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Inspect for nasal flaring and pursed lip breathing
abnormal: nasal flaring is seen with labored respirations and is indicative of hypoxia. Pursed lip breathing may be seen in asthma, emphysema, of CHF as a physiologic response to help slow down expiration and keep alveoli open longer.
observe color of face, lips and chest.
abnormal: ruddy to purple complexion may be seen in clients with COPD or CHF as a result of polycythemia. Cyanosis may be seen if client is cold or hypoxic.
Inspect color and shape of nails.
pale or cyanotic nails may indicate hypoxia. Clubbing(180, >180) can occur from hypoxia.
Inspect configuration
Abnormal:Spinous process that deviate laterally in the thoracic area may indicate scoliosis. Spinal configurations may have respiratory implications. ribs appearing horizontal at an angle greater than 45 degrees with spinal column are frequently the result of an increased ratio between anteroposterior-transverse diameter(barrel chest) common result of emphysema due to hyperinflation of the lungs.
Observe use of accessory muscles
Abnormal:trapezius or shoulder, muscles are used to facilitate inspiration in cases of acute and chronic airway obstruction or atelectasis.
Inspect the client's positioning.
Client leans forward and uses arms to support weight and lift chest to increase breathing capacity (tripod position), often seen in COPD.
Palpate for tenderness and sensation
abnormal: tender or painful areas may indicate inflamed fibrous connective tissue. Pain over the intercostal spaces may be from inflamed pleurae. Pain over the ribs, especially at the costal chondral junctions is a symptom of fractured ribs.
Palpate for crepitus(subcutaneous emphysema is a crackling sensation- like bones or hairs rubbing against each other that occurs when air passes through fluid or exudate.
Abnormal: crepitus can be palpated if air escapes from the lung or other airways into the subcutaneous tissue as occurs after an open thoracic injury, around chest tube or tracheostomy. May be palpated in areas of extreme congestion or consolidation
Palpate surface characteristics
abnormal: any unusual palpable mass should be evaluated further by a physician.
Palpate for fremitus"ninety-nine)
abnormal: unequal fremitus is usually the result of consolidation(which increase fremitus) or bronchial obstruction air trapping in emphysema, pleural effustion or pneumothorax. Diminished fremitus may indicate an obstruction of the tracheobronchial tree.
Assess chest expansion(T9orT10)
abnormal: unequal chest expansion can occur with severe atelectasis(collapse or incomplete expansion), pneumonia, chest trauma, or pnemothorax(air in the pleural space)
Percuss for tone
abnormal: hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space such as in lobra pneumonia, pleural effusion or tumor.
Percuss for diaphragmatic excursion (T7)
abnormal: diaphragmatic descent may be limited by atelectasis of the lower lobes or by emphysema in which diaphragmatic movement and air trapping are minimal. Diaphragm remains in low position on inspiration and expiration.
Auscultate for breath sounds(lungs at C7 to the bases of the lungs at T10  and laterally from the axiall down to 7th/8th rib)
abnormal: diminished or absent breath sounds often indicate that little or no air is moving in or out of the lung area being auscultated. indicate obstruction of the lungs, also indicate abnormalities of the pleural space such as pleural thickening, pleural effusion, or pneumothorax. Increased/louder sound often occur when consolidation or compression results in a denser lung area that enhances the transmission of sound.
auscultate for adventitious sounds
abnormal: lung sounds such as crackles[rales] and wheezes[rhonchi]
auscultate voice sounds bronchophony-"ninety-nine"
abnormal: words are easily understood and louder over areas of increased density.
Egophony: letter "E"
abnormal: over areas consolidation or compression the sound is louder and sounds like an "A"
Whispered Pectoriloquy: "one-two-three"
abnormal: over areas of consolidation or compression, the sound is transmitted clearly and distinctly. In such areas, it sounds as if the client is whispering directly into the stethoscope.
Anterior Thorax: Inspect for shape and configuration
anteroposterior equals transverse diameter = barrel chest, often seen in emphysema because of hyperinflation of the lungs.
Inspect position of the sternum; watch for retractions
pectus excavatum markedly sunken sternum and adjacent cartilages(funnel chest) Pectus carinatum is a forward protursion of the sternum causing the adjacent ribs to slope backward(pigeon chest)
Inspect slope of the ribs
abnormal: barrel-chest configuration results in a more horizontal position of the ribs and costal angle of more than 90 degrees, results from long-standing emphysema
observe quality and pattern of respiration
abnormal: labored and noisy breathing is often seen with severe asthma or chronic bronchitis. Abnormal breathing patterns include tachypnea, bradypnea, hyperventilation, hypoventilation, cheyne-stokes respiration and biot's respiration
inspect intercostal spaces
abnormal: retraction of the intercostal spaces indicates an increased inspiratory effort, result of an obstruction of the respiratory tract or atelectasis. Bulging of the itnercostal spaces indicates trapped air such as emphysema or asthma.
observe for use of accessory muscles
abnormal: neck muscles in cases of acute or chronic airway obstruction or atelectasis. Abdominal/internal intercostal muscles are used in COPD.
Palpate for tenderness sensationm and surface masses.
tenderness over thoracuc mucles can result from exercising, or sedentary client.
palpate for fremitus
diminished vibrations, even with a loud spoken voice, may indicate an obstruction of the tracheobronchial tree.
palpate anterior chest expansion:
unequal chest expansion can occur with severe atelectasis, pneumonia, chest trauma, pleural effusion or pneumothorax
percuss for tone
abnormal: hyperresonance, dullness
Auscultate for anterior breath sounds, adventitious sounds, and voice sounds
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