Interpreting Percussion Sounds in Stethoscope

Thorax Assessment

• Objectives:
  • Explain significance of selected findings in the thorax, lungs, and breast
  • Identify questions during thorax, lungs, and breast assessment
  • Methods of assessment, characteristics, cultural variations, age variations, health promotion, and patient/family teaching

Health Assessment Obtain

• Family history
• Occupational history
• Country of origin
• Exposure

The Respiratory System

• Chest landmarks:
  • First rib
  • First intercostal space
  • Second rib
  • Second intercostal space

Medical and Surgical History

• Trauma or surgery
• Chest pain with deep breathing
• Cough
• Smoking
• Allergies
• Environmental exposures
• Lung disease
• Respiratory infections
• Pillow use

Anterior View of the Thorax

• 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

Thoracic/Chest Landmark

• Methods and order of chest assessment:
  • General inspection
  • Patient history
  • Inspection
  • Palpation
  • Percussion
  • Auscultation

General Inspection and Observation

• Count respiratory rate for a full minute – longer if there’s any abnormalities
• 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

• Posterior thorax:
  • 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

• Definition: a method of medical diagnosis in which various areas of the body, especially the chest, back, and abdomen, are tapped to determine by resonance 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 flat disc of the diaphragm for high-frequency sounds
• Use the bell of the stethoscope for low-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, idiopathic scoliosis
• Kyphosis:
  • Excessive curve in lumbar spine
  • Slack tummy muscles
  • Protruding buttocks

Abnormal Breath Sounds

• Adventitious breath sounds:
  • Crackles (rales)
  • Wheezes
  • Pleural friction rubs
  • Rhonchi (gurgles)
  • Stridor
• Fine crackles:
  • High-pitched, intermittent, cracking, popping sound
  • Heard at the bases on inspiration
  • Common cause: air passing through fluid
  • 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
  • Predominantly heard over trachea and bronchi

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 and assessment:
  • Between the 2nd and 6th ribs
  • Between the sternal edge and mid-axillary line
• Methods of breast assessment:
  • Inspection
  • Palpation

Breast Assessment Divided

• Divided into four quadrants, using the “clock” for abnormality position
• Tail of Spence:
  • Contains the largest portion of glandular tissue
  • Most common site for female breast cancer