Mosby’s Nursing Video Skills: Physical Examination and Health Assessment
Step-by-Step Procedure
Thorax and Lungs
I. Inspection: Inspect the patient’s chest from the front, the sides, and the back, looking for the
following features:
A. Chest symmetry and characteristics
B. Anteroposterior diameter of chest
C. Thoracic landmarks and skin characteristics
D. Respiratory rate, pattern, and movement
E. In addition to examining the thorax, examine the fingers, using Shamroth technique
II. Palpation: Using warmed hands, palpate the patient’s thorax from the front, the sides, and the
back. Note that the examination has been organized to start by examining for general features,
progressing to more specific procedures once the overall status of the patient’s thoracic structures
has been ascertained.
A. Thoracic muscles and bones
B. Thoracic expansion
C. Tactile fremitus
D. Tracheal position
III. Percussion: Again, beginning with a general examination and progressing to the specialized
assessment of diaphragmatic excursion, begin on the posterior surface of the thorax, progress to
the lateral surfaces, and finish on the anterior surface. Note that the patient should be asked to
change arm positions when examining the posterior and lateral aspects of the thorax to allow for
best exposure to the examiner’s percussion.
A. Lung tissue for resonance or dullness
Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
B. Diaphragmatic excursion: Note that the examiner returns to the posterior aspect of the
thorax, and percusses downward while the patient holds a breath at maximum inflation of
the lungs. Once a shift to dullness has marked the bottom of the fully inflated lung, the
examiner identifies the location with a piece of tape and cues the patient to resume breathing
until he or she is ready to hold his or her breath at maximum deflation. This time, the
examiner begins from the low point marked in the last step and progresses upward until a
return to resonance has revealed the lower border of the deflated lung. Again, this location
is marked and the patient is cued to begin breathing. The distance between these two marks
is the diaphragmatic excursion. The whole procedure should be repeated on the other side
of the spine to compare the two lungs.
IV. Auscultation
A. Lung tissue for breath sounds: Notice that the examiner again begins on the posterior
surface of the thorax and again requests proper positioning of the arms and head to allow
for best access to posterior and lateral surfaces. Also, while the video separates the
presentation of normal and adventitious sounds, remember that the examiner in practice will
examine each lung surface only once, integrating the observation of normal and adventitious
sounds into one smooth process. Once that general survey of lung sounds is complete, the
examiner will check for vocal resonance using one or more of the techniques specified
below. Finally, notice that for the older adult, auscultation begins on the lower portion of
the posterior lungs and moves upward.
1. Bronchovesicular sounds
2. Vesicular sounds
3. Bronchial sounds
B. Lung tissue for adventitious sounds
Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
1. Fine or coarse crackles
2. Rhonchi
3. Wheezes
4. Pleural friction rub
C. Vocal resonance
1. Bronchophony
2. Whispered pectoriloquy
3. Egophony
Mosby items and derived items © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.