Lung& Thorax Assessment
—Breast self-examination (BSE) is a screening method used in an attempt to detect early breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps,
distortions or swelling.
—BSE was once promoted heavily as a means of finding cancer at a more curable stage
Breast Examination
Equipment Needed : None
The patient must be properly gowned for this examination. All upper
body clothing should be removed.
General Considerations
The patient must be properly gowned for this examination. All upper body clothing should be removed.
Breast tissue changes with age, pregnancy, and menstrual status.
The procedure described here can also be used for self-examination using a mirror for inspection. Give a brief overview of examination to patient Have the patient sit at end of exam table.
Ask the patient to remove gown to her waist, assist only if needed
Inspection
Have the patient relax arms to her side.
Examine visually for following:
Size , symmetry and shape : Female rounded slightly unequal , symmetry in size , while in male breast even with chest wall , if the client obese may be as female breast shape.
Dimpling or retraction of skin: free of scar or retraction because of invisible tumor Color and pigmentation : even to abdominal color without pigmentation . While abnormal localized discoloration and hyper pigmentation Swelling or edema pig skin (Orange peel ) on skin because of exaggeration pores
Observe the movement of breast tissue during the following maneuvers:
- Shrug shoulders with hands on hips
- Slowly raise arms above head
- Pushing the hand together to observed retraction
- Lean forward with hands on knees (large breasts only)
Inspect the areola for :
shape and size :
Normal finding : rounded or oval
Normal finding : rounded or oval
bilaterally symmetry.
Color and surface look for lesion : light pink to dark brown , surface irregular because of sebaceous gland
—Inspect nipple for size and position:
—Normal: equal ,rounded , similar in color and everted ,both nipple pointed to the same direction free of discharge except pregnant woman and breast feeding female ,inversion present from puberty .
—Abnormal finding : Asymmetrical in size or color , presence of discharge or crusts
Palpation
Have the patient lie supine on the exam table.
Ask the patient to remove the gown from one breast and place her
hand behind her head on that side.
Begin to palpate at junction of clavicle and sternum using the pads of the index, middle, and ring fingers. If open sores or discharge are visible, wear gloves.
Press breast tissue against the chest wall in small circular motions.
Use very light pressure to assess superficial layer, moderate pressure for middle layer and firm pressure for deep layers.
Palpate the breast in overlapping vertical strips. Continue until
you have covered the entire breast including the axillary "tail."
Palpate around the areola and the depression under the nipple.
Press the nipple gently between thumb and index finger and make note of any discharge.
Lower the patient's arm and palpate for axillary lymph nodes.
Have the patient replace the gown and repeat on the other side.
palpation method : palpate for tenderness , mass (lump) , (either
superficial or deeper in tissue) or soreness. There are several common patterns, which are designed to ensure complete coverage.
1- The vertical strip pattern involves moving the fingers up and down over the breast.
2- The pie-wedge pattern starts at the nipple and moves outward.
The circular pattern involves moving the fingers in concentric circles from the nipple outward.
3- Some guidelines suggest mentally dividing the breast into four quadrants and checking each quadrant separately.
The palpation process covers the entire breast, including the"axillary tail" of each breast that extends toward the axilla .
The palpation process covers the entire breast, including the"axillary tail" of each breast that extends toward the axilla .
—Finally, women that are not breastfeeding gently squeeze each
nipple to check for any discharge
Lymph nodes
By asking the client to hold his arm palpate :
Lateral node
Central
Posterior
Infraclavicular lymph node
Lung Examination
Objectives:
At the end of this lab, the students will be able to:
1. Demonstrate the ability to safely &accurately complete thorax & lung assessment.
2. Demonstrate the ability to accurately document thorax &lung assessment data in organized
manner.
Equipment Needed
1. Stethoscope
2. Small ruler, marked in centimeters
3. Marking pen
4. Alcohol swab
Preparation
1. Ask the client to sit upright &the male to disrobe to the waist.
2. For female, leave the gown on &open at the back.
3. When examining the anterior chest, lift up the gown& drape it on her shoulders rather than removing it completely.
4. For farther comfort: a warm room, a warm diaphragm end piece.
5. Private examination time with no interruption.
Subjective data:
Cough
Past history of respiratory infections
Self-care behaviors
Shortness of breath
Smoking historyü
Chest pain with breathing
Environmental exposure
Chest Landmarks
Anterior : Right anterior axillary line ,
Right midclavicular line ,
Mid sternum line
left midclavicular line ,
left anterior axillary line
Mid axillary line
Posterior: L . posterior axillary line ,
L.mid scapular line
,mid spinal line ,
R. mid scapular line
R. posterior
axillary line ,
Inspect anterior, posterior, &lateral thorax for the following:
Color : Pink
Intercostals spaces : Even
Chest symmetry: Equal
Rib slope : Less than 90 degree downward Respiration (rate, depth, rhythm) ,Even, 12-20/min,unlabored Anterior-posterior to lateral diameter 1: 2 ratio Shape &position of sternum : level with ribs Position of trachea Midline
Inspection
Normal chest
Slight retraction of
intercostal spaces
2x as wide as deep
Anterior/ posterior
diameter
1:2
Inspection
Barrel chest
anterior-posterior
diameter
2:2
Inspection
Pigeon chest
Sternum protrudes
outward
anterior-posterior
diameter
h
Inspection
Scoliosis
Lateral curvature of
thoracic spine
Assessment
Shoulders elevated?
Complications
Lung &heart damage
Back problems
Body image
Inspection
Kyphosis—
Abnormal curvature of—
the thoracic spine
Inspection
Lordosis—
Sway-back—
Abnormal curvature of—
the lumbar spine
Inspection
Uniform expansion of
the chest
Pneumonia
Pleural effusion
Pneumothorax
Bulging intercostal
spaces
Obstruction
Emphysema
Palpate thorax at three levels for the following:
Sensation : no pain or tenderness
Vocal fremitus ( tactius) as client says 99Use either the palm base (the ball) of fingers, or the ulnar edge of one hand.
- Touch the client's chest- Ask the client to repeat aresonant phrases that generate strong vibration Like 99.
- Start over the lung apices &palpate from side to another.
- Avoid palpating over the scapulae.
- Avoid palpating over the scapulae.
Vibration decreased over periphery of lungs &increased
over major airways .
Palpate chest expansion :
Posterior : placing your warmed hand on the poster lateral chest wall
- The thumbs should be at level of T9 or T10.
- Slide your hands medially to pinch up a small fold between your thumbs.
- Ask the client to take deep breath.
- Your thumb should move with respiration.
Anterior: placing your warmed hand on the anterolateral wall.
- Thumbs should be along the costal margins &pointing toward the xiphoid process.
- Ask the client to take deep
breath.
- Watch your thumbs move with respiration.
2 to 3-inch symmetrical thoracic expansion.
Symmetrical expansion (thumbsmove apart
equal distance in both directions).
Percussion (Diaphragmatic Excursion)
Posteriorely :
ask the client to exhale &hold it.
- Percuss down the scapular line until the sound changes from resonant to dull each side.
- Mark the level where the sound changed to dull.
- Ask the client to take deep breath &hold it. -Continue percussing from the mark down ward.
- Mark the level the sound changed to dull on deep inspiration.
- Measure the difference.
Normal Finding :
It should be equal bilateraly, &measure about 3-5cm in
adult, although it may be up to 7-8cm.
Auscultation
Purpose
Asses normal and
abnormal air flow
through bronchial
tree by using
Diaphragm of
stethoscope
Compare R to L
Auscultation: normal lung sound
Bronchial : Trachea , high ,
inspiration shorter than
expiration
Bronchovesicular :
Moderate , Between scapulae
Side of sternum intercostals
space , inspiration equal with
expiration
Vesicular : Lung field ,
inspiration longer than
expiration is it soft and low
Auscultation: Results
Adventitious
Crackles—
air à bronchi with —
secretions
Auscultation: Results
Wheezes
Sonorous wheezes
Deep low pitched
Snoring > E
Caused by air à
narrowed passages
R/t h secretions
Sibilant Wheezes
High pitched
Whistle-like I &E
Caused by air à
narrowed passages
R/t constriction
Asthma
Auscultation: Results
Pleural friction rub
R/t inflammation of
pleural space
Grating, creaking I &E
Best heard Anterior,
Lower, lateral area
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