Assessment of the Pulmonary System
I.
A.
B.


A&P Overview
see text
Function:
The primary fx of Pulmonary System:
 Supply O2 to body cells
 To remove CO2 from the body cells
Four Components of Respiration:
Ventilation: “movement of air
“

The movement of air from outside
to inside the body.
The distribution of the air within the 
tracheobroncial tree.

The
Diffusion and Perfusion
The movement of O2 and CO2 across
the alveolar-capillary membrane to the
blood in the pulmonary capillaries
C.
Blood Flow
The transporation of respiratory
gases through the pulmonary and
arterial circulation
The distribution and exchange of
O2 and CO2 at the peripheral
tissues
The return of respiratory gases to
the lungs
Control of Breathing
Adequate gas exchange.
Impact of:
O2 & CO2
Diaphragm
Principle muscle for inspiration.
D.
E.
F.
Intercostal Muscles contract with inspiration
Upper Airway
Components:
Major functions of the Upper Airway:
I.
II.
III.
Lower Airway
Components:
Major functions of the Lower Airway:
I.
II.
III.
G.
Landmarks of the Thorax
Anterior Thorax
1.
Clavicle: The apex of the lung rises approx 3-4 cm above ea
clavicle
2.
Suprasternal Notch: The depression just above the sternum
3.
Sternum: divided into three segments
A.
Manubrium (Upper)
B.
Body of Sternum (Middle)
C.
Xiphoid Process (Lower)
4.
Angle of Louis (Manubriosternal angle)
5.
Coastal Angle:
6.
Intercostal space:
Posterior Thorax
1.
Vertebra Prominens
2.
Spinous Processes
3.
Inferior Border of the Scapula
Reference Lines
Anterior
Mid-sternal
Mid-clavicular
II.
Axillary
Anterior axillary
Mid-axillary
Posterior axillary
Posterior
Scapular Line
Vertebral Line
Assessment of the Respiratory System
A.
History
1.
Coughing: could be r/t:
Symptom analysis:
Duration:
1. How long have you had the cough?
2. How long does ea episode last?
Frequency
How often does it occur? Once/day, week, hr?
Circumstances
What causes? Activity? Time of day, Position (lying down at
night? Sitting?) Talking?
Exercise/activity
How affects? Does the cough interfere with activities?
How much activity precipitates? (Walking 5 feet? Walking 10 feet
or more)
History
Personal history of allergies? Family hx allergies? Respiratory
problems? Smoking hx (personal, does anyone in the household
smoke?)
Self-care
1. What helps? Sitting, standing, lying down….
2. What have you done to treat? (specifics re: medications/
treatments (warm shower, lemon tea, etc).
Exacerbation/Improvement Perceptions re: whether the cough is improving or getting worse.
The pt should define “worse” for himself.
Other:
 Type of cough (Dry, hacky, bubbling, barking, congested)
 Sputum production
(Describe:1. amt
2. Consistency
3. Color
2. Shortness of Breath or Dyspnea on Exertion;
Difficulty Breathing or Breathlessness
Symptom analysis:
Symptom analysis:
Duration:
Frequency
Circumstances
Exercise/activity
History
Self-care
Exacerbation/Improvement
Other:
3.
B.
Miscellaneous History
a. Previous hx respiratory illness, hospitalization, surgeries
b. Date of last Chest X-ray
c. Currently taking any medications
d. Environmental factors:
Fumes, chemicals, insecticides, place of employment, use of
air freshenors
e. Smoking hx:
 What
 How long?
 How much/day
 Does he inhale
 Does he have a cough which seems to be asso with
smoking
 Does he have the desire to quit smoking?
Preparation for Exam
1.
Position of Client
2.
Sequence:
Inspection of the thorax
Palpation, Percussion, Auscultation of anterior thorax
Palpation, Percussion, Auscultation of the posterior thorax
3.
Clothing:
4. Odor)
C.
Physical Exam of the Thorax
1.
Inspection
a. Breathing Pattern
Men:
Women:
Terms:
Tachypnea
Bradypnea
Kussmaul’
s
Biot
Breathing
CheyneStokes
Terms to Know
Definition
“Normal”
occurance
Resp. rate greater than
Fear, anxiety,
24/min.
exercise
Resp rate less than
12/min
Breathing pattern that
involves increased rate
and depth of
respirations.
Breathing pattern that
involves shallow
breathing for 3-4
breaths, followed
by a period of apnea.
Breathing pattern that
involves a period of
rapid rate respirations
followed by
normal/slower
respirations.
What would be abnormal?
Use of accessory muscles to breath
 Supraclavicular retractions
 Intercostal retractions
 Intercostal bulging
b. Nailbeds
Bluish discoloration suggests:
Clubbing suggests:
c. Chest wall configuration
d. Anterior posterior diameter
Potential Pathology
Fever, Pulmonary
pathology
Drug induced;
Increased intracranial
pressure
Diabetic Ketoacidosis
e. Level of Consciousness
2.
Assessment of the Posterior Chest
a.
Assessment of Respiratory Excursion of the Posterior
Chest
Procedure:
b.
Assessment of Tactile Fremitus over the Posterior Chest
Procedure:
Abnormalities:
c.
d.
Palpation of the Skin of the Posterior Chest
Note:
 Tenderness
 Skin temp
 Moisture
 Superficial lumps or masses
 Crepitus (subcutaneous emphysema).

Percussion of the Posterior Chest
Position
.
Procedure:
Findings:.
Tones:
Resonance:
Dullness:
Tympany:
Abnormalities:
e.
Diaphragmatic excursion
Tape reviews – this is a method used to determine the size
of the diaphragm. We will not do in lab – but notice how it is
done.
f.
Auscultation of the Posterior Thorax
Position:
Procedure:
Sound
Bronchial
Bronchovesicular
Vesicular
Respiratory sounds:
Normal Location
Trachea, larynx
Major bronchi (where
there are no alveoli):
Between scapula, around
the sternum
Peripheral lung
Description
Expiration is the loudest,
longest sound. Loud,
harsh sound.
Inspiration = Expiration
Moderate pitch.
Inspiration is loudest and
longest. Soft, rustling
sound. Like the sound of
the wind. Air is flowing
through the smaller
bronchioles and alveoli.
Abnormalities:
Decreased/absent breath sounds
Silent chest
Increased breath sounds
Abnormal Breath Sounds:
Crackles (Rales):
Rhonchi:
Wheeze:
.
Documentation of abnormal breath sounds. Must include:
 Sound heard (crackles, rhonchi, wheeze),
 location of sound (Right upper chest, Left Lower Lobe, etc.),
 respiratory phase (Inspiration, Expiaration, both),
 does coughing improve?
g.
3.
Vocal Resonance/Whispered Pectoriloquy
You will see on video – we will not cover in lab/exam.
Assessment of the Anterior Chest
a.
Assessment of Respiratory excursion of the Anterior
Chest
b.
Assessment of Vocal Fremitus of the Anterior Chest
c.
Percussion of the Anterior Chest
d.
Auscultation of the Anterior Chest
D.
Considerations with Infants and Children
 Encourage parent participation. Parents can hold during exam. If
asleep – take advantage of opportunity to inspect, auscultate, palpate,
percuss.
 Crying enhances tactile fremitus
 Play with the child
 Infants have a rounder thorax, by age 6 it should be 1:2
 Infants are nose breathers until the age of 3 months.
E.
Considerations with the Elderly
 Increased anterior/posterior diameter
 Kyphosis (outward curve of the spine)
 Slight decrease in chest expansion (what does this mean?) Note that
it should remain symmetrical.