema or normal aging.
 Note any retraction of the interspaces during inspiration- found in emphysema,
tracheal or laryngeal obstruction. Seen in newborns.
 Palpate – respiratory excursion. Place hands over lower thorax (10th rib) with thumbs
adjacent to spine should separate 1 ½” – method of determining equal expansion of
the lungs
 Percussion- advanced technique. Range: resonance (hollow); hyperresonance
(booming); dullness (masses, fluid).

Anterior Thorax

 Inspect/ count respiratory rate (15-20/min) and note rhythm. Note respiratory effort;
use of neck muscles or abdominal breathing. Observe intercostals spaces for retraction
(obstruction) or bulging (emphysema).
 Palpation- may palpate for masses or crackling feeling (crepitus subcutaneous air).

Auscultation: To assess breath sounds that occurs as a result of the movement of air through
the trachea, bronchi and alveoli. Use of diaphragm; have client breath through mouth, more
deeply than usual. Avoid hyperventilation. Remember the right lung is divided into 3 lobes,
the left into 2 lobes. Try to visualize each lobe. Apex is at the top; base at the bottom. Sounds
are compared side-to-side, top to bottom; anterior and posterior. The middle lobe is best
assessed on the right side under the arm.

Normal Breath Sounds: depending on where you listen, sounds may be different. Sounds may
be decreased when client fails to breath deeply or is obese.

 Vesicular- inspiration > expiration; soft, low, heard in periphery and base of lungs.
 Bronchovesicular- inspiration = expiration; medium pitch, heard between scapula and
anteriorly close to sternum.
 Bronchial- expiration > inspiration; loud and harsh; heard over trachea. Abnormal
when heard elsewhere (pneumonia, tumor).

Adventitious (abnormal) breath sounds occur when air passes through narrowed airways
filled with fluid or mucus; superimposed over normal breath sounds.

Crackles- fine, high pitched crackling sound; best heard on inspiration at the base caused by
reinflation of the alveoli.

Rhonchi- low pitched, gurgling; moaning, snoring quality; heard between scapula and lateral
to sternum; clear with coughing.

Wheeze- high pitched, squeaky; best heard on expiration; heard anywhere.

Documentation: Clear, if normal breath sounds are heard in all areas. Document: Clear breath
sounds throughout all lung fields. Otherwise, state the abnormal sounds you have heard and
where you heard it

The Heart

Function can be assessed to a large degree by findings in the history: shortness of breath
(SOB), edema of ankles/legs, pain, pulse rate and rhythm; vital signs, signs and symptoms of
oxygen deficit.

Location: Heart lies behind and to the left of the sternum. The upper portion or atria (BASE)
lies to the back; the ventricles (APEX) points forward, the apex of the left ventricle actually
touches the anterior chest wall near the left midclavicular line at or near the 5th left ICS.
Known as point of maximal impulse (PMI) and is where apical beat is assessed. Impulse is a
good index of heart size.

Landmarks for assessment: The precordium is the area on the anterior chest overlying the
heart. Hearts sounds are heard throughout the precordium, but there are 4 major areas for
examining heart sounds. Each area corresponds to one of the hearts 4 valves.

 Aortic area- 2nd ICS to right of sternum (closure of the aortic valve loudest here).
  Pulmonic area- 2nd ICS to left of sternum (closure of the pulmonic valve loudest
here).
 Tricuspid- 5th ICS left of sternal border (closure of tricuspid valve).
 Mitral- 5th ICS left of the sternum just medial to MCL (closure of mitral valve). When
cardiac output is increased as in anemia, anxiety, HTN, fever, the impulse may have
greater force- inspect for lift or heave.

Techniques of Assessment:

 Inspection- look for lift at apex.

 Auscultation- Client should be assessed in supine position with head up to 45 deg.;
examiner stands at right side. Use diaphragm for basic sounds; bell for murmurs and
extra sounds.
 Identify the heart rate, rhythm; bell for murmurs aortic, pulmonic, mitral.

Heart Sounds

 Review of A&P: Blood flows from R. atrium to R. ventricle through the

atrioventricular valve, the tricuspid. Blood flows from L. atrium to L. ventricle
through the mitral valve. Blood passes from R. ventricle to pulmonary artery through
the pulmonic valve and from the left ventricle to aorta through the aortic valve
(semilunar valves). Events on the left side of the heart slightly precede those on the
right.
 There are 2 basic normal heart sounds and several abnormal ones. Normal:
o S-1 (produced by closure of the atrioventricular valves, mitral and tricuspid)-
at mitral area and tricuspid area S1 is louder than S2. The sound is a dull, low
pitched “lub.”
o S-2 (produced by closure of aortic and pulmonic valve) is higher pitched,
shorter and is the “dub” sound. Heard best at the base (aortic and pulmonic
areas) where S-2 is louder than S-1

 Systole begins with the 1st sound. As ventricles start to contract, pressure within
exceeds the atria, shutting the mitral and tricuspid valves. Blood is forced into the
great vessels.
 When the ventricles have emptied themselves, the pressure in the aorta and
pulmonary arteries force the semilunar valves shut (aortic/pulmonic), which is the
2nd sound and diastole (ventricular relaxation) begins.
Other heart sounds

 S-3 – rapid filling of the ventricle with blood; heard following S-2. Can be normal in
young adults and children; pathologic in elderly.
 S-4 – atrial contraction and thought to result from stiffened left ventricle; directly
precedes S-1. Heard in elderly.
 Extra sounds: snaps and clicks are associated with valves: aortic and mitral stenosis,
prosthetic valves.
 Murmurs: S1 or S2 is a swishing or blowing sounds caused by
o Forward flow through a stenotic (narrowed) valve
o Increased flow through a normal valve
o Backward flow through a valve that fails to close (insufficiency).

Murmurs should be identified as systolic (S-1) or diastolic (S-2). Murmurs are common in
children and occur often in the elderly. Try to identify grade of murmur: Grade I (barely
audible) to Grade VI (loud and may be heard with the stethoscope not quite on the chest or
barely touching the chest).

Documentation: Normally, you should be able to note that S-1, S-2 heard without extra
sounds.

Peripheral Vascular System

 Assessment of BP, peripheral pulses, jugular and peripheral vessels; and inspection of
skin tissues to determine perfusion to the extremities.
 Inspect neck for pulsations and jugular veins for distention. JVD refers to jugular
venous distention- index of function of the right atrium.
 Advanced practitioners would auscultate the carotid artery for a bruit (blowing or
swishing sound) and palpate a thrill (a vibrating sensation).
 Inspect and palpate skin of hands, feet and legs for color, temperature and edema.
Unilateral coolness may be associated with decreased blood flow and should be
correlated with pulse in that extremity.
o Arterial insufficiency- cool extremity, dec. or absent pulse, color changes.
o Venous insufficiency- normal temperature, normal pulses, color changes; skin
changes.
o Deep vein thrombosis (DVT)- Homan’s sign: Knee flexed- pain in calf with
dorsiflexion of foot. Not performed if pt. is dx’d with thrombus.
o Edema- fluid accumulation in the tissues; assess by pressing firmly with the
thumb- usually over shin or medial malleolus of foot. Graded on scale of 1+ -
4+.
 ENGLISH ASSIGNMENT

BY:

EKA RUSDIYANTI RN

PO713201161095

POLITEKNIK KESEHATAN MAKASSAR

JURUSAN KEPERAWATAN PRODI D-III 2016/2017