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NUR 2092 Health Assessment Exam 2 Study Guide
Respiratory assessment: methods of lung assessment, Types of breath sounds
(normal and abnormal and what they might indicate; signs of long term
hypoxia; vocal sound
The thoracic cage is a bony structure with a conical shape, which is narrower at the top. It is
defined by the sternum, 12 pairs of ribs, and 12 thoracic vertebrae. Its floor is the diaphragm.
The costochondral junctions are the points at which the ribs join their cartilages; they are
not palpable! Rib 1-7 attach to the costal cartilage, 8-10 attach to the costal cartilage above, and
11-12 are floating with free palpable tips.
*Surface landmarks on the thorax are signposts for underlying respiratory structures.
Anterior Thoracic Landmarks
- Suprasternal Notch – Feel this hollow U-shaped depression just above the sternum,
between the clavicles
- Sternum – The “breastbone” has 3 parts: the manubrium, the body, and the xiphoid
process. Walk your fingers down the manubrium a few cm until you feel a distinct bony
ridge, the sternal angle.
- Sternal Angle – Often called the “angle of Louis,” this is the articulation of the
manubrium and body of the sternum, and is continuous with the second rib. It is useful
place to start counting ribs, which helps to localize a respiratory finding horizontally.
Also marks the site of tracheal bifurcation into the left/right main bronchi.
- Costal Angle – The right and left costal margins form an angle where they meet at the
xiphoid process. Usually 90 degrees or less, this angle increases when the rib cage is
chronically overinflated, as in emphysema.
Posterior Thoracic Landmarks
- Vertebra Prominens – Start here. Flex your head and feel for the most prominent bony
spur protruding at the base of the neck. This is the spinous process of C7.
- Spinous Processes – Count down these knobs on the vertebrae, which stack together to
form the spinal column. The spinous processes align with their numbered ribs only down
to T4.
- Inferior Boarder of the Scapula – The scapulae are located symmetrically in each
hemithorax. The lower tip is usually at the 7th or 8th rib.
- Twelfth Rib – Palpate midway b/t the spine and the person’s side to identify its free tip.
Reference Lines
Use reference lines to pinpoint a finding vertically on the chest, such as the midsternal line and
the midclavicular line on anterior chest. The posterior side has the vertebral (or midspinal) line
and the scapular line, which extends through the inferior angle of the scapula when the arms at
the sides of the body. Lift up the patient’s arm 90 degree and divide lateral chest by three lines:
Anterior axillary line, posterior axillary line, and maxillary line.
,2
*The mediastinum is the middle section of the thoracic cavity containing the esophagus, trachea,
heat, and great vessels. The left/right pleural cavities are on either side of the mediastinum
and contain the lungs.
Lobes of the Lungs
The Lungs are paired but not precisely symmetric structures. The right side is shorter than the
left because of the underlying liver, while the left lung is narrower than the right because the
heart bulges to the left. The right lung has three lobes, and the left lung has two lobes.
Mechanics of Respiration
The four major functions of the respiratory system:
(1) Supplying oxygen to the body for energy production
(2) Removing Carbon Dioxide as a waste product of energy reactions
(3) Maintaining homeostasis (acid-base balance) of arterial blood
(4) Maintaining Heat Exchange (less important in humans)
Methods of Lung Assessment
1. Inspect the posterior chest
2. Note the shape and configuration of the chest wall.
3. Check Anteroposterior diameter as it should be less than
the transverse diameter
4. Neck and Trapezius should be developed normally
5. Note the position of the client
6. Assess the skin color and condition of the patient
7. Palpate the posterior chest
8. Assess symmetric chest expansion
Tactile Fremitus – Assess the tactile, or vocal, fremitus. It is a palpable vibration. Sounds are
generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the
chest wall, where you feel them as vibrations. Use the palmar base of the fingers and touch
person’s chest while they repeat the words “99” or “blue moon.” These phrases generate strong
vibrations.
Percuss the Posterior Chest – Lung Fields: Determine the predominant note over the lung fields.
Start at the apices and percuss the band of normally resonant tissue across the tops of both
shoulders. Then, percussing in the interspaces, make side to side comparison all the way down
the lung region. Percuss in 5-cm intervals!
Diaphragmatic Excursion – Determine the diaphragmatic excursion. Percuss to map out the
lower lung boarder in both expiration and inspiration. Ask the patient to exhale and hold it while
you briefly percuss down the scapular line until the sound changes from resonant to dull.
(Thoracic Expansion).
Auscultate the posterior, anterior, and axillary parts of the body. There are 6-7 points on the
anterior line, 6-8 on the posterior side, and 2 points per axillary side.
, 3
Palpate the Anterior chest – Palpate symmetric chest expansion by placing your hands on the
anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid
process.
Assess the tactile (vocal) fremitus of anterior line. Begin palpating over the lung apices in the
supraclavicular areas. Compare vibrations from one side to the other as the person repeats “99.”
Palpate the anterior chest wall to note any tenderness and detect any superficial lumps or masses.
Note skin mobility and turgor and skin temperature and moisture.
Percuss the Anterior Chest – Begin percussing the apices in supraclavicular areas. Then,
percussing the interspaces and comparing one side with the other, moving down the anterior
chest. Interspaces are easier to palpate on the anterior chest than back. Do not percuss directly
over female breast tissue because it will produce a dull note!
Types of Breath Sounds
Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in the
subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as
after open thoracic injury or surgery.
Resonance is the low-pitched, clear, hollow sound that predominates in healthy lung tissue in the
adult. However, it is a relative term and has not constant standard. The resonant note may be
duller in the athlete with heavily muscular chest wall and in the heavily obese, subcutaneous fat
produces scattered dullness.
Hyperresonance is a lower-pitched, booming sound found when too much air is present such as
in emphysema or pneumothorax.
A dull note (soft, muffled thud) signals abnormal density in the lungs, as with pneumonia, pleural
effusion, atelectasis, or tumor.
Decreased/Absent breath sounds occur when the bronchial tree is obstructed by secretions,
mucus plug, or a foreign body. In emphysema, it can be a result from the loss of elasticity in the
lung fibers and decreased force of inspired air. Anything that obstructs the transmission of sound
between the lung and stethoscope, such as pleurisy, fluid, air in the pleural space can cause a
decrease in breath sounds. A silent chest means there is no air moving in or out!
Increased breath sounds mean that sounds are louder than they should be (bronchial sounds are
abnormal when they are heard over an abnormal location, the peripheral lung fields). They have
a high-pitched, tubular quality, with a prolonged expiratory phase and a distinct pause between
inspiration and expiration. Occur when consolidation (pneumonia) or compression (fluid in the
intrapleural space) yields a dense lung area that enhances the transmission of sound from the
bronchi.
Adventitious Sounds are added sounds that are not normally heard in the lungs. If present, they
are heard as being superimposed on the breath sounds. They are caused by moving air colliding
with secretions in the tracheobronchial passageways or by the popping open of previously
NUR 2092 Health Assessment Exam 2 Study Guide
Respiratory assessment: methods of lung assessment, Types of breath sounds
(normal and abnormal and what they might indicate; signs of long term
hypoxia; vocal sound
The thoracic cage is a bony structure with a conical shape, which is narrower at the top. It is
defined by the sternum, 12 pairs of ribs, and 12 thoracic vertebrae. Its floor is the diaphragm.
The costochondral junctions are the points at which the ribs join their cartilages; they are
not palpable! Rib 1-7 attach to the costal cartilage, 8-10 attach to the costal cartilage above, and
11-12 are floating with free palpable tips.
*Surface landmarks on the thorax are signposts for underlying respiratory structures.
Anterior Thoracic Landmarks
- Suprasternal Notch – Feel this hollow U-shaped depression just above the sternum,
between the clavicles
- Sternum – The “breastbone” has 3 parts: the manubrium, the body, and the xiphoid
process. Walk your fingers down the manubrium a few cm until you feel a distinct bony
ridge, the sternal angle.
- Sternal Angle – Often called the “angle of Louis,” this is the articulation of the
manubrium and body of the sternum, and is continuous with the second rib. It is useful
place to start counting ribs, which helps to localize a respiratory finding horizontally.
Also marks the site of tracheal bifurcation into the left/right main bronchi.
- Costal Angle – The right and left costal margins form an angle where they meet at the
xiphoid process. Usually 90 degrees or less, this angle increases when the rib cage is
chronically overinflated, as in emphysema.
Posterior Thoracic Landmarks
- Vertebra Prominens – Start here. Flex your head and feel for the most prominent bony
spur protruding at the base of the neck. This is the spinous process of C7.
- Spinous Processes – Count down these knobs on the vertebrae, which stack together to
form the spinal column. The spinous processes align with their numbered ribs only down
to T4.
- Inferior Boarder of the Scapula – The scapulae are located symmetrically in each
hemithorax. The lower tip is usually at the 7th or 8th rib.
- Twelfth Rib – Palpate midway b/t the spine and the person’s side to identify its free tip.
Reference Lines
Use reference lines to pinpoint a finding vertically on the chest, such as the midsternal line and
the midclavicular line on anterior chest. The posterior side has the vertebral (or midspinal) line
and the scapular line, which extends through the inferior angle of the scapula when the arms at
the sides of the body. Lift up the patient’s arm 90 degree and divide lateral chest by three lines:
Anterior axillary line, posterior axillary line, and maxillary line.
,2
*The mediastinum is the middle section of the thoracic cavity containing the esophagus, trachea,
heat, and great vessels. The left/right pleural cavities are on either side of the mediastinum
and contain the lungs.
Lobes of the Lungs
The Lungs are paired but not precisely symmetric structures. The right side is shorter than the
left because of the underlying liver, while the left lung is narrower than the right because the
heart bulges to the left. The right lung has three lobes, and the left lung has two lobes.
Mechanics of Respiration
The four major functions of the respiratory system:
(1) Supplying oxygen to the body for energy production
(2) Removing Carbon Dioxide as a waste product of energy reactions
(3) Maintaining homeostasis (acid-base balance) of arterial blood
(4) Maintaining Heat Exchange (less important in humans)
Methods of Lung Assessment
1. Inspect the posterior chest
2. Note the shape and configuration of the chest wall.
3. Check Anteroposterior diameter as it should be less than
the transverse diameter
4. Neck and Trapezius should be developed normally
5. Note the position of the client
6. Assess the skin color and condition of the patient
7. Palpate the posterior chest
8. Assess symmetric chest expansion
Tactile Fremitus – Assess the tactile, or vocal, fremitus. It is a palpable vibration. Sounds are
generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the
chest wall, where you feel them as vibrations. Use the palmar base of the fingers and touch
person’s chest while they repeat the words “99” or “blue moon.” These phrases generate strong
vibrations.
Percuss the Posterior Chest – Lung Fields: Determine the predominant note over the lung fields.
Start at the apices and percuss the band of normally resonant tissue across the tops of both
shoulders. Then, percussing in the interspaces, make side to side comparison all the way down
the lung region. Percuss in 5-cm intervals!
Diaphragmatic Excursion – Determine the diaphragmatic excursion. Percuss to map out the
lower lung boarder in both expiration and inspiration. Ask the patient to exhale and hold it while
you briefly percuss down the scapular line until the sound changes from resonant to dull.
(Thoracic Expansion).
Auscultate the posterior, anterior, and axillary parts of the body. There are 6-7 points on the
anterior line, 6-8 on the posterior side, and 2 points per axillary side.
, 3
Palpate the Anterior chest – Palpate symmetric chest expansion by placing your hands on the
anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid
process.
Assess the tactile (vocal) fremitus of anterior line. Begin palpating over the lung apices in the
supraclavicular areas. Compare vibrations from one side to the other as the person repeats “99.”
Palpate the anterior chest wall to note any tenderness and detect any superficial lumps or masses.
Note skin mobility and turgor and skin temperature and moisture.
Percuss the Anterior Chest – Begin percussing the apices in supraclavicular areas. Then,
percussing the interspaces and comparing one side with the other, moving down the anterior
chest. Interspaces are easier to palpate on the anterior chest than back. Do not percuss directly
over female breast tissue because it will produce a dull note!
Types of Breath Sounds
Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in the
subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as
after open thoracic injury or surgery.
Resonance is the low-pitched, clear, hollow sound that predominates in healthy lung tissue in the
adult. However, it is a relative term and has not constant standard. The resonant note may be
duller in the athlete with heavily muscular chest wall and in the heavily obese, subcutaneous fat
produces scattered dullness.
Hyperresonance is a lower-pitched, booming sound found when too much air is present such as
in emphysema or pneumothorax.
A dull note (soft, muffled thud) signals abnormal density in the lungs, as with pneumonia, pleural
effusion, atelectasis, or tumor.
Decreased/Absent breath sounds occur when the bronchial tree is obstructed by secretions,
mucus plug, or a foreign body. In emphysema, it can be a result from the loss of elasticity in the
lung fibers and decreased force of inspired air. Anything that obstructs the transmission of sound
between the lung and stethoscope, such as pleurisy, fluid, air in the pleural space can cause a
decrease in breath sounds. A silent chest means there is no air moving in or out!
Increased breath sounds mean that sounds are louder than they should be (bronchial sounds are
abnormal when they are heard over an abnormal location, the peripheral lung fields). They have
a high-pitched, tubular quality, with a prolonged expiratory phase and a distinct pause between
inspiration and expiration. Occur when consolidation (pneumonia) or compression (fluid in the
intrapleural space) yields a dense lung area that enhances the transmission of sound from the
bronchi.
Adventitious Sounds are added sounds that are not normally heard in the lungs. If present, they
are heard as being superimposed on the breath sounds. They are caused by moving air colliding
with secretions in the tracheobronchial passageways or by the popping open of previously
