Chapter 18: Thorax and Lungs (pg.

413)
1. Position and Surface Landmarks

a. Anterior Thoracic Landmarks: Signposts for underlying

respiratory structures.
i. Suprasternal Notch: Hollow U-shaped depression
just above the sternum, between clavicles.
ii. Sternum: (breastbone) Has three parts: the
manubrium, the body, and the xiphoid process.
1. Walk your fingers down the sternum until you
feel a distinct bony ridge, the sternal angle
iii. Sternal Angle: (Angle of Louis) The articulation of
the manubrium and the body of the sternum
(continuous with the second rib).
1. Also marks the site of tracheal bifurcation into
the right and left main bronchi
2. Corresponds with upper border of the atria of
the heart
3. Lies above the fourth vertebra on the back
iv. Costal Angle: Right and left costal margins form an
angle where they meet at the xiphoid process.
(Usually 90 degrees or less)
1

1. Angle increases when rib cage is chronically

overinflated (i.e. emphysema)

b. Posterior Thoracic Landmarks: More difficult to count

ribs and intercostal spaces because of the surrounding
muscles.

i. Vertebra Prominens: (C7) the most bony

prominence when you flex your head.
1. If two vertebra seem equally prominent, the
upper on is C7
ii. Spinous Processes: Note: C7-T4 the spinous
process points outward, after T4 the spinous process
points downward overlying the next vertebral body
and rib below.
iii. Inferior Border of the Scapula: symmetrical in
each hemithorax. Lower tip is usually at the 7th or 8th
rib.
iv. Twelfth Rib: The tip is usually midway between
someones side and their spine.
c. Reference Lines: Use to pinpoint a finding vertically on the
chest (i.e. Mid sternal and midclavicular)

Line

Picture

Midclavicular &
Midsternal

Vertebral
(midspinal) &
Scapular

Anterior
axillary,
Midaxillary, &
Posterior
axillary

2. The Thoracic Cavity:

i. Mediastinum: Middle section
ii. Pleural Cavities: right a left of the mediastinum
iii. Lung Borders: In the anterior chest, the apex of the
lung tissue is 3 or 4cm above the inner third of the
clavicle. The base rests on the diaphragm at about
the 6th rib in midclavicular line
1. Laterally: lung tissue extends from apex of
axilla to 7th or 8th rib
2. Posteriorly: C7 marks apex, T10 corresponds to
base.
b. Lobes of Lungs: Both lungs are NOT precisely symmetrical.
1. Right lung: shorter than left (b/c Underlying
liver on the right), THREE lobes (separated by
fissures)
2. Left lung: narrower than the right (b/c heart
bulges to the left), TWO lobes
ii. Anterior: Contains mostly upper and middle lobes
1. Oblique (the major or diagonal) fissure:
crossed the 5th rib in the midaxillary line and
ends at the 6th rib in midclavicular line

2. Horizontal (minor) fissure: Divides right

upper and middle lobe. Extends from 5th rib
(right midaxillary) to 3rd intercostal space, or 4th
rib at the right sternal border

iii. Posterior: Almost ALL lower lobes. Upper lobes end

at about T3 or T4, then lower lobes begin, reaching
all the way to T10 (expiration) and T12 (inspiration).
a. Right Middle Lobe (RML): does not
project on the posterior chest.
2. Lobes projected in the posterior chest include:
Left upper lobe, Left Lower Lobe, Right Upper
Lobe, Right Lower Lobe.

iv. Lateral: Lunges extend from apex of axilla to 7th or 8th

rib.
5

v. TAKE A SPECIAL NOTE: 3 points that often confuse

beginning examiners.
1. The left lung has no middle lobe
2. The anterior chest contains mostly upper and
middle lobe with very little lower lobe.
3. The posterior chest contains almost all lower
lobe
c. Pleurae: serous membranes that form and envelope
between the lungs and chest wall
i. Visceral pleurae: lines the outside of the lungs,
dipping down into the fissures.
1. Continuous with parietal pleurae
ii. Parietal pleurae: lines the inside of chest wall and
diaphragm
iii. Costodiaphragmatic recess: pleurae extend
approximately 3cm below the level of the lungs. This
is the potential space; when it abnormally fills with
air or fluid it compromises lung expansion.
d. Trachea and Bronchial Tree:
i. Trachea: anterior to esophagus. 10-11 cm long in and
adult
ii. Trachea and bronchi = Dead Space (150 mL)
1. Transport gasses between environment and
lungs
iii. Acinus: Functional respiratory unit that consists of
the bronchioles, alveolar ducts, alveolar sacs, and
alveoli
3. Mechanics of Respiration:
a. 4 major functions of the respiratory system.
1. Supply 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 (maintains pH)
4. Maintaining heat exchange (less important in
humans)
b. Control of Respirations: controlled by respiratory center
in the brain stem (Pons and Medulla) normal stimulus to
breath is and increase carbon dioxide in the blood.
i. Hypercapnia: increased carbon dioxide in the blood
(increased respirations)
ii. Hypoxemia: decreased oxygen in the blood (also
increases respirations, but is less effective than
hypercapnia)
c. Changing Chest Size:
6

1. Inspiration: inhale
2. Expiration: exhale
ii. Expansion and Contraction of the chest cavity, alters
the size of the thoracic container in 2 dimensions:
1. The vertical diameter lengthens or shortens,
which is accomplished by downward or upward
movement of the diaphragm
2. The anteroposterior (AP) diameter increases or
decreases, which is accomplished by elevation
or depression of the ribs.
4. DEVELOPMENTAL COMPETENCE:
a. Infants and Children:
i. Respiratory Development in the Fetus.
Age
During the first 5
weeks
16 weeks
32 weeks
By Birth

Development
Primitive lung bud emerges
The conducting airways reach the
same number as the adult
Surfactant is present in adequate
amounts
The lungs have 70 million
primitive alveoli ready to start
respiration

ii. Respiratory ALONE does not function until birth.

iii. Respiratory development continues throughout
childhood
1. Increases in:
a. Diameter of airways
b. Length of airways
c. Size of Alveoli
d. Number of Alveoli (300 million by
adolescence)
iv. Consider: Childrens pulmonary system is IMMATURE
(not fully developed)
1. Children exposed to smoke are at a high health
risk
2. Prenatal exposure to smoke causes the
following in the developing fetus:
a. Chronic hypoxia
b. Premature birth

c. Low birth weight

d. Risk of nicotine addiction
e. SIDS (both prenatal and
postnatal exposure)
f. Lower respiratory
illnesses
g. Acute and chronic otitis
media,
h. Breathlessness
i. Asthma
j. Adverse lung function
throughout childhood
k. Increase risk for ADHD
l. Increase risk for Depression in childhood
and adolescence
b. The Pregnant Woman: enlarging uterus elevates
diaphragm 4cm
i. Decrease vertical diameter of thoracic cage
ii. Increase horizontal diameter of thoracic cage (2cm)
1. Increase ESTROGEN levels relaxes the chest
cage ligaments to allow for transvers
expansion
2. Costal angle widens
3. Total circumference of the chest cage increase
by 6cm
4. 40% increase in Tidal Volume (even though
diaphragm is elevated, it moves even more
during pregnancy)
iii. Growing fetus increase demand for oxygen on the
mother (this is met easily by increase in tidal
volume)
iv. No change in RR
v. Physiologic dyspnea (75% of women): increased
awareness to breath, does NOT alter ADLs, and is
NOT associated with cough, wheezing or exercise.
c. The Aging Adult: more rigid and hard to inflate
i. Costal cartilages become calcifies (thorax less
mobile)
ii. Respiratory muscle strength declines after age 50
1. Also a Decrease in elasticity in lungs
2. Small airway closure
a. Decreased vital capacity (max air on can
expel)
b. Increase residual volume (air left behind
after forceful expiration)

iii. Histologic Changes: (i.e. gradual loss of intra-alveolar

septa and decreased number a alveoli) less surface
area for gas exchange
1. Increased risk for:
a. Postoperative pulmonary
complications
b. Postoperative atelectasis
c. Infection from a decrease ability to
cough, loss of protective airway reflexes,
and increased secretions
iv. Lung base become less ventilated as a result of
closing off a number of airways
1. Increased risk for dyspnea
5. CULTURE AND GENETICS:
a. Tuberculosis (TB): Number of cases declined for 20 years in
the U.S.
b. Asthma: most common chronic disease in childhood with a
prevalence of 9.5% in children ages 0-17.
i. Cases have increase in the U.S. since 2001.
1. 8.4% (2011)
2. Most common in lower income families
3. Prevalence according to Ethnicity (2010)ethnicity wide increase in prevalence of
Asthma
a. White: 7.8%
b. Black: 11.9%
c. Hispanics: 7.2%
6. INTERVIEW: Health History and Subjective Assessment

a.Cough:
i. Questions to ask/Things to Keep in Mind in an
interview:
1. Do you have a cough?
2. When did it start? Gradual or Sudden?
a. Acute vs. Chronic
3. How long have you had a cough?
a. Acute Cough: 2-3 weeks
b. Chronic Cough: over 2 months
4. How often do you cough? Any special time of
day? Does it wake you up at night?
a. Continuous throughout the day: Acute
illness (e.g. respiratory infection)
b. Afternoon evening (maybe exposure to
irritants at work)
c. Night: Post nasal drip (sinuses)

d. Early morning: Chronic bronchial

inflammation of smokers
5. Do you cough of phlegm or sputum? How
much? What color?
i. Chronic Bronchitis: productive
cough, 3 months of a year, lasts 2
years
b. White or Clear mucoid: colds,
bronchitis, viral infections
c. Yellow or Green: bacterial infection
d. Rust colored: TB, Pneumococcal
pneumonia
e. Pink frothy: Pulmonary edema
i. Some sympathomimetic
medications have a side effect of
pink-tinged mucus
6. Any blood? What does it look like? Oder?
a. Hemoptysis: coughing up blood
7. How would you describe your cough? (Hacking,
dry, barking, hoarse, congested, bubbling).
Type of cough
Sign Of:
Mycoplasma pneumonia, chronic
Hacking
bronchitis
Early
heart failure
Dry
Croup
Barking
Colds, Acute Bronchitis,
Congested
Pneumonia
8. Is your cough correspond with activity, position
(lying), fever, congestion, talking, anxiety?
What makes it better or worse?
9. Have you tried any treatment?
Prescription/Over-the-counter medications,
vaporizer, rest, position change?
10.
Does the cough bring on anything: chest
pain, ear pain? Tiring? Are you concerned
about it?
b. Shortness of Breath: In hospitalized patients
Dyspnea is a common symptom and a predictor of
adverse outcomes.
i. Questions/Things to Consider during interview:
1. Are you having any shortness of breath now?
Within the last few days?

10

2. Ever had any shortness of breath or hardbreathing spells? When did it START? What
brings it on? Severity? How long does it last?
3. Is it affected by position?
a. Orthopnea: difficulty breathing when
supine
4. Occur at specific time? Night/Day?
a. Paroxysmal nocturnal dyspnea
(PND): awakening from sleep with SOB
(Shortness Of Breath) and needing to be
upright to achieve comfort
5. SOB episodes associated with night sweats
(diaphoresis)?
6. Cough, chest pain or bluish color around lips or
nails, wheezing sound?
7. Episodes seem to be related to food, pollen,
dust, animals, season, emotion, or exercise?
a. Asthma aattacks occur with a specific
allergen, extreme cold, anxiety
(Described at chest tightness)
8. What do you do during an episode? Take
special position or purse lip breathing? Oxygen,
inhalers, medication?
9. How does SOB effect your activities? Getting
better or worse or neither? (Assessing ADLs)
ii. People with smoking history, dyspnea, and cough,
you can use the short 5-item questionnaire to
identify who should be asses with spirometry for
chronic obstructive pulmonary disease (COPD). (pg.
424)
Neve Rarel SomeVery
Often
Score
r
y
times
Often
How often do you cough?
How often does your
chest sound noisy
(wheezy, whistling,
rattling) When you
breathe?
How often do you
experience shortness of
breath during physical
activity?
How many years have
you smoked?

1
11

What is your age?

c.

Chest Pain with Breathing: Caused by muscle

soreness from coughing, or from inflammation of pleura

overlying pneumonia.
1. Keep in mind: distinguish from cardiac pain or
heart burn of stomach acid
ii. Questions to Ask
1. Any chest pain with breathing? Point to
location.
2. When did it start? Continuous, intermittent?
3. Burning? Stabbing?
4. Brought on by respiratory infection, coughing,
or trauma? Associated with fever, deep
breathing, unequal chest inflation?
5. What have you done to treat it medication or
heat?
d. History of respiratory infections: Consider
sequelae (a condition that is the consequence of a
previous disease or injury) after these conditions
i. Questions to ask/Things to consider:
1. Any past history of breathing trouble or lung
diseases such a bronchitis, emphysema,
asthma, pneumonia.
2. Any unusually frequent or unusually severe
colds?
a. Meaningful to ask about excess number
or severity (because everyone gets a
cold here and there)

e.Smoking History.
i. Questions to Ask/Things to consider:
1. Do you smoke? What age did you start? How
many packs a day?
2. Have you ever tried to quite? What happened?
Why do you think it didnt work? What
activities do you associate with smoking?
3. Do you live with someone who smokes?
ii. Depending on the stage of the persons readiness to
quit, offer counseling using the 5 As.
1. Ask about his or her tobacco use status at
every visit. Record response.

12

2. Advise. Give clear, nonjudgmental, and

personalized suggestions for quitting.
3. Assess each persons readiness for and
interest in quitting
4. Assist each person with a specific cessation
plan that includes medication, behavioral
modification, exercise programs or referrals.
Encourage a quit date and give support and
feedback.
5. Arrange follow-up visit. If relapse, state that
you are there to help and start over.

f. Environment exposure:
i. Questions/Considerations
1. Any environmental conditions that may affect
your breathing? Where do you work (factory,
chemical plant, coal mine, farming, outdoors in
heavy traffic area)?
2. Do you take protective precautions (i.e. mask)?
Are you examined frequently (pulmonary
function tests, x-ray image)?
3. Do you know which specific symptoms to note
that may signal breathing problems?
g. Patient-centered Care: CDC recommends Flu
vaccine every year for people 6 months and older.
i. Question/Considerations
1. When was your last kin test, chest x-ray study,
pneumonia vaccine, or influenza immunization?
7. The Subjective and objective data that indicate common findings
associated with abnormal conditions.

Condition

Chronic
Bronchitis
Proliferation of mucus
glands in passage
ways, resulting in
excessive mucus
secretion,
inflammation of
bronchi, partial
obstruction of bronchi
(secretions or

Subjective Data

Objective Data
Inspection: Hacking,
rasping cough,
productive (thick
mucoid sputum)
Chronic Dysneya,
fatigue, cyanosis,
possible clubbing of
fingers
Palpation: Tactil
Fremitus is normal
Auscultation:
Prolonged expiration,
adventitious sounds
13

constriction). Usually
caused by smoking.

COPD

Emphysema
Caused by destruction
of Pulmonary
connective tissue;
characterized by
permanent
enlargement of air
sacts distal to terminal
bronchioles and
rupture of
interalveolar calls.
Increase airway
resistance.
Hyperinflated lung,
increase lung volume.
Smokers: 80-90% of
cases

Atelectasis
Collapsed shrunken
section of aveoli or
entire ung as a result
of:
1) airway obstruction;

SOB (ex: after flight

of stairs), Early
morning Cough (w/
sputum),

(crackles over deflated

areas, may have
wheeze)
VS: Hypertension,
afebrile, HR WDL,
elevated respirations
(resting), under weight
Inspection: Barrel
Chest, Tripod, regular
shallow respirations
(accessory muscles),
prolonged expiration,
SOB ambulation,
Palpation: minimal
(symmetric) chest
expansion, Tactil
fremitus (bilaterally),
Auscultation: BS
diminished, wheeze
(expiration,
Inspection: Increased
AP diameter, Barrel
chest, Acessory
muscles used, Tripod,
position, SOB(especialy
on exertion) resp.
distress, Tachypnea
Palpation: Decrease
Tactile Fremitus and
chest expansion
Auscultation:
Decreased Breath
sounds, May have
Prolonged expiration.
Muffled heart sounds,
Adventitious Sounds
(occationally a wheez)
Inspection: Cough. Lag
on expansion on
affected side increased
repiratory rate and
pulse. Possible
cyanosis
Palpation: Chest

14

alveolar air beyond

the obstruction is
gradually absorbed
by the pulmonary
capillaries and
alveolar walls cave
in
2) Compression on
lung
3) Lack surfactant

Pneumonia
Pneumocystis jiroveci
(P. carinii) virulent
form of pneumonia.
Protozoal infection
(associated with AIDS)

Tuberculosis
Caused from
inhalation of tubercle
bacilli into the alveolar
wall:
1) Acute
inflammatory
response
macrophages
engulf bacilli
(dont kill).
Tubercle forms
around bacilli

expansion on affected
side. Tactile Fremitus
decreased or absent
over area. Large
collapse could mean
tracheal shift toward
affected side
Auscultation Breath
sounds Decreased
vesicular or absent
over affected area.
Adventitious sounds
(none if bronchus
obstruction, occasional
fine crackles if
bronchus is patent)
Inspection: Anxiety,
SOB, dyspnea
onexertion, malaise
(common), tachypnea,
fever, dry
nonproductive cough,
intercostal retraction in
children, cyanosis
Palpation: Decreased
chest expansion
Auscultation: BS
decreased,
adventitious sounds
(crackles may be
present often absent)
Initially
Inspection: cough
asymptomatic
initially noproductive,
(positive on x-ray).
later productice of
Progressive TB:
purulent, yellow-green
weight loss,
putum, may be blood
anorexia, fatigability, tinged, Dyspnea,
low-grade afternoon orthopnea, fatigue,
fevers, night sweats, weakness
may have pleural
Palpation: skin moist at
effusion, recurrent
night
respiratory infections Auscultation: Normal or
decreased vesibular
breath sounds,
Adventitious Sounds
(crackles over upper
15

2) Scar tissue forms,

lobes common persist
lesion calcifies and
following full ecpiration
shows on x-ray
and cough
3) Reactivation of
previously healed
lesion. Dormant
bacilli now
multiply,
producing
necrosis, caviation,
and caseous lung
tissue (cheeselike)
4) Destruction as
lesion erodes into
bronchus, forming
air-filled acity
(apex usually most
damaged)
Hyperresonance: Lower pitched, booming sound (too much air is
present)
Anteroposterior (AP) diameter < Transverse diameter (0.70:0.75)
More Conditions:
Condition
Definition
Free
Air
in
Pleural
space
(causes hyperresonance)
Pneumothor

ax
Pulmonary
emoblism

Undissolved materials (thrombus, air bubbles, fat

globules) origninating in legs or pelvis detach and
tracel via venous system, returning blood to
right heart, and lodge to occlude pulmonary
vessels.

8. Techniques for Collecting Objective Data about the Thorax

(anterior and posterior):

a.Anterior:
i. Inspection:
1. Shape and Configuration: ribs sloping
downward, symmetric interspaces, costal angle
within 90 degrees, development of abdominal
muscles (consistant with age, weight, and
athletic condition)
2. Facial expression: Relaxed indicates
unconscious breathing efforts (thats good).
3. Level of Consciousness: alert, cooperative

16

4. Color and Condition: assess lips/nailbeds

(look for cyanosis or unusual pallor), nails
(configuration), skin (lesions?)
5. Respirations: Normal relaxed breathing, no
noise, symmetry, note any localized lag on
inspiration
a. Note use of accessory muscles to breathe
is abnormal, unless in exercise, one may
use calene, sternomastoid, trapezius
muscles to enhance respiration.
6. Respiratory rate: occasional sighs normally
punctuate breathing
ii. Palpation:
1. Symmetric Chest Expansion: place hands along
costal margins, point thumbs toward xiphoid
process, Ask person to breathe deep, watch
your thumbs move apart
2. Tactile (vocal) Fremitus: Vibrations
a. Begin at lung apices (subclavicular areas)
b. Caompar vibrations one side to the other
while patient say 99
c. Avoid female breasts. The breast tissue
damps the sound
3. Palpate anterior chest wall for tenderness:
none should be present
iii. Auscultation
1. Listen from apices to 6th rib

2. Measurement of Pulmonary Function Status:

a. Forced expiratory time:

17

b. Handheld Spirometer: measures lung

health in chronic conditions such as
asthma.
i. Forces vital capacity (FVC) the
total volume of air exhaled
ii. Forced expiratory volume in 1
second (FEV1) the volume exhale
in the first measure second
iii. FEV1/FVC ratio 75% or greater =
no obstruction
c. Pulse oximeter: SpO2: 97%-99%
i. Must be elevated in context of
hemoglobin level, acid-base
balance, and ventilator staus
d. 6-minute walk test (6 MWT): safer,
simpler, inexpensive clinical measure of
gunctional status in aging adults
i. used in pulmonary rehabilitation
ii. find a hallway with little traffic and
make sure patient is wearing
comfortable shoes and pulse ox.
iii. Assess O2 saturation as they are
walking
iv. STOP if below 85% to 88% or upon
extreme breathlessness

b.Posterior:
i. Inspection:
1. Note the shape and configuration of chest
wall
2. Spinous processes should be in a straight line
3. Thorax is symmetric
4. Thorax elliptical shape, downward sloping ribs
(45 degrees from spine)
5. Scapulae symmetrical in each hemithorax
6. AP diameter should be less than transverse
diameter
7. The neck and trapezius muscles, developed
normally for age and occupation
8. Note: position the person takes to breathe
(including a relaxed position)
9. Skin Color and condition
ABNORMAL FINDINGS in Inspection.
Skeletal deformities may limit thoracic cage excursion: scoliosis,
kyphosis (pg. 442)
AP is equal to Transverse Diameter (Barrel Chest)
o Ribs horizontal, chest appears as if held in continuous
18
inspiration
o Found In COPD
Cyanosis

ii. Palpation:
1. Assessing Symmetric Chest Expansion: Place
hands sideways on the posterolateral chest
wall with thumbs pointing together at the level
of T9 or T10. Slide hands medially to pinch up a
small fold of skin between your thumbs

a. Ask the person to take a deep breath

(Note any lag in expansion)
2. Assessing Tactile (vocal) Fremitus (palpable
vibration): Use palmar base of the fingers or
the ulnar edge of one hand and tough the
persons chest while he or she repeats the
words 99 or Blue Moon
a. Symmetry is most important: vibrations
should feel the same in the
corresponding area on each side (avoid
palpating over scapulae, the bone damps
out sound transmission)

19

ABNORMAL FINDINGS in Palpation:

Unequal chest expansion: sign of atelectasis, lobar pneumonia, pleural
effusion, thoracic trauma (fractured ribs or pneumothorax)
o Asymmetry suggest dysfunction, can be assessed further with
the stethoscope
Decreased Fremitus: any barrier that comes between the
sound and your palpating hand decreases fremitus (i.e.
obstructed bronchus, pleural effusion, or thickening,
pneumothorax, or emphysema)
Increased Fremitus: Compression or consolidation of lung
tissue (i.e. lobar pneumonia)
Rhonchal Fremitus: Palpable with thick bronchial
secretionswe are skipping percussion)
iii. (Apparently
iv. Auscultation: Air that passes through the
tracheobronchial tree is an audible sound through
the chest wall.
1. Breath Sounds: Evaluate the presence and
quality of Normal Breath Sounds
a. Position of Patient: sitting, leaning
forward slightly, with arms resting
comfortably across the lap
b. Tell patient to breathe deep through the
mouth, assure them they can stop if they
start to feel dizzy

(pg
429)

20

2. IMPORTANT to be aware of. There are 5

Common background noises that are often
confused with lung sounds. They are:
a. Examiners breathing on stethoscope
tubing
b. Stethoscope tubing bumping together
c. Patient shivering
d. Patients hairy chest (minimize this by
pressing harder or by wetting the hair
with a damp cloth)
e. Rustling of paper gown or paper drapes
3. While standing behind the person, listen to
a. Posterior for apices at C7 to the bases
(around T10)
b. Laterally from the axilla down to the 7th
or 8th rib
4. Characteristics of Normal Breath Sounds

21

ABNORMAL FINDINGS in Auscultation:

Breath sounds changed by obstruction in the passageways or by
disease in the lung parenchyma, the pleura, or the chest wall
Decreased or Absent Breath sounds:
o When brochial tree is obstructed (by secretions, mucus, plug, or
foreign body)
o Emphysema: loss of elasticity in lung fibers and decreased force of
inspired air
Lungs also already hyperinflated inhaled air does notmake
as much noise
o Anything (in the pleural space) that obstructs transmission of sound
between lung and stethoscope i.e. pleurisy, leural thickening, air
[pheumothorax], fluid [peural effusion]
Crackles (Sign of Pulmonary edema, pneumonia, pulmonary, fibrosis, and
the terminally ill who have a depressed cough reflex
Adventitious Sounds: added sounds that are not normally heard in the
lungs. Heard as being superimposed on the breath sounds
o Caused by moving air colliding with secretions in the
tracheobronchial passageways or by popping open of previously
deflated airways
o Crackles (rales) and wheeze (rhonchi) are terms commonly used
by most examiners. There are also sounds called stridor (heard in
the lungs of children with the Croup) and Friction Rubs (the sound
of the plurae rubbing together).
Crackles: discontinuous popping sounds heard over inspiration
Wheezes: continuous musical sounds heard mainly over
expiration
Page 446; table 18-6
9. Respiratory Patterns

22

10.
Normal voice sounds: Can be auscultated over the chest
wall (same pattern used for tactile fremitus)
a. Voice Sounds: not elicited routinely only if you suspect
lung pathology (based on earlier data)
i. Testing for: Bronchophoney, egophoney, and
whispered pectoriloquy
ABNORMAL FINDINGS:
1. Bronchophoney: 99 is more distinct than normal
2. Egophoney: e sounds like a (in Say)
3. Whispered pectoriloquy: a whispered 1-2-3 sounds very clear
and close
4. Consolodation of lung tissue will enhance the voice sounds,
words more Competence:
distinct.
11. maing
Developmental
a. Infants and Children
i. Inspection:

23

1. Barrel Chest after 6 years lead to chronic

asthma or cystic fibrosis
2. Apgar Scoring System

Cardiovascular System (Hear & Neck Vessels) &

Peripheral Vascular System: Chapter 19-20
(Page 459)
a. Cool Facts:
i. Blood Volume= ~5 leters = ~6-5 quarts =1.5 gallons
ii. 1 hear beat pumps ~ 60-80 ml (1/3 cup)
iii. Heart pumps about ~2,000 gallons a day (4-6
liters/min)

2. Position and Surface Landmarks: Cardiovascular system: the

heart (muscular pump), blood vessels
a. Precordium: Area on anterior chest directly overlying the
heart
b. Heart and Great Veins located between lungs and in the
middle third of the thoracic cage (mediastinum)
c. Heart extends from the 2nd to the 5th intercostal space

24

i. Right border of sternum (Base)Left mid clavicular

line

Describe where each heart sound is heard best APETM (All Pigs Eat Too
Much)

1)
2)
3)
4)
5)

Aortic (Right sternal border, 2nd ICS)

Pulmonic (Left sternal border, 2nd ICS)
Erbs (Left sternal border, 3rd ICS)
Tricuspid (Left sternal border, 4th ICS)
Mitral (Left midclavicular line, 5th ICS)

25

PMI (Point of Maximum Impulse): Apical Pulse at the Apex

(landmarks: midclavicular line, fifth intercostal space).
Anatomy and Physiology of CV system

d. Heart Valves

26

i. AV (Atrioventricular): prevent return of blood to

atrium chamber of the heart.
1. Tricuspid (right side) and mitral/bicuspid (left
side) -- Try befor you Buy
a. Open with Diastole (allow ventricles to fill
from Atrium)
b. Closed with Systole (Pumping phase so
no backflow)
ii. Semilunar Valve: heart Valve, shaped like halfmoons; prevents blood from flowing back into the
heart.
e. Cardiac Cycle: The rhythmic movement of blood through
the heart (pg.463) know when valves are open and when
they are closed!!
i. Diastole: The filling phase Ventricles are relaxed
AV open, SL closed
1. 2/3 of cycle is filling (longest)
ii. Systole: Pumping Phase Ventricular contraction
AV open, SL closed
1. Ventricular pressure is higher than atrial
2. AV valves swing shut (S1): beginning of systole
a. Prevents regurgitation into atria during
contraction
3. All 4 valves closed
a. Ventricular walls contract (isometric
contraction) to build pressure inside the
ventricles to a high level
b. Ventricle P > Aorta
i. Aortic valves open
iii. Diastole (again): Atria fills with blood
1. All four valves closed, ventricles relax
(isometric relaxation)
a. Atria fills with blood delivered from lungs
b. Atria Pressure > Ventricular Pressure
iv. Events in the Right and Left Sounds:
1. S1: AV valves close--first Heart sound (begin
systole)
a. M1: Mitral closes
b. T1: Tricuspid closes
c. S1 is loudes at Apex
2. S2: semilunar valves close (end systole)
a. A2: Aortic closes
b. P2: Pulmonic closes
c. S2 is loudest at Base

27

3. Extra Heart Sounds: Bell is best (pg. 464)

a. Third Heart Sound (S3): in Diastole
comes after S2
i. Ventricles resistant to filling
(volume too much, backing up and
developing Heart Failure or Valve
regurgitation)
ii. Lub dub da (Ken Tuck KEY)
b. Diastole Extra Heart Sound (S4): in
Diastole comes before S1
i. Later resistant sound (ventricle too
full, still wall, heart damage
Myocardial infarction (MI))
ii. Lub Dub (TENN a see)
4. Murmurs: Tubulent blood flow
a. Gentle, blowing, wishing sound
b. MURMURS documented
i. Pitch or Frequency (high, low)
ii. Loudness -- Graded 1-6 loud or
soft (intensity)
iii. Timing (systolic or diastolic)
iv. Pattern (grows louder, tapers,
peaks)
v. Quality (rumbling, musical,
blowing harsh)
c. Conditions that cause Murmurs: Dont
need to know these for the test

28

Example
Exercise, thyrotoxicosis

Murmur
Velocity of blood increases

Anemia

Viscosity fo blood decreases

A stenotic or narrowed valve, an

incompetent or regurgitant valve,
dilated chamber, septal defect

Structural defects in the valves (a

stenotic or narrowed valve, an
incompetent or regurgitant valve),
or unusual openings occure in the
chambers (dilated chamber,
septal defect)

3. EKG (Chamber depolarization and repolarization)

4. Subjective Data (pg.471)

a. Chest Pain: COLDSPA
a. Angina: Chest Pain Important cardiac symptom,
occurs when hearts own blood supply cannot keep up
with metabolic demand

29

b.

c.

d.

e.

f.
g.

h.
i.
j.

i. Chest Pain Origin my be found in different areas:

(pg. 493)
1. Pulmonary
2. Musculoskeletal
3. Gastrointestinal
ii. Universal sign of chest pain: Clenched fist to the
chest
1. Men: classic
2. Women: differ (jaw pain, back pain, etc.)
Dyspnea: shortness of breath
i. Dyspnea on exertion (DOE) Quantify exactly
(i.e. after walking two blocks) Paroxymal,
Constant or intermittent, Recumbent
ii. Paroxymal nocturnal dyspnea (PND): occurs
with Heart failure, supine increases volume of
intrathoracic blood, weakened heart cannot
accommodate
1. Typically, After 2 hours of sleep, person
awakens with the need for fresh air
Cough: Any sputum
i. Productive cough, mucoid or purulent.
ii. Hemoptysis: coughing up blood
1. Often pulmonary disorder
2. Does occur with mitral stenosis
Fatigue: tiring easily
i. Unusual fatique is a top prodromal MI symptom
for women
ii. Decrease cardiac output is worse in the evening
iii. Anxiety or depression occurs all day, or worse in
morning
Edema: Swelling
i. Edema: Dependent when caused by heart failure
ii. Cardia edema: worse in evening
1. Better in morning (elevated legs all night)
2. Bilateral; unilateral swelling has local vein
cause
Cyanosis or Pallor: Both occurs with MI or low cardiac
output decreased tissue perfussion
Nocturia: waking up at night to urinate
i. Recumbency at night promotes fluid resorption
and excretion; this occurs with heart failure in
the person who is ambulatory during the day
Past Health History
Family Cardia History
Lifestyle & Health Habits

30

i. Nutrition, Smoking, Exercise, MEDS, stress,

weight, cholesterol, checkup?
5. Preparation for ascultating the heart: Should be review
1. Wash hands
2. Clean Steth
3. Warm and quiet room
4. Privacy
5. Access to chest gown
6. Watch with second hand
7. Stethoscope
8. Patient sitting upright
6. Objective Data Inspection anterior
a. PT in upright sitting position
b. Not skin color
c. Ease of Respirations
d. Not visivle pulsations in neck or chst
e. Neck Vessel Destintion (JVD)
7. Carotid Artery: (pg. 466)
a. Groove between Trachea and
sternocleidomastoid muscle
b. Palpation and Ausculation:
i. Palpate gently and locate
1. Light, apply bell (light: vagal
stimulation could decrease heart
rate)
2. Listen for Bruit (Normal: none)
a. Bruit: Blowing, swishing
sound: turbulence
3. Breathe: Exhale Hold Breath
Breathe
4. Bilateral But WARNING: ONE SIDE
at a time
5. No percussion of arteries! (DUH)

31

8. Jugular Veins
a. Clues about riht side of heart
i. Internal deep
ii. External more superficial
b. Inspection (tells us heart efficiency as a pump and volume
status)
i. Pt in supine position (face up)
ii. Stand on the right side of the pation, ask them to
turn their head slightly to the left
1. Normal: flattened (no JVD) with HOB elevated
(45 degrees)
2. Normal: no palpable venous pulsation
3. If Destension: Unilateral or bilateral?
4. JVD can be measured in cm
iii. Note: Visible neck vein distension while patient is
lying flat is NORMAL
1. Raise the head of the bed, it should disappear
9. The Precordium
a. Inspection: Anterior Chest Precordium

32

i. Pulsation: May be able to see apical impulse (left

ventricle rotating against the chest wall during
systole).
1. 4th or 5th intercostal space at or inside
midclavicular line
2. Easier to see in children
3. Abnormal: Heave or lift: sustained forceful
thrusting of ventricle during systole
a. Ventricle hypertrophy (increased
workload)
b. Right Ventricular Heave: seen at sternal
border
c. Left Ventricular Heave: seen at apex
b. Palpation: Precordium
i. Apical Impulse (can be palpated in 25-40% adults
50-73% in left lateral position) palpate with one
finger.
1. Ask Patint to exhale and hold
ii. Palpation across the Precordium: using palmar
aspects
1. plapate the apex, left sternal borde, and the
base (searching for any other pulsations)
ABNORMAL FINDINGS:
1) Cardiac enlargement
2) Left ventricular dilation (volume overload) displaces impulse
down and to left and increases size more than one space
(Diameter 4cm or greater = dilated)
a. Occurs in Heart failure
b. Occurs in Cardiomyopathy
3) Sustained Impulse: increased force and duration but no
change in location occurs in left ventricular hypertrophy and no
dilation (pressure overload)
4) Palpable vibrations (Thrill)
c. Percussion: Not on the heart
d. Ausculatation
i. Auscultory Areas

33

10. Heart Failure: (pg 495) Signs and Symptoms

a. Shortness of Breath
b. Adventitious Sounds
c. Dissiness
d. Tiredness (fatigue) & weakness
e. Rapid or irregular HR, S3
f. Swelling in ankles, legs and abdomen and weight gain
g. Other: Nausea, palpitations, Chest pain, waking suddenly
at night unable to breath (PND), changes in sleep patterns
h. ** Suggest aspirin
11. Developmental Considerations:
a. Infants and Children (pg. 467)
i. Listen whenever you can (sleeping, quiet)
ii. Functional (innocent) murmurs common
1. Usually change or disappear with position
change
2. REFER ALL MURMURS
iii. Check heart and femoral pulse simultaneously in
infant for delay (coarctation)
iv. Significant History Findings in Infants and Children:
1. Mothers health in pregnancy
2. Cyanosis
3. Growht Chart (delays)
4. Activity
5. Joint pain fever
6. Frequent respiratory infection
7. Family history
b. Elderly: Consider
i. Slow position changes in elderly: Risk orthostatic
hypotension (sudden drop in BP)
ii. BP gradual systolic rise with age
iii. Carefully listen for S3 and S4
iv. Occasional irregular beats common
v. Known cardiac/Respiratory history?
34

vi. Medications
vii. Environment
12. Accurately document findings to determine your patient's

cardiovascular status. ( see examples at the end of the

chapter!)

Chapter 20: Peripheral Vascular System and

Lymphatic System (Pg. 509)
Cool Fact: if laid in line an adults blood vessels would be about
100,000 miles long
1) Arterial Vs. Venous
Venous Filling
Arterial
(deoxygenated blood)
(oxygenated blood)
Veins superficial
Higher Pressure system
Returns blood to heart
Elastic Fibers, tough walls,
stretch with systole and
Skeletal Muscles contract
diastole
UNI-Directional venous valves
HR: Preasure wave (pulse)
2) Lymphatics:
a. Separate vessel system

35

b. Takes extra fluid to blood stream

(drainage system)
c. Lymph nodes clumps of tissue
surrounded by the vessels
d. Superficial and deep
e. Superficial cervical, axillary,
epitrochlear, and inguinal
f. HEENT & GI class
3) Peripheral Vascular Assessment:
a. Subjective: History
i. Leg Pain or cramps
1. Peripheral vascular
disease (PVD): blood
flow cannot match
demand during
exercise (muscle
fatigue or pain when
walking claudation)
2. Claudation Distance:
number of blocks
walked or stair climed
to produce pain.
ii. Skin Changes on arms or
legs
1. Color change
2. Hair loss
3. Temp (symm)
4. Sores/ulcers (leg ulcers with chronic arterial
and venous disease)
iii. Swelling in arms or legs
1. Edema: bilateral when the cause is generalized
(heart failure)
a. Unilateral when it is the result of local
obstruction/inflammation
iv. Lymph node enlargement: occur with infection,
malignancies, and immunologic disease
v. Medications?
1. May cause hypercoagulable state
2. Low-dose aspirin or clopidogrel are used to
prevent blood clots in selected people
vi. Smoking?
1. Tobacco Causes all of the following
a. constricts arteries
b. increases coagulability
c. injures endothelium
36

d. promotes inflammation
2. Strongest risk for PAD
3. Starting 16 yrs and under, 2x risk
b. Objective
i. Inspect and palpate the Arms:
1. Note color skin and nail beds; temperature,
texture, and turgor of skin; present of any
lesions, edema or clubbing
a. Lift both patients hands in yours, inspect
and turn
b. Pofile sign: view finger from the side
detects early clubbing
2. Capillary refill:
a. Make sure patients hand is level with
heart
3. Symmetry
4. Presence of scars (hands/arms)
5. Grading a Pulse on 3 point Scale:
a. 3+: Increased, Full, Bounding
i. Abnormal finding: occurs with
hyperkinetic states (exercise,
anxiety, fever), anemia, and
hyperthyroidism
b. 2+: Normal
c. 1+: Weak
i. Abnormal Finding: With shock and
PAD (Peripheral Arterial Disease)
d. 0: Absent
6. Collateral Circulation:
a. Allen Test (explained later)
ii. Inspect and palpate the Legs
1. Symmetry:
a. Inspect both legs together: note color,
hair distribution, venous pattern, size
(swelling/atrophy), any lesions/ulcers
i. Abnormal:
1. Pallor: vasoconstriction
2. Erythema: vasodilation
3. Cyanosis: decrease tissue
perfusion
4. Malnutrition: thin, shiny,
atrophic skin; thick ridged
nails, loss of hair; ulcers;
gangrene
a. Pallor, coolness
(arterial insufficiency)
37

b. Measure circumference (note location of

any abnormality)
i. Asymmetry:
1. 1-3cm: mild lymphedema
2. 3-5cm: moderate
lymphedema
3. >5cm: severe lymphedema
c. Temperature
d. Pulses:
i. Femoral (groin)
1. Abnormal: bruit occurs with
turbulen blood flow (indicates
partial occlusion)
ii. Popliteal (behind knee)patient
supine or prone
iii. Posterior tibial (posterior to ankle)
iv. Dorsal pedis pulse (on the tarsals)
e. Pretibial edema: Abnormal
i. Grading
1. 1+, Mild pitting, slight
indentation, no perceptible
swelling of the leg
2. 2+, Moderate pitting,
indentation subsides rapidly
3. 3+. Deep pitting, indentation
ramins for a short time, leg
looks swollen
4. 4+, Very deep pitting,
indentation lasts a long time,
leg is grossly swollen and
distorted
ii. If bilateral: examine neck veins
1. Distention of neck veins:
peripheral edema may be
related to heart disease
2. Normal neck veins: other
complications (i.e. liver
disease, nephrosis, chronic
venous insufficiency,
antihypertensive or hormonal
medication)
iii. Color changes
1. If you suspect arterial deficit, raise legs about
30 cm (12 inches) drains off venous blood so
you can inspect coloration due to arterial
blood.
38

a. Normal:
i. Light skinned: little pale but still
should be pink
ii. Dark skinned: soles should reveal
extreme color change
iv. The Doppler ultrasonic Probe (pg. 525)
1. Only way to be sure of Varicosities.
a. Palpation is unreliable b/c varicosities
occure below or between even
competent valves
v. The Ankle and Brachial Index (dont think we need to
know)
vi. The Wells Score for Leg Deep Bein Thrombosis:

COLDSPA symptom: Legs Pain (PAD, PVD)

Arterial
Venous
(oxygen deficit)
(metabolic waste build-up)
Deep muscle pain, calf, foot
Calf, lower lef
Cramp, numb, tingling,
Arching, tired, fullness
throbbing
(chronic)
Acute or chronic, onset with
Sharp, tender (acute)
walking, exertion
Worse long standing
Better: rest or elevation
Better: rest elevation,
Cool, pale skin, hairless,
walking
maybe loss of pulse
Edema (brawny), red,
Intermittent claudication
warmth, varicosities
(untx
Weeping ulcers

39

neuro/muscular/vascular/tiss
ue damage)
*Neuropathic: pain and sensation decrease
4) Assessing Pulses
a. Carotid
b. Brachial
c. Radial
d. Femoral
e. Popliteal
f. Posterior Tibial (medial)
g. Dorsalis pedis (lateral to tendon
of big toe)
5) Assessing extremities:
a. Inspection:
i. Color
ii. Size
iii. Symmetry
iv. Nails
v. Hair
vi. Varicosities
vii. Bulges
viii. Vascular patterns
ix. Lesions or ulcers
b. Palpation:
i. Compare Bilaterally
ii. Symmetry in size, shape, color
iii. Temperature (back of hand)
iv. Condition (skin, nail bed, hair distribution)
v. Pulses
vi. Edema (see skin assessment)
vii. Measurements
viii. Capillary Refill (<2-3 seconds)
6) PVS Assessment Mneumonic:
a. Please Make Sure To Chart
i. Pulses
ii. Movement
iii. Temperature
iv. Color and or Capillary Refill
b. Always look for symmetry
7) Edema:
a. Check for pretibial edema, Press firm for 5 seconds, release
i. Normal: no indentation
b. Pitting Edema (pg 523)
i. Bilateral (generalized; fluid overload)
ii. Unilateral (obstruction or inflammation)
40

8) Allen Test:Used to evaluate the adequacy of collateral

circulation

13.

a. Prior to arterial stick (check for adequacy of collateral

circulation)
b. ABNORMAL: Pallor persistes, or sluggish reutn to color
suggests occlusion (reduced blood flow due to
atherosclerosis) of the collateral arterial flow. Avoid radial
artery annulation until adequate circulation is shown.
Ulcers: Venous vs. Arterial
Venous Stasis
Arterial (Ischemic) Ulcer
Ulcer
Subjecti Aching Pain
Deep muscle pain,
ve Data
below knee
lower calf or foot
Worse standing, Pain with walking
may itch
(claudication)
Objectiv Firm, Brawny
Cool, pallor, diminished
e Data
edema
pulses
Normal Pulses
Thin, shiny skin, hairless
toe
Ulcer uneven

Thick nails
edges
Ulcer: well defined
edges, punched out
look

41

a. Venouse Stasis Ulcer: After Acute or chronic incompetent

vlaves in deep veins. Venous ulcers account for 80% of
lower leg ulcers
i. Occur at medial malleolus and are

ii.

Characterized by: bleeding, uneven edges.

(because blood is getting there, but not oxygen)
b.Arterial (Ischemic) Ulcer: Buildup of fatty plaques on
intima (atherosclerosis chronic gradual build up of
fatty streaks, fibroid plaque, calcification of vessel
wall, and thrombus formation in that order) plus
harden, calcification of arterial wall (arteriosclerosis)
iii. Occur at toes, metatarsal heads, heels, and lateral
ankle.
i. Characterized by: Pale ischemic base, well defined
edges and no bleeding (b/c decreased tissue
perfusion)
14. DVT (Deep Vein Thrombophlebitis)
a. Vein occlusion by thrombus (clot)
b. Risk: Bedrest (>3 days), trauma, varicosities
c. Subjective: sudden onset, sharp, deep muscle pain
d. Objective: Warmth, swelling, redness, tender to palpation
i. Risk: embolism

15. Aneurysm (pg. 535)

i. A sac formed by dilation in the artery wall

42

ii. Atheroclerosis (most common cause) weaken middle

layer (media) of vessel wall
iii. Stretches inner and outer
layers (intima and
adventitia)
iv. Effect of blood pressure
creates balloon
enlargement
b. Most COMMOM sites: Aorta or
Cerebral
c. Highest at risk:
i. Men over 55
ii. Women over 70
d. Symptoms vary
i. Serious: can be deadly!
16. Common ABNORMALITY: Phlebitis & Thrombophlebitis
a. Thrombophlebitis: inflammation of the wall of a vein with
associated thrombosis, often occurring in the legs during
pregnancy.
b. Phlebitis: Inflammation o f vein
i. IV infiltration or irritation
ii. Often with thrombosis (clot) - Thrombophlebitis

17. Thrombophlebitis vs DVT:

43

a. Thrombophlebitis: more superficial

b. DVT: Deep
18.
Developmental Considerations (children and aging adult)
PVS and Lymphatic system:
a. Infants and Children: Pulse force should be normal and
symmetric (same in upper and lower extremeties)
i. Palpable lymph nodes: often in healthy infants and
children
1. Small, firm, mobile, nontender
2. May be sequelae from
a. past infection
b. vaccines
3. Still not location and characterics (local or
generalized)
ABNORMAL FINDINGS:
Weak pulses: vasoconstriction of diminished cardiac output
Full, bounding pulses occur with patent ductus arteriosus from
the large left-to-right shunt
Diminished or Absent (femoral Pulse): while upper extremity
pulses are normal (coarctation of aorta)
Enlarged Tender Nodes: current infection

b. Aging adult: DP and PT pulses may become more difficul to

find.

i. Trophic changed associated with arterial insufficiency

1. Thin
2. Shiny skin
44

3. Thick-ridged nails
4. Loss of hair on lower legs
ii. All occur normally with Aging.
ABNORMAL FINDINGS:
Generalized Edema: suggests heart disease
Hypertension: suggests preeclampsia (dangerous obstetric
condition)

45