Interpreting Percussion Sounds

THORAX Assessment

• Objectives: Explain the significance of selected findings in the thorax, lungs, and breast, and identify questions during assessment.
• Methods of assessment:
• General inspection and patient history
• Inspection
• Palpation
• Percussion
• Auscultation

Chest Landmarks

• First rib: Accurate localization and count
• First intercostal space: Accurate localization and count
• Second rib: Accurate localization and count
• Second intercostal space: Accurate localization and count

Anterior View of the Viscera of Thorax

• Shows the various parts of the heart, lungs, and ribs
• Apex: where the upper lobe begins
• Base: broad, concave, and rests upon the convex surface of the diaphragm
• Three lobes to the right
• Two lobes to the left

Methods and Order of Chest Assessment

• General inspection and patient history
• Inspection
• Palpation
• Percussion
• Auscultation

General Inspection and Observation

• Count respiratory rate for a full minute
• Normal respiratory rate: 12 to 20 BPM for adults
• Observe the rhythm, depth, and effort of breathing
• Respiratory pattern should be even, coordinated, and regular
• Inspiration to expiration ratio: 1:2

Palpation

• Normal findings:
  • Skin intact
  • Uniform temperature
  • Use the back of hands
  • No tenderness
  • No masses
  • No pain
• Tactile fremitus:
  • Definition: the faintly perceptible vibration felt through the chest wall when the client speaks
  • Procedure:
    • Place palm on landmarks
    • Have client repeat “ninety-nine”
  • Normal finding: Bilaterally symmetrical

Percussion

• A method of medical diagnosis to determine the condition of internal organs
• Interpreting percussion sounds:
  • Normal lung tissue: Long, loud, low-pitched, hollow sound
  • Hyperresonance: Lung hyperinflation, COPD, Pneumothorax
  • Tympany: Gastric air bubble, Large Pneumothorax
  • Dullness: Medium intensity, pitch, and length, thud-like
  • Flatness: Short, high-pitched, extremely dull sound

Auscultation

• Use the bell of the stethoscope to detect low-pitched sounds
• Use the diaphragm of the stethoscope to detect high-pitched sounds
• Systematic side-to-side approach
• Ask client to take slow, deep breaths through the mouth

Normal Breath Sounds

• Vesicular:
  • Soft-intensity
  • Low-pitched (gentle sighing)
  • Heard over most lung fields
  • Best location: Peripheral lung, base of lung
• Bronchovesicular:
  • Moderate intensity and pitch
  • “Blowing” sound created by air movement through larger airway
  • Location: Between scapulae and lateral to sternum, first and second intercostal spaces
• Bronchial:
  • High-pitched, loud, harsh sounds
  • Created by air moving through trachea
  • Location: Over trachea

Chest Deformities

• Barrel Chest:
  • Ratio of AP to transverse diameter is 1:1
  • Increased AP diameter is normal for COPD patients
  • Caused by chronic lung diseases (emphysema)
• Scoliosis:
  • Lateral curvature or deviation of the spine
  • Caused by trauma, present since birth, or idiopathic scoliosis
• Kyphosis:
  • Excessive curve in lumbar spine
  • Slack tummy muscles
  • Protruding buttocks

Abnormal Breath Sounds

• Crackles (rales):
  • Fine crackles:
    • High-pitched, intermittent, cracking, popping sound
    • Common cause: Air passing through fluid
    • Commonly heard at the bases on inspiration
    • Disease process: Bronchitis, Pneumonia, Emphysema, Heart Failure
  • Coarse crackles:
    • Continuous, low-pitched, coarse, harsh sounds
    • “Snoring quality”
    • May disappear or decrease with coughing
    • Occurs when air passes through narrowed air passages due to secretions, swelling, or tumors
• Wheezes:
  • Continuous, high-pitched, squeaky musical sounds
  • Happens when airflow is blocked
  • Occurs because of airway inflammation or narrowing (asthma or infection)
  • Can also occur because of airway obstruction related to tumor or foreign body
  • Not cleared by coughing
• Rhonchi:
  • Continuous, low-pitched, coarse, harsh sounds
  • “Snoring quality”
  • May disappear or decrease with coughing
  • Occurs when air passes through narrowed air passages due to secretions, swelling, or tumors
• Stridor:
  • Loud, high-pitched crowing sound or harsh honking wheeze with severe broncholaryngeal spasm
  • Can be heard loudest over the neck, usually without a stethoscope, when a patient inhales
  • Caused by an upper airway obstruction
  • REQUIRES IMMEDIATE ATTENTION

Health Promotion

• Promotion of health screening, health maintenance, and self-care teaching
• Health promotion plans need to be developed according to the needs, desires, and priorities of the client
• The client decides on the health promotional goals
• Early detection and vaccinations

Breast Assessment

• Location: Between the 2nd and 6th ribs, between the sternal edge and mid-axillary line
• Methods of breast assessment:
  • Inspection
  • Palpation
• Divided into four quadrants, using the “clock” for abnormality position
• Tail of Spence:
  • Contains largest portion of glandular tissue
  • Most common site for female breast cancer
• Preparation:
  • Introduce self
  • Include your professional title
  • Verify/identify client
  • Use two identifiers
  • Assess allergy status
  • Explain procedure
  • Reason for examination
  • Provide privacy
  • Door
  • Curtain
  • Sheet
  • Expose ONLY the part that needs to be assessed
  • Wash and warm hands
• Assessment of the breast:
  • Observe and inspect:
    • Size/Symmetry
    • Shape
    • Skin discoloration
    • Nipple discharge, integrity, and retraction
    • Tenderness and masses, dimpling
  • Palpation of the breast:
    • Use the flat surface of the middle three fingertips
    • Making gentle rotating motion on the breast
    • Position of choice:
      • Client supine
      • Breasts flatten evenly against the chest wall
      • High-risk patients examine in both supine and sitting positions