Physical Assessment of Thorax, Lungs, Cardiovascular, and Abdomen (PDF)

PHYSICAL ASSESSMENT Physical Assessment of the Thorax & Lungs; Cardiovascular & Abdomen PRESENTED BY: MRS. KERON JONES-FRASER PHD CANDIDATE, MSCN, BSCN, CERT ED, RN Thorax & Lungs Thorax: portion of body extending from base of neck superiorly to level of diaphragm inferiorly;...

PHYSICAL ASSESSMENT Physical Assessment of the Thorax & Lungs; Cardiovascular & Abdomen PRESENTED BY: MRS. KERON JONES-FRASER PHD CANDIDATE, MSCN, BSCN, CERT ED, RN Thorax & Lungs Thorax: portion of body extending from base of neck superiorly to level of diaphragm inferiorly; outer structure = thoracic cage; inner structure = thoracic cavity Thoracic cavity – Mediastinum: trachea, esophagus, heart, great vessels – Lungs: Right: 3 lobes Left: 2 lobes VERTICAL REFERENCE LINES  To describe a location around the circumference of the chest wall, the examiner uses imaginary lines running vertically on the chest wall.  On the anterior chest, these lines are known as the mid- sternal line and the right and left mid-clavicular lines.  The mid-sternal line - an imaginary line that extends over the body of the breastbone.  Mid-clavicular line – an imaginary line that extends downward over the trunk from the mid-point of the clavicle, dividing each side of the anterior chest into two parts.  Anterior axillary line – an imaginary vertical line on the body wall continuing the line of the anterior axillary fold with the upper arm. Thorax & Lungs Thorax & Lungs Thorax & Lungs  The thoracic cavity consists of the mediastinum and the lungs.  The mediastinum refers to a central area in the thoracic cavity that contains the trachea, esophagus, heart, and great vessels.  The lungs lie on each side of the mediastinum.  The lungs are two cone-shaped, elastic structures suspended within the thoracic cavity.  The apex of each lung extends slightly above the clavicle.  The base is at the level of the diaphragm.  Although the lungs are paired, they are not symmetric. Thorax & Lungs  Both lungs are divided into lobes by fissures.  The right lung is made up of three lobes, whereas the left lung contains only two lobes.  The thoracic cavity is lined by a thin, double-layered serous membrane collectively referred to as the pleura.  The parietal pleural line the chest cavity, and the visceral pleura covers the external surfaces of the lungs.  The pleural space lies between the two pleural layers.  In the healthy adult, the lubricating serous fluid between the layers allows movement of the visceral layer over the parietal layer during ventilation without friction. Thorax & Lungs Collecting Objective Data: PE – Client preparation – Equipment and supplies: exam gown and drape, gloves, stethoscope, light source, mask, skin marker, metric ruler Key assessment points: – Provide privacy for the client – Keep your hands warm to promote client’s comfort during exam – Remain nonjudgmental about client’s habits and lifestyle, particularly smoking Thorax & Lungs Inspect: – For nasal flaring and pursed lip breathing – Color and shape of nails Observe color of face, lips, and chest Posterior Thorax – Inspect configuration and client’s positioning – Observe for use of accessory muscles and assess chest expansion – Palpate for: tenderness and sensation, crepitus, surface characteristics, fremitus Thorax & Lungs  Positions to Palpate Thorax & Lungs Chest expansion Posterior Chest  Percuss for tone, diaphragmatic excursion  Auscultate for breath sounds, adventitious sounds (Same positions as palpation) Thorax & Lungs  Diaphragmatic Excursion: to map out the lower lung border  Ask client to “exhale and hold it” while you percuss down the scapular line until sound changes from resonant to dull on each side.  This estimates the level of the diaphragm separating the lungs from abdominal viscera. Mark the spot. Thorax & Lungs Diaphragmatic Excursion Ask client to “take a deep breath and hold it.” Continue percussing down from the first mark and mark the level where the sound changes to dull on deep inspiration Measure the difference: - diaphragmatic excursion should be equal bilaterally and measure about 3 to 5 cm in adults. Can go up to 7 to 8 cm in well conditioned people Thorax & Lungs Anterior Thorax – Inspect for shape and configuration, position of sternum, slope of ribs, intercostal spaces, – Observe quality and pattern of respiration, use of accessory muscles – Palpate for tenderness, sensation, and surface masses; fremitus; anterior chest expansion – Percuss for tone – Auscultate for anterior breath sounds, adventitious sounds, and voice sounds Auscultation of Thorax Anterior chest Posterior chest  Auscultation of Thorax BREATH SOUND CHARACTERISTICS Bronchial High Pitch, Loud Intensity, tubular, hollow sound -Trachea expiration > inspiration Bronchovesicular Moderate Pitch, Moderate Intensity -Medial Chest inspiration = expiration Vesicular Low Pitch, Soft Intensity - Peripheral lung areas inspiration > expiration ADVENTITIOUS BREATH SOUNDS  Crackles: (discontinuous sounds)  Fine  High-pitched, short, popping sounds heard during inspiration and not cleared with coughing.  Sounds are discontinuous and can be simulated by rolling a strand of hair between your fingers near your ear.  The source is from inhaled air suddenly opens the small deflated air passages that are coated and sticky with exudate.  Crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia and congestive heart failure.  Crackles occurring early in symptoms are associated with obstructive disorders such as bronchitis, asthma, or emphysema. ADVENTITIOUS BREATH SOUNDS  Crackles (coarse):  Low pitched, bubbling, moist sounds that may persist from early inspiration to early expiration.  Also described as softly separating velcro.  The source is inhaled air encounters secretions in the large bronchi and trachea.  May indicate pneumonia, pulmonary edema and pulmonary fibrosis.  Velcro rales of pulmonary fibrosis are heard louder and closer to stethoscope, usually do not change location, and are more common in clients with long-term COPD. ADVENTITIOUS BREATH SOUNDS  Pleural friction rub:  Low-pitched, dry, grating sound.  Sound is much like crackles, only more superficial and occurring during both inspiration and expirations.  Sound is the result of rubbing of two inflamed pleural surfaces.  Is associated with pleuritis.  Wheeze (sibilant):  High-pitched, musical sounds heard primarily during expiration but may also be heard on inspiration.  Air passes through constricted passages (caused by swelling, secretions, or tumor).  Sibilant wheezes are often heard in case of acute asthma or chronic emphysema. ADVENTITIOUS BREATH SOUNDS  Wheeze (sonorous):  Low-pitched snoring or moaning sounds heard primarily during expiration but may be heard throughout the respiratory cycle.  These wheezes may clear with coughing.  The source is same as sibilant wheeze.  The pitch of the wheeze cannot be correlated to the size of the passageway that generates it.  Sonorous wheezes are often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea.  Stridor is a harsh honking wheeze with severe broncho-larngospasm, such as occurs with croup. Auscultation of Thorax Auscultate voice sounds (bronchophony):  Ask the client to repeat the phrase “ninety- nine” while you auscultate the chest wall. (the sound of the voice may be heard but the actual phrase cannot be distinguished).  Egophony: ask the client to repeat the letter “E” while you listen over the chest wall. (the letter “E” should be distinguishable)  Whispered pectoriloquy:  Ask the client to whisper the phrase 1,2,3, while you auscultate the chest wall. (transmission of sound is very faint and muffled. It may be inaudible). Heart & Neck Vessels  Heart  Located in mediastinum  Four chambers - left atrium and ventricle, right atrium and ventricle  Two atrioventricular valves, two semilunar valves  Three layers - epicardium, myocardium, endocardium Heart Chambers, Valves, and Direction of Circulatory Flow Neck Vessels  Carotid artery, jugular veins  Carotid artery pulse - ventricular systole  Level of the jugular venous pressure reflects right atrial (central venous) pressure Heart & Neck Vessels  Assessment procedure: great vessels  Observe and evaluate jugular venous pulse  Auscultate and palpate carotid arteries  Assessment procedure: heart  Inspect and palpate for abnormal pulsations, and palpate apical pulse  Auscultate heart rate and rhythm, with irregularity calculate deficit  Listen for normal and abnormal heart sounds with client in different positions Palpation of the Heart  Localize apical pulse using one finger pad  Confirm characteristics of the apical pulse  May detect other pulsations e.g. thrills (not normal)  Begin with general chest wall Auscultation of the Heart  In a quiet room, listen to the heart with your stethoscope in the right 2nd interspace close to the sternum, along the left sternal border in each interspace from the 2nd through the 5th, and at the apex.  Auscultate the entire precordium with the patient in supine position. First with diaphragm then the bell of the stethoscope Auscultation of the Heart  Ask the patient to roll partly onto the left lateral decubitus position, bringing the left ventricle close to the chest wall. Place the bell of your stethoscope lightly on the apical pulse.  Pressing the diaphragm on the chest, listen along the left sternal border and at the apex, pausing periodically so the patient may breathe. Auscultation of the Heart  Heart Sounds: L atrium, L ventricle & Aorta  Systole: is the period of ventricular contraction.  During systole, the L ventricle starts to contract, and ventricular pressure rapidly exceeds left atrial pressure, thus shutting the mitral valve.  Closure of mitral valve in the L ventricle produces the first heart sound, S1.  Diastole: is the period of ventricular relaxation.  Auscultation of the Heart  As the L ventricle starts to eject most of its blood, ventricular pressure begins to fall. When L ventricular pressure drops below aortic pressure, the aortic valve shuts.  Aortic valve closure produces the second heart sound, S2.  In children and young adults, a third sound, S3, may arise from rapid deceleration of the column of blood against the ventricular walls.  In older adults, a S3, usually indicates a pathologic change in ventricular compliance. Auscultation of the Heart  Although not often heard in normal adults, a fourth heart sound, S4, marks atrial contraction.  It immediately precedes S1 of the next beat and reflects a pathologic change in ventricular compliance.  Murmurs: S1 or S2 is a swishing or blowing sounds caused by  Forward flow through a stenotic valve  Increased flow through a normal valve  Backward flow through a valve that fails to close Peripheral Vascular Arteries:  Carry oxygenated, nutrient-rich blood from the heart to the capillaries.  Major arteries of arm: brachial, radial, ulnar  Major arteries of the leg: femoral, popliteal, dorsalis pedis, posterior tibial Peripheral Vascular Veins:  Carry deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart  Three types of veins: deep veins, superficial, veins, and perforator veins.  Femoral, popliteal, saphenous veins Peripheral Vascular Lymphatic System:  Lymphatic capillaries; lymphatic vessels; lymph nodes  Capillaries and fluid exchange  Small blood vessels  Form the connection between the arterioles and venules  Allow the circulatory system to maintain the vital equilibrium Peripheral Vascular  Subjective Data: Lifestyle & Health Practices  Tobacco use  Regular exercise  Oral contraceptives use  Stress  Peripheral vascular problems interfere with ADLs  Medications  Support hose Peripheral Vascular  Client Preparation  Equipment:  Gloves  Explain  Centimeter tape procedure to  Stethoscope Doppler ultrasound client  probe  Ask client to  Tourniquet Gauze gown   Waterproof pen  BP cuff Peripheral Vascular Arm Inspection Arm Palpation  Size, presence of  Fingers, hands, & arms for edema, venous temperature patterning  Capillary refill time  Skin color  Radial, ulnar, & brachial pulses  Fingertips for  Epitrochlear lymph clubbing nodes  Allen’s test Peripheral Vascular  Allen’s test Peripheral Vascular  Skin color Leg Palpation  Distribution of hair  Temperature  Superficial inguinal  Lesions or ulcers lymph nodes  Edema  Femoral pulse  Popliteal,dorsalis pedis, posterior tibial pulses Peripheral Vascular  Leg  Inspect for varicosities and thrombophlebitis by asking client to stand  Manual compression test  Trendelenburg test Peripheral Vascular Leg  Homan’s sign: : pain in the calf of the leg upon dorsiflexion of the foot with the leg extended that is diagnostic of thrombosis in the deep veins of the area Peripheral Vascular Arterial Insufficiency Venous Insufficiency  Pain: intermittent  Pain: aching, claudication to cramping sharp, unrelenting, constant  Pulses: present but  Pulses: diminished may be difficult to or absent palpate through  Skin characteristics: edema dependent rubor Peripheral Vascular  Subjective Data  Subjective Data: History  Skin changes  Past  Leg pain, heaviness,  Previous problems with or aching circulation in arms or legs  Leg veins  Heart or blood vessel  Leg sores or open surgeries or treatments wounds  Family  Swelling in legs or feet  Varicose veins, diabetes,  Men: sexual activity hypertension, coronary changes heart disease, or elevated cholesterol or  Swollen glands or triglyceride levels nodules Cardiovascular Assessment Video Auscultation of Heart Sounds Video Abdomen  Include all information related to GI function  Abdominal pain, dyspepsia, gas, nausea and vomiting, constipation, diarrhea, fecal continence, change in bowel patterns, characteristics of stool, jaundice, history of GI surgery or problems, appetite and eating patterns, teeth, and nutritional assessment, including weight patterns  Psychosocial, spiritual, and cultural factors  Assess knowledge; need for patient education Quadrants of the Abdomen Abdomen  Key assessment points:  Observe and inspect abdominal skin and overall contour and symmetry  Auscultate AFTER inspection and BEFORE percussion  Palpate last Abdomen Inspect: skin, contour, symmetry, movement; umbilicus; bowel and vascular sounds; friction rubs  Auscultate: Rest the diaphragm of your stethoscope lightly on the right lower quadrant of the abdominal wall with a steady hand and listen for bowel sounds for at least 30 seconds. Abdomen  Normal Findings:  Normal sounds consist of clicks and gurgles, occurring at an estimated frequency of 5 to 34 per minute.  Auscultate Vascular Sounds:  Use the bell of the stethoscope to auscultate for bruits over the aorta, renal arteries, iliac and femoral arteries.  Usually, no sound is present Abdomen Auscultation sites Percussion Percuss: liver, spleen Percussion is done to assess the relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses. Percussion of the Abdomen General tympany General tympany  Percuss lightly all four quadrants to determine the amount of tympany and dullness.  Tympany should be dominant because air in the intestines rises to the surface when the person is in the supine  http://www.cuhk.edu.hk/cslc/material position. s/pclm08/pclm08.html  Percussion of the Abdomen  Liver span:  Percuss to map out the boundaries of certain organs.  Measure the height of the liver in the right midclavicular line.  Begin in the area of lung resonance and percuss down the interspaces until the sound changes to a dull quality.  Mark the spot, usually in the 5th intercostal space  Then find abdominal tympany and percuss up in the midclavicular line  Percussion of the Abdomen  Liver span:  Mark where the sound changes from tympany to dullness, normally the right costal margin  Measure the distances between the two marks; normal liver span ranges from 6 to 12 cm  The height of the liver span correlates with the height of the person  Males have a larger liver span than females of the same height. Average 10.5 cm (males) and 7 cm (females) Percussion of the Abdomen  Splenic dullness:  The spleen is often obscured by stomach contents, may be located by percussing for a dull note from the 9th to 11th intercostal space just behind the left mid-axillary line  Percuss in the lowest interspace in the left anterior axillary line. Tympani should result.  Ask the person to take a deep breath. Normally tympani remains through full inspiration  Percussion of the Abdomen  Costovertebral angle tenderness:  To assess kidney, place one hand over the 12th rib at the Costovertebral angle on the back  Thump that hand with the ulnar edge of the other fist hand – the person normally feels a  http://medinfo.ufl.edu/year 1/bcs/slides/abdomen/imag thud but no pain es/cva.gif Palpation of Abdomen  Liver  Spleen  Kidneys  In infants aid palpation by flexing baby’s knee with one hand while palpating with other. The liver fills the RUQ. It is normal to palpate the spleen tip both kidneys and bladder.  Child: position child in parents lap, sitting knee-to-knee with parent References  Weber, J., & Kelley, J. 2018. Health assessment in nursing. Lippincott, Williams & Wilkinson.