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446 PHYSICAL EXAMINATION
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UNIT 2
Depth
E
1. Stand in front of the consumer.
2. Observe the relative depth with which the consumer draws a breath
during inspiration.
The normal depth of inspiration is not exaggerated, and effortless.
N
In hypoventilation, or shallow respirations, the chest wall is moved
A
minimally during inspiration and expiration. A small tidal volume is being
inspired (
Obese consumers frequently have small tidal volumes due to the sheer weight of
P
Figure 13.11I).
the chest wall and the effort it takes to move it with each breath.
The consumer in pain or with a recent abdominal or thoracic incision has
P
shallow respirations due to the discomfort of moving the rib cage, the
integument and the respiratory muscles with each breath.
Shallow respirations are also seen in conditions where lung pathology exists and
P
breathing is painful (e.g. pulmonary embolus, pneumonia, pneumothorax).
Hyperpnoea is a breath that is greater in volume than the resting tidal
A
volume (
Figure 13.11J). The respiratory rate is normal and the pattern is even
in hyperpnoea.
In the warm-up and cool-down periods of exercise, hyperpnoea is present. The
P
deep breath is drawn to meet the increased metabolic needs of the body.
Consumers in highly emotional states exhibit hyperpnoea as the body attempts
P
to meet the increased oxygen demand.
Consumers who are thrust into high-altitude regions will become hyperpnoeic
P
due to the decreased partial pressure of oxygen. Deep breaths and slight
tachypnoea represent an attempt to supply the oxygen needs of the body.
Air trapping is an abnormal respiratory pattern with rapid, shallow
A
respirations and forced expirations (
Consumers with COPD have difculty with exhaling. When these consumers
P
Figure 13.11K).
exercise or experience increased heart rate, they have insufcient time to fully
exhale. As a result, air is trapped in the lungs and, over time, the chest
overexpands. Likewise, an asthmatic consumer experiencing an acute attack has
difculty exhaling due to increased mucus and bronchial constriction. Air
trapping ensues.
Kussmaul respirations are characterised by extreme increased depth and rate
A
of respirations (
Figure 13.11L). These respirations are regular and the inspiratory
and expiratory processes are both active.
Diabetic ketoacidosis and metabolic acidosis may result in Kussmaul respirations.
P
The body is lowering its PaCO
level, thereby raising the pH and attempting to
2
correct the acidosis.
Sighing is characterised by normal respirations interrupted by a deep
A
inspiration and followed by a deep expiration (Figure 13.11M). It may be
accompanied by an audible sigh. Sighing is pathological if it occurs frequently.
Excessive sighing can occur in central nervous system lesions.
P
Symmetry
E
1. Stand in front of the consumer.
2. Observe the symmetry with which the chest rises and falls during the
respiratory cycle.
The healthy adult’s thorax rises and falls in unison with the respiratory cycle.
N
There is no paradoxical movement.
Unilateral expansion of either side of the thorax is abnormal.
A
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
RESPIRATORY 447
A. Eupnoea (normal)
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D. Apnoea
F. Biot's
J. Hyperpnoea
L. Kussmaul
C. BradypnoeaB. Tachypnoea
E. Cheyne-Stokes
G. Apneustic
I. ShallowH. Agonal
K. Air trapping
M. Sighing
CHAPTER 13
FIGURE 13.11 Respiratory patterns
Conditions in which the lung is absent or collapsed (pneumonectomy,
P
pneumothorax) are characterised by unilateral
thoracic expansion secondary
to the lack of active alveolar expansion on inspiration.
Absence of expansion is evident on the affected lung side in a consumer with
P
pulmonary brosis due to the thickening of the lung and decreased elasticity.
Acute pleurisy and massive atelectasis are pathologies where pain and collapsed
P
alveoli, respectively, interfere with the respiratory process and prevent adequate
bilateral and equal chest symmetry.
Paradoxical, or seemingly contradictory, chest wall movement is always abnormal.
A
In paradoxical chest wall movement, the unaffected part of the thorax will rise
during inspiration while the affected area will fall. Conversely, during expiration
the unaffected part of the thorax will fall while the affected area will rise.
Broken ribs from trauma to the chest wall or ail chest interferes with the
P
normal rib cage dynamics during the respiratory process and may lead to
paradoxical chest wall movement.
Hoover’s sign is the paradoxical inwards movement of the lower ICS during
A
inspiration. This occurs when the diaphragm is at instead of its normal dome
shape. Muscle bres are horizontal, and diaphragmatic contraction pulls the rib
cage inwards rather than down.
Broken ribs from trauma to the chest wall or ail chest interferes with the
P
normal rib cage dynamics during the respiratory process and may lead to the
presence of Hoover’s sign.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
448 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
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UNIT 2
Audibility
E
1. Stand in front of the consumer.
2. Listen for the audibility of the respirations.
N
A consumer’s respirations are normally heard by the unaided ear a few
centimetres from the consumer’s nose or mouth.
It is abnormal to hear audible breathing when standing 1 metre from the
A
consumer. Upper airway sounds may also be heard. These should not be
confused with pulmonary sounds.
Any condition in which air hunger exists has the potential to create audible and
P
noisy breathing. The body is attempting to meet its oxygen demands. Examples
of these states are exercise, COPD, pneumonia and pneumothorax.
Loud and persistent coughing can indicate asthma, COPD and many other
P
pulmonary conditions. Be alert to a ‘whooping’ sound because of the increasing
incidence of pertussis. One can hear an example of an adult who has a
‘whooping cough’ at https://www.youtube.com/watch?v=31tnXPlhA7w.
HEALTH EDUCATION
Pertussis (whooping cough) resurgence
Whooping cough is a serious respiratory infection caused by the bacteria Bordetella
pertussis. Whooping cough is highly contagious, spread through airborne droplets from
person to person and can affect people of all ages. Symptoms commence about 7–10 days
after acquiring pertussis, and include a cold, blocked or runny nose, mild fever and cough.
The cough becomes worse and can be quite violent. Not everyone develops a cough with
a distinctive ‘whooping’ sound. Current immunisation coverage does not confer long-term
immunity. As a nurse you should be aware that those immunised against whooping cough
can still contract the disease, especially if they have not sought out a booster dose in the
previous 10 years. As some individuals may have the disease and not be aware, they may
spread this to others. Susceptible groups include babies less than six months, those living
in the same home as someone who is diagnosed with whooping cough, and individuals who
have not had a booster for whooping cough in the previous 10 years. A pertussis booster
was added in December 2017 to the Australian NIP for 18-month-old children (Australian
Technical Advisory Group on Immunisation (ATAGI), 2022; Ministry of Health/Manatù Hauora,
2021; Australian Government Department of Health, 2017).
FIGURE 13.12 Tripod position
MEDICAL IMAGES/MEDICUS
Consumer position
E
1. Ask the consumer to sit upright for the respiratory assessment.
2. View the consumer either before or after the assessment and note the
assumed position for breathing. Ask if the assumed position is required for
respiratory comfort.
3. Note if the consumer can breathe normally when in a supine position.
4. Note if pillows are used to prop the consumer upright to facilitate breathing.
N
The healthy adult breathes comfortably in a supine, prone or upright position.
Orthopnoea is difculty breathing in positions other than upright.
A
COPD, heart failure and pulmonary oedema exemplify conditions where
P
orthopnoea may be present. The upright position maximises the use of the
respiratory muscles in consumers who might otherwise be unable to breathe in a
supine position, secondary to uid in the lungs. Consumers with COPD may
assume the tripod position to breathe easier and make breathing look natural
(Figure 13.12). The tripod position allows for easier use of accessory muscles.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
RESPIRATORY 449
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Mode of breathing
E
1. Stand in front of the consumer.
2. Note whether the consumer is using the nose, the mouth, or both,
to breathe.
3. Note for which part of the respiratory cycle each is used.
N
Normal ndings vary among individuals but, generally, most consumers inhale
and exhale through the nose.
Continuous mouth breathing is usually abnormal.
A
Any type of nasal or sinus blockage obstructs the normal breathing passageway
P
and leads to mouth breathing.
Pursed-lip breathing is performed by consumers who need to prolong the
A
expiration phase of the respiratory cycle. It appears that the consumer is trying
to blow out a candle or is preparing for a kiss.
Pursed-lip breathing is performed by consumers with COPD. It is the consumer’s
P
innate mechanism to apply positive-pressure breathing to prevent total alveolar
collapse with every breath. Less energy is expended with each breath because the
alveoli do not completely collapse after expiration.
Consumers may breathe through a stoma or tracheostomy (Figure 13.13).
A
Consumers with laryngeal cancer who have had a surgical removal of the larynx
P
breathe initially through a tracheostomy and then through a stoma. This is their
normal mode of breathing.
FIGURE 13.13 Tracheostomy
ALAMY STOCK PHOTO/MEDISCAN
CHAPTER 13
Sputum
To ease sputum collection, it is best to increase the consumer’s uid intake and
humidify the environment. For consumers with copious secretion, such as in cystic
brosis, it may be helpful to rst use postural drainage and chest physiotherapy.
Postoperative consumers and those who have pain may benet from splinting the
painful area with a pillow during the expectoration.
E
1. Ask the consumer to expectorate a sputum sample.
2. If the consumer is unable to expectorate, ask the consumer for a recent
sputum sample from a handkerchief or tissue.
3. Note the colour, odour, amount and consistency of the sputum.
N
A small amount of sputum is normal in every individual. The colour is light
yellow or clear. Normal sputum is odourless. Depending on the hydration status
of the consumer, the sputum can be thick or thin.
Abnormal colours of sputum are mucoid, yellow or green, rust or blood-tinged,
A
black, and pink (and frothy).
Table 13.1 lists the pathologies that are associated with different colours
P
of sputum.
Foul-smelling sputum is always abnormal.
A
Anaerobic infections produce foul-smelling sputum.
P
A large amount of sputum can be pathological.
A
Chronic bronchitis produces a large amount of sputum as a result of the
P
irritation to the respiratory tract.
Consumers with pneumonia expectorate large quantities of sputum. The sputum
P
is produced in reaction to the infectious process.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
450 PHYSICAL EXAMINATION
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TABLE 13.1 Pathologies associated with different colours of sputum
SPUTUM COLOUR PATHOLOGY
UNIT 2
Mucoid Tracheobronchitis, asthma, coryza
Yellow or green Bacterial infection
Rust or blood-tinged Pneumococcal pneumonia, pulmonary infarction, tuberculosis, lung cancer
Black Black lung disease
Pink Pulmonary oedema
An excessive amount of sputum is found in pulmonary oedema as a result of
P
uid that has leaked from pulmonary capillary membranes into large airways.
Very thick sputum can be abnormal.
A
Water is a normal component of the sputum. Therefore, when a consumer is
P
dehydrated, the sputum will be thicker because the mucus, blood, purulent
material and cellular debris form the bulk of the sputum.
Sputum that has a thin consistency can be abnormal.
A
In overhydration, the extra uid tends to dilute the remaining components of
P
the sputum. In pulmonary oedema, the sputum is thin, pink and frothy.
Palpation
General palpation
General palpation assesses the thorax for pulsations, masses, thoracic tenderness
and crepitus.
To perform anterior palpation:
E
1. Stand in front of the consumer.
2. Place the nger pads of the dominant hand on the apex of the right lung
(above the clavicle).
3. Using light palpation, assess the integument of the thorax in that area.
4. Move the nger pads down to the clavicle and palpate.
5. Proceed with the palpation, moving down to each rib and ICS of the right
anterior thorax. Palpate any area(s) of tenderness last.
6. Repeat the procedure on the left anterior thorax.
To perform posterior palpation:
E
1. Stand behind the consumer.
2. Place the nger pads of the dominant hand on the apex of the right lung
(approximately at the level of T1).
3. Using light palpation, assess the integument of the thorax in that area.
4. Move the nger pads down to the rst thoracic vertebra and palpate.
5. Proceed with the palpation, moving down to each thoracic vertebra and ICS
of the right posterior thorax.
6. Repeat the procedure on the left posterior thorax.
To perform lateral palpation:
E
1. Stand to the consumer’s right side.
2. Have the consumer lift the arms overhead.
3. Place the nger pads of the dominant hand beneath the right auxiliary fold.
4. Using light palpation, assess the integument of the thorax in that area.
5. Move the nger pads down to the rst rib beneath the auxiliary fold.
6. Proceed with the palpation, moving down to each rib and ICS of the right
lateral thorax.
7. Move to the consumer’s left side.
8. Repeat steps 2–6 for the left lateral thorax.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
RESPIRATORY 451
A. Anterior
B. Posterior
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Pulsations
No pulsations should be present.
N
The presence of pulsations on the thorax is abnormal.
A
A thoracic aortic aneurysm that is large may be seen pulsating on the anterior
P
chest wall.
Masses
No masses should be present.
N
The presence of a thoracic mass is abnormal.
A
The presence of a thoracic tumour or cyst should be closely evaluated and
P
malignancy ruled out.
Thoracic tenderness
No thoracic tenderness should be present.
N
Fractured ribs may cause thoracic tenderness.
A
Blunt chest trauma can affect any component of the respiratory tract, as well as
P
the heart and great vessels. The region involved, the type of injury and the
impact of the injury dictate the amount of internal damage.
Locating the site of a fractured rib
To locate the site of a fractured rib:
E
1. Tell the consumer what you are going to do and that some pain may
be involved.
2. Place the consumer in a supine or upright position. In the latter position,
support the consumer’s back with one hand.
3. Place your hand over the middle of the sternum and depress lightly.
4. Quickly remove your hand from the sternum.
5. Outcome: The consumer will complain of pain at the fracture site. Have the
consumer point to the site of pain. This technique is not effective for the
11th and 12th pairs of ribs because of their anatomic nature and location.
CHAPTER 13
Crepitus
Crepitus should be absent.
N
The presence of
A
crepitus, also referred to as subcutaneous emphysema, is
always an abnormal nding. Fine beads of air escape the lung and are trapped in
the subcutaneous tissue. As this area is palpated, a crackling sound may be
heard. This air is slowly absorbed by the body. Crepitus is usually felt earliest in
the clavicular region, but it can easily be found in the neck, face and torso. It can
also be described as feeling similar to bubble packing material that can be
palpated and popped.
Any condition that interrupts the integrity of the pleura and the lungs has the
P
potential to lead to crepitus. Pathologies in which crepitus is frequently found
are pneumothorax, chest trauma, thoracic surgery, mediastinal emphysema,
alveolar rupture and tearing of pleural adhesions.
Thoracic expansion
Thoracic expansion assesses the extent of chest expansion and the symmetry
of chest wall expansion. Anterior and posterior thoracic expansions can be
assessed (
Figure 13.14).
FIGURE 13.14 Thoracic expansion
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
452 PHYSICAL EXAMINATION
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UNIT 2
To perform anterior thoracic expansion:
E
1. Stand directly in front of the consumer. Place the thumbs of both hands on
the costal margins and pointing towards the xiphoid process. Gather a small
fold of skin between the thumbs to assist with the visualisation of the results
of this technique.
2. Lay your outstretched palms on the anterolateral thorax.
3. Instruct the consumer to take a deep breath.
4. Observe the movement of the thumbs, both in direction and in distance.
5. Ask the consumer to exhale.
6. Observe the movement of the thumbs as they return to the midline.
To perform posterior thoracic expansion:
E
1. Stand directly behind the consumer. Place the thumbs of both hands at the
level of the 10th spinal vertebra, equidistant from the spinal column and
approximately 2.5 to 7.5cm apart. Gather a small amount of skin between
the thumbs as directed for anterior expansion.
2. Place your outstretched palms on the posterolateral thorax.
3. Instruct the consumer to take a deep breath.
4. Observe the movement of the thumbs, both in direction and in distance.
5. Ask the consumer to exhale.
6. Observe the movement of the thumbs as they return to the midline.
The thumbs separate an equal amount from the spinal column or xiphoid
N
process (distance) and remain in the same plane of the 10th spinous vertebra or
costal margin (direction). The normal distance for the thumbs to separate during
thoracic expansion is 3 to 5cm.
Unilateral decreased thoracic expansion is abnormal.
A
Unilateral decreased thoracic expansion on the affected or pathological side
P
occurs in pneumothorax, pneumonia, atelectasis, lower lobe lobectomy, pleural
effusion and bronchiectasis. In these conditions, the alveoli are either not
present or not fully expanding on the affected side due to pathology inside or
external to the lung.
Bilateral decreased thoracic expansion is an abnormal nding.
A
Bilateral disease external or internal to the lungs must be present in order for
P
bilateral decreased thoracic expansion to be present. Hypoventilation,
emphysema, pulmonary brosis and pleurisy exemplify diseases where the
alveoli do not fully expand.
Displacement of thumbs from the 10th spinal vertebra region (thumbs will not
P
meet in the midline when the consumer exhales) is abnormal.
In scoliosis, the spine is laterally deviated to a particular side. Thus, when the
P
consumer takes a deep breath, there can be a slight or marked expansion of the
lungs in an unequal fashion due to the compression of the lungs by the spine.
Tactile fremitus
Tactile or vocal fremitus is the palpable vibration of the chest wall that is
produced by the spoken word. This technique is useful in assessing the underlying
lung tissue and pleura. The anterior, posterior and lateral chest walls are assessed.
Three different aspects of the hand can be used to perform this skill: the palmar
bases of the ngers, the ulnar aspect of the hand, and the ulnar aspect of a closed
st (Figure 13.15). You might like to experiment with each technique and decide
which is the most comfortable. It is recommended that the ulnar aspect of the
hand be used initially because this exposes the least amount of surface area, and,
therefore, more discrete areas can be assessed.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
RESPIRATORY 453
A. Using palmar base of fingers
B. Using ulnar aspect of hand
C. Using ulnar aspect of closed fist
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FIGURE 13.15 Tactile fremitus
CHAPTER 13
To perform tactile fremitus:
E
1. Firmly place the ulnar aspect of an open hand (or palmar base of the ngers
or ulnar aspect of a closed st) on the consumer’s right anterior apex (above
the clavicle).
2. Instruct the consumer to say the words ‘99’ or ‘1, 2, 3’ with the same
intensity every time you place your hand on the thorax.
3. Feel any vibration on the ulnar aspect of the hand as the consumer
phonates. If no fremitus is palpated, you may need to have the consumer
speak more loudly.
4. Move your hand to the same location on the left anterior thorax.
5. Repeat steps 2 and 3.
6. Compare the vibrations palpated on the right and left apices.
7. Move the hand down 5 to 7.5cm and repeat the process on the right and
then on the left. Ensure that your hand is in the ICS in order to avoid the
bony structures. Minimal or no fremitus will be felt over the ribs because
they lie on top of the lungs.
8. Continue this process down the anterior thorax to the base of the lungs.
9. Repeat this procedure for the lateral chest wall and compare symmetry.
Either do the entire right then the entire left thorax, or alternate right and
left at each ICS.
10. Repeat this procedure for the posterior chest wall. Figure 13.16 illustrates the
progression of the assessment.
Normal fremitus is felt as a buzzing on the ulnar aspect of the hand. The
N
fremitus will be more pronounced near the major bronchi (second ICS
anteriorly, and T1 and T2 posteriorly) and the trachea, and will be less palpable
in the periphery of the lung. The diaphragm is approximately at the level of
T10–T12 posteriorly and it is slightly higher on the right because of the presence
of the liver.
Increased tactile fremitus is abnormal.
A
Diseases that involve consolidation, such as pneumonia, atelectasis and
P
bronchitis, also involve increased tactile fremitus in the affected area. A
compressed lung will also exhibit increased tactile fremitus because solids
conduct sound better than air does.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
454 PHYSICAL EXAMINATION
A. Anterior thorax
B. Posterior thorax
C. Right lateral thorax
D. Left lateral thorax
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UNIT 2
Decreased or absent tactile fremitus is a pathological nding.
A
Because porous materials conduct vibrations less effectively than do uids and
P
solids, decreased tactile fremitus will be present in pneumothorax, emphysema
and asthma.
In a pleural effusion, the exudate is external to the alveoli and therefore acts
P
as a blockade to the transmission of sound waves. This results in decreased
tactile fremitus.
4
1
2 2
3
1
3
4
1
2 2
3 3
4
1
4
1
FIGURE 13.16 Pattern for tactile fremitus
1
2
3
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
2
3
Advanced Assessment
RESPIRATORY 455
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A consumer with a large chest wall and an obese consumer will have decreased
P
tactile fremitus because the sound waves are dampened as they pass through a
greater distance.
A high diaphragm level is abnormal.
A
The diaphragm level is abnormally high in a consumer with a lower lobe
P
lobectomy. Tactile fremitus will be present above the surgical site.
There are three additional ndings that can be revealed during tactile fremitus:
A
pleural friction fremitus, tussive fremitus and rhonchal fremitus.
Pleural friction fremitus is a palpable grating sensation that feels more
P
pronounced on inspiration when there is an inammatory process between the
visceral and the parietal pleuras.
Tussive fremitus is the palpable vibration produced by coughing.
P
Rhonchal fremitus is the coarse palpable vibration produced by the passage
P
of air through thick exudate in large bronchi or the trachea. This can clear
with coughing.
CHAPTER 13
Tracheal position
To assess the position of the trachea:
E
1. Place the nger pad of the index nger on the consumer’s trachea in the
suprasternal notch (Figure 13.17).
2. Move the nger pad laterally to the right and gently move the trachea in the
space created by the border of the inner aspect of the sternocleidomastoid
muscle and the clavicle.
3. Move the nger pad laterally to the left and repeat the procedure.
Another method by which the trachea can be palpated is:
E
1. Gently place the nger pad of the index nger in the midline of the
suprasternal notch.
2. Palpate for the position of the trachea.
The trachea is midline in the suprasternal notch.
N
Tracheal deviation to the affected side is abnormal.
A
The normal midline position of the trachea is maintained by the
P
counterbalancing forces of the air in the alveoli in the right and left lungs. In
atelectasis and pneumonia, alveoli are closed to some degree or lled with
exudate. Fewer aerating alveoli are present and therefore the trachea is slightly
pushed by the healthy lung to the affected side, which contains less air.
The mechanical pulling force of ventilator tubing that is attached to an
P
endotracheal tube or tracheostomy for a prolonged period can cause tracheal
deviation toward the side of the pulling.
Tracheal deviation to the unaffected side is abnormal.
A
A tension pneumothorax, pleural effusion and a tumour may each generate
P
sufcient pressure to force the trachea towards the unaffected side.
An enlarged thyroid may deviate the trachea via its space-occupying capacity.
P
FIGURE 13.17 Assessing tracheal position
Percussion
Indirect or mediate percussion is used to further assess the underlying structures of
the thorax. Remember that percussion reverberates a sound that is generated from
structures approximately 5cm below the chest wall. Deep pathological conditions
will not be revealed during the percussion process.
There is no harm in repeating the percussion strike in a given area if you are
uncertain about the sound that was produced or if you would like to compare
it to the sound from another area. Remember always to visualise the underlying
structures that are being assessed.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
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