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Normal Breath Sounds (Kozier 613)
Type
Description
Location
Vesicular
Soft-intensity, low-pitched,
Over peripheral lung;
“gentle sighing” sounds created best heard at base of
by air moving through smaller lungs
airways (bronchioles & alveoli)
Characteristics
Best heard on
inspiration, which is
about 2.5 times longer
than the expiratory
phase (5:2 ration)
Broncho-vesicular Moderate-intensity and
moderate-pitched “blowing”
sounds created by air moving
through larger airway (bronchi)
Between the scapulae Equal inspiratory &
and lateral to the
expiratory phases (1:1
sternum at the first and ratio)
second intercostal
spaces
Bronchial
(tubular)
Anteriorly over the
trachea; not normally
heard over lung tissue
Louder than vesicular
sounds; have a short
inspiratory phase and
long expiratory phase
(1:2 ratio)
Cause
Location
High-pitched, loud, “harsh”
sounds created by air moving
through the trachea
Adventitious Breath sounds (Kozier 613)
Name
Description
Crackles (rales or Fine, short, interrupted
Air passing through
crepitations)
cracking sounds; alveolar rales fluid or mucus in any
are high pitched. Sound can be air passage
simulated by rolling a lock of
hair near the ear. Best heard on
inspiration but can be heard on
both inspiration and expiration.
May not be cleared by
coughing.
Most commonly heard
in the bases of the
lower lung lobes
Gurgles (rhonchi) Continuous, low-pitched,
coarse, gurgling, harsh, louder
sounds with a moaning or
snoring quality. Best heard on
expiration but can be heard on
both inspiration and expiration.
May be altered by coughing.
Loud sounds can be
heard over most lung
areas, but predominate
over the trachea and
bronchi
Air passing through
narrowed air passages
as a result of secretions,
swelling, tumors.
Friction rub
Superficial grating or creaking Rubbing together of
sounds heard during inspiration inflamed pleural
and expiration. Not relieved by surfaces.
coughing.
Wheeze
Continuous, high-pitched,
squeaky musical sounds. Best
Heard most often in
areas of greatest
thoracic expansion
(e.g. lower anterior
and lateral chest)
Air passing through a Heard over all lung
constricted bronchus as fields.
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heard on expiration. Not
usually altered by coughing.
Absence of breath n/a
sounds
a result of secretions,
swelling, tumors
Associated with
Can be “heard”
collapsed and surgically wherever airflow is
removed lobes or
lacking.
severe pneumonia
Assessing the Thorax & Lungs (Kozier 614)
Planning
Equipment
For efficiency, the nurse usually examines the
posterior chest first, then the anterior chest. For
posterior and lateral chest examinations, the client
is uncovered to the waist and in a sitting position.
A sitting or lying position may b e used for
anterior chest examination. The sitting position is
preferred because it maximizes chest expansion.
Good lighting is essential, especially for chest
inspection.
•
•
•
Stethoscope
Skin marker/pencil
Centimeter rule
Delegation
Assessment of the thorax and lungs is not
delegated to a UAP. However, many aspects of
breathing are observed during usual care and may
be recorded by persons other than the nurse.
Abnormal findings must be validated and
interpreted by the nurse
Implementation
Performance
1. Prior to performing the procedure, introduce self and verify the client's identity using agency
protocol. Explain to the client what you are going to do, why it is necessary, and how he or she
can cooperate. Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection control procedures.
3. Provide for client privacy. In women, drape the anterior chest when it is not being examined.
4. Inquire if the client has any history of the following: family history of illness, including cancer,
allergies, tuberculosis; lifestyle habits such as smoking & occupational hazards (e.g. inhaling
fumes); medications being taken; current problems (e.g. swellings, coughs, wheezing, pain)
Assessment [Posterior thorax]
5. Inspect the shape and
symmetry of the thorax
from posterior and lateral
views. Compare the
anteroposterior diameter to
the transverse diameter
Normal Findings
•
•
Anteroposterior to
transverse diameter in
ratio of 1: 2
Chest symmetric
Deviations from Normal
•
•
Barrel chest; increased
anteroposterior to
transverse diameter
Chest asymmetric
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6. Inspect the spinal
alignment for deformities.
Have the client stand.
From a lateral position,
observe the three normal
curvatures: cervical,
thoracic, and lumbar
◦ To assess for lateral
deviation of spine
(scoliosis), observe the
standing client from the
rear. Have the client
bend forward at the
waist and observe from
behind.
•
•
7. Palpate the posterior
thorax.
◦ For clients who have
no respiratory
complaints, rapidly
assess the temperature
and integrity of all
chest skin.
◦ For clients who do
have respiratory
complaints, palpate all
chest areas for bulges,
tenderness, or
abnormal movements.
Avoid deep palpation
for painful areas,
especially if a fractured
rib is suspected. In
such a case, deep
palpation could lead to
displacement of the
bone fragment against
the lungs
•
8. Palpate the posterior chest
for respiratory excursion
(thoracic expansion). Place
the palms of both your
hands over the lower
thorax with your thumbs
adjacent to the spine and
•
Spine vertically aligned
Spinal column is
straight, right and left
shoulders and hips are
at the same height
•
•
Exaggerated spinal
curvatures (kyphosis,
lordosis)
spinal column deviates to
one side, often
accentuated when
bending over. Shoulders
or hips not even.
☼ See chart on page 7 for
abnormal chest configurations
•
Skin intact; uniform
temperatures
Chest wall intact; no
tenderness; no masses
•
Full and symmetric
chest expansion. For
example, when the
client takes a deep
breath, your thumbs
should move apart an
equal distance and at
•
•
Skin lesions; areas of
hyperthermia
lumps, bulges;
depressions; areas of
tenderness; movable
structures (e.g. rib)
Asymmetric and/or
decreased chest
expansion.
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your fingers stretched
laterally.(a) Ask the client
to take a deep breath while
you observe the movement
o your hands and any lag
in movement.
the same time; normally
the thumbs separate 3 to
5 cm (1.5 to 2 inches)
during inspiration.
•
(a) Position of the
nurse's hands when
assessing respiratory
excursion on the
posterior thorax.
9. Palpate the chest for vocal
(tactile) fremitus, the
faintly perceptible
vibration felt through the
chest wall when the client
speaks
◦ Place the palmar
surfaces of your
fingertips or the ulnar
aspect of your hand or
closed fist on the
posterio chest, starting
•
•
•
Bilateral symmetry of
vocal fremitus
Fremitus is heard most
clearly at the apex of
the lungs
Low-pitched voices of
males are more readily
palpated that higher
pitched voices of
females
•
•
Decreased or absent
fremitus (associated with
pneumothorax)
Increased fremitus
(associated with
consolidated lung tissue,
as in pneumonia).
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near the apex of the
lungs [(b) spot 1]
◦ Ask the client to repeat
such words as “blue
moon” or “one, two,
three”
◦ Repeat the two steps,
moving your hands
sequentially to the base
of the lungs, through
positions 2-5 in (b).
◦ Compare the fremitus
on both lungs and
between the apex and
the base of each lung,
using either one hand
and moving it from one
side of the client to the
corresponding area on
the other side or using
two hand that are
placed simultaneously
on the corresponding
areas of each side of
the chest.
•
(b) Areas and sequence
for palpating tactile
fremitus on the
posterior chest
☼ See pg 10 for chart
on Voice Sounds
10. Percuss the thorax
Percussion of the thorax is
performed to determine
whether underlying lung
tissue is filled with air,
liquid, or solid material
and to determine the
positions and boundaries of
certain organs. Because
percussion penetrates to a
dept of 5 to 7 cm (2 to 3
inches) it detects
superficial rather than deep
• (c) Normal percussion
lesions. Percussion sounds
sounds on the posterior
and tones are described in
chest
Kozier on page 583 and
Brunner on 504.(c)
☼ See chart on page 9 for
◦ Ask the client to bend
characteristics of Percussion
the head and fold the
Sounds.
arms forward across
the chest. Rationale:
•
(d) sequence for posterior
chest percussion
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This separates the
scapula and exposes
more lung tissue to
percussion.
◦ Percuss in the
intercostal spaces at
about 5 cm (2in)
intervals in a
systematic sequence
(d)
◦ Compare one side of
the lung with the other
◦ Percuss the lateral
thorax every few
inches, starting at the
axilla and working
down to the eighth rib
11. Percuss for diaphragmatic
excursion (movement of
the diaphragm during
maximal inspiration and
expiration)
◦ Ask the client to take a
deep breath and hold it
while you percuss
downward along the
scapular line until
dullness is produced at
the level of the
diaphragm. Mark this
point with a marking
pencil, and repeat the
procedure on the other
side of the chest.
◦ Ask the client to take a
few normal breaths and
then expel the last
breath completely and
hold it while you
percuss upward from
the marked point to
assess and mark the
diaphragmatic
excursion during deep
expiration on each side
•
•
Excursion is 3 to 5 cm
(1.5 to 2 in) bilaterally
in women and 5-6 cm
(2 to 3 in) in men.
Diaphragm is usually
slightly higher on the
right side.
•
Restricted excursion
(associated with lung
disorder).
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◦ Measure the distance
between the two marks
12. Auscultate the chest using
the flat disc diaphragm of
the stethoscope (best for
transmitting the high
pitched breath sounds).
◦ Use the systematic
zigzag procedure used
in percussion
◦ Ask the client to take
slow, deep breaths
through the mouth.
Listen at each point to
the breath sound during
a complete inspiration
and expiration
◦ Compare findings at
each point with the
corresponding point on
the opposite side of the
chest.
•
Vesicular and
bronchovesicular breath
sounds
•
•
Adventitious breath
sounds (e.g. crackles,
gurgles, wheeze, friction
rub)
Absence of breath sounds
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Abnormal Chest Configurations
Barrel Chest
•
•
•
Funnel Chest
(Pectus Excavatum)
•
•
•
Pigeon Chest
(Pectus Carinaturm)
•
•
•
Occurs as a result of overinflation of the lungs
increase in an anteroposterior
diameter of the thorax
ribs are more widely spaced &
intercostal spaces tend to bulge
on expiration
Occurs when there is a
depression in the lower portion
of the sternum
can compress the heart & great
vessels, resulting in murmurs
can occur with rickets or
Marfan's syndrome
Occurs as a result of
displacement of the sternum
increases the anteroposterior
diameter
can occur with rickets, Marfan's
syndrom, or severe
kyphoscoliosis
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Kyphoscoliosis
(Kyphosis)
•
•
•
Lordosis
•
•
•
Characterized by elevation of
the scapula & corresponding sshaped spine
limits lung expansion within the
thorax
can occur with osteoporosis &
other skeletal disorders affecting
the thorax
Characterized by an exaggerated
lumbar curve
can occur with osteoporosis, any
skeletal disorders affecting the
thorax, weak lower back
muscles and poor posture
depending on severity, may not
affect chest configuration
Characteristics of Percussion Sounds (Brunner 504)
Sound
Relative
Intensity
Relative
Pitch
Relative
Duration
Location Example Examples
Flatness
Soft
High
Short
Thigh
Large pleural
effusion
Dullness
Medium
Medium
Medium
Liver
Lobar pneumonia
Resonance
Loud
Low
Long
Normal Lung
Simple chronic
bronchitis
Hyperresonance
Very Loud
Lower
Longer
None normally
Emphysema,
pneumothorax
High –
–
Gastric air bubble,
puffed-out cheek
Large pneumothorax
Tympany
Loud
distinguished by a
musical timbre
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Voice Sounds
• sound heard through stethoscope as pt speaks is known as vocal resonance
Sound
Description
Indicative
Bronchophony
Vocal resonance that is more
intense and clearer than normal
Indicative of consolidation, as it
occurs in pneumonia or pleural
effusion.
Egophony
Voice sounds that are distorted. Indicative of consolidation, as it
Best appreciated by having the pt occurs in pneumonia or pleural
repeat the letter E. The distortion effusion.
produced by the consolidation
transforms the sound into a
clearly heard “A” rather than
“E”.
Whispered pectoriloquy
Distinctly hearing words that
seem to come from a spot being
auscultated.
Heard in the presence of rather
dense consolidations of the
lungs. This is not part of normal
physiology, but is difficult to
identify.