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NSG 5512
Assessment of the Chest and Lungs
Patsy Riley, DSN, CRNP, Diane Weed, Ph.D CRNP

History of Present Illness

Common complaints
Cough, Shortness of breath, Chest pain, Coughing up blood

Review Risk Factors for Lung Disease

ASSESS: Seidel p.365 personal/social history
- type of material smoked, mode, pack years, exposure to secondhand smoke,
attempts to quit smoking, p. 153 Goolsby
Preexisting conditions, Genetic disorders, Environmental factors
Irritants, exposure to pathogens, altitude, humidity, Temperature, Psychosocial factors
Other
Immobility, surgery, tube feedings, CHF ,thrombophlebitis, age related changes

Cough: HPI, 364, 388, 398 Goolsby 157, 161

Onset
Acute
Chronic
Work history
Smoker pack year history
Recent exposure
History of lung disease
Time of day, Recent travel, exposure
Medication induced cough, psychogenic cough
Quality
Dry, productive, wheezy, strong, weak, brassy or harsh
Quantity
Frequency
Does it keep them from going to sleep at night?
Does it wake them up during the night?
Location
Precipitating or alleviating factors
Exercise, cold air, laughing, environmental irritants (e.g., cigarette smoking,
second-hand smoke) GERD, Postnasal drip, Taking a deep breath, ACE inhibitors
Alleviating factors
Getting up, walking around, OTC meds, MDI, Humidifier, Hard candy
Associated manifestations
Hoarseness, Last TB skin test, Night sweats, weight loss,Heartburn, sour taste in
mouth (GERD),Muscles aches, fever, rhinitis, Chest pain, dyspnea
Sputum production
Clear/white, Yellow/ green/ gray, Gray,Rust-colored, Pink, frothy

Cough: Physical Exam

VS including temp, weight
Inspect: cyanosis- mucous membranes, skin, difficulty breathing, use of axillary
muscles, finger clubbing, TMs, JVD
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Palpate : sinus tenderness, lymphadenopathy, tactile fremitus
Percuss: hyperresonance, dullness
Auscultate: heart, lungs

Cough: Differential Dx
Environmental irritants
Cigarette, cigar, pipe smoking, Pollutants. Dust, Lack of humidity
Upper respiratory problems
Rhinitis: chronic or acute, Chronic sinusitis, Pharyngitis, Laryngeal cancer
Lower respiratory tract problems
Asthma, Acute bronchitis,Chronic bronchitis, (COPD),Interstitial lung disease
Pneumonia, Bronchiectasis, Congestive heart failure Lung cance, rTB
Medication-induced cough from ACE inhibitors
Extrinsic compression lesions
Adenopathy,Malignancy, Aortic aneurysm
GI problems such as GERD
Genetic problems such as cystic fibrosis

Dyspnea
Subjective sensation of uncomfortable breathing, the feeling of being unable to get
enough air Goolsby, p.162
“I can’t get my breath” “I’m short of breath” “I have trouble getting my wind” I
can’t…………breathe” “I need air”

Dyspnea: Acute
Focus on immediate situation and respiratory assessment:
Onset, Foreign body obstruction Goolsby p.163, History of lung disease, Allergies

Causes:
Foreign body obstruction, Anaphylactic reaction, Dyspnea with chest pain: Spontaneous pneumothorax,
Pulmonary embolus, MI, Severe anemia of acute onset, Anxiety or panic disorder

Dyspnea: HPI
Onset, Quality, Quantity, Location, Precipitating or aggravating factors
Alleviating factors, Associated manifestations

Onset
Acute or Chronic
Work history Smoker - pack year history, exposure History of lung disease
(asthma, croup, COPD) Allergies Time of day (PND, GERD) Travel, exposure
Quantity
Frequency, Does it keep them from going to sleep at night?
Does it wake them up during the night?, Does it interfere with normal activities?
Does it keep them from doing things they want to do?, Progression over time
Precipitating or alleviating factors
Exercise or activity , Cold air, Talking, Environmental irritants (e.g., cigarette
smoking, second-hand smoke), Stress, Beta blockers or calcium channel blockers
Alleviating factors
Getting up, walking around, Sitting up, leaning forward, Rest
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OTC meds, MDI, Humidifier, Sitting in front of a fan, Heimlich maneuver
Associated manifestations
S/S anaphylactic reaction, S/S congestive heart failure, edema
GERD, Inactivity, fatigue, somnolence, Muscles aches, fever, rhinitis
Chest pain and dyspnea
Hx of thrombophlebitis or taking OCTs
Advanced pregnancy, ascites
Dyspnea: PE
VS including temp, weight
I: cyanosis- mucous membranes, skin, difficulty breathing, use of axillary muscles,
finger clubbing, TMs, JVD, position
P: lymphadenopathy (include supraclavicular nodes)
P: hyperresonance, dullness
A: heart, lungs

Dyspnea: Differential DX
Acute or recurrent
Asthma, Pulmonary emboli, Hyperventilation anxiety, Poor physical conditioning,
Foreign body obstruction, Pulmonary edema, Pneumothorax, Obstructive lung
diseases
Restrictive lung diseases

Chest Pain: HPI p.365

Onset, Quality, Quantity, Location, Precipitating or aggravating factors, Alleviating

factors, Associated manifestations
Onset, very important, what activity before the onset?
Location, very important, moving?, localized?
Quality
Aching, pressure, sharp, stabbing, burning
Quantity
Pain scale
Does it interfere with activities
Constant or intermittent
Precipitating or alleviating factors
Alleviating factors
Associated manifestations
Dyspnea. Sputum production, Sweating, diaphoresis, nausea, vomiting, History of
cancer

Chest Pain: PE
Thorough heart and lung assessment

Chest Pain: Differential DX

Onset
Acute
Cardiac
Pulmonary causes:
Pulmonary emboli, Spontaneous pneumothorax
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Other p.364 Clinical pearl..young adult with cocaine use
GERD, Esophageal spasm
Pleuritic Pain, Goolsby 165-166

Onset
Chronic
Pulmonary causes:
Micropulmonary emboli, TB, Lung cancer, Costochondritis

Hemoptysis: HPI Goolsby p.165

Onset-
How long have you noticed blood
Quality
Color: rust colored, bright red, blood-tinged (pink), pink and frothy
Quantity
How often, recurrent? How much
Location
From lung or stomach ?
Precipitating or alleviating factors
What brings on the coughing up of blood? Vomiting? Coughing? Nausea?
Women of child-bearing age: do you use oral contraceptives?
Associated manifestations
Hoarseness
Last TB skin test
Night sweats, weight loss
Heartburn, sour taste in mouth (GERD)
Muscles aches, fever, rhinitis
Chest pain, dyspnea
Hemoptysis: PE
Inspect
Skin pallor, pale conjunctiva, listen to voice, sputum sample
Palpate
Tactile fremitus
Percuss
Dullness
Auscultate
Adventitious sounds

Hemoptysis: Differential Dx
Hemoptysis or hematemesis? Pulmonary embolus, Lung cancer, Laryngeal cancer
Congestive heart failure, Pneumonia/ inflammatory process, GI – esophagitis, ulcer,
esophageal varices

Review Anatomy Seidel 357-362,

Left and right mainstem bronchi
Left lung
Right lung

Review Anatomical Landmarks, p 362, 361, 367, 369

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Sternomanubrial angle (angle of Louis)
Midsternal line
Midclavicular line
Midaxillary line
Vertebral line
Scapular line
Assessment: Inspection
Facial expression
Positioning
Skin
Shape of chest
Posterior thorax
Anterior thorax
Symmetry of expansion

Abnormal findings
Tripod position
Cyanosis/ruddy complexion
Asymmetrical expansion
Chest wall deformities: p.368, Colyar 83
Pectus excavatum,
Pectus carinatum
Barrel chest
Kyphoscoliosis

Abnormal findings p.372

Altered breathing pattern:
Bradypnea
Tachypnea
Apnea
Hyperpnea
Kussmaul’s respirations
Obvious shortness of breath
Difficulty talking in full sentences
Retractions
Bulging of IC spaces
Nares flaring
Pursed lip breathing

Assessment: Palpation
Symmetry of expansion
Tactile fremitus
Chest wall tenderness

Abnormal findings:
Asymmetrical expansion
Increased tactile fremitus
Decreased tactile fremitus
Tracheal deviation
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SQ emphysema, crepitus

Assessment: Percussion, p377-381

Percussion tones, p.377
Resonance
Diaphragmatic excursion

Assessment: Percussion
Abnormal Findings
Hyperresonance
Decreased resonance
Increased tactile fremitus
Decreased tactile fremitus
Assessment: Auscultation p.381-387
Speech
Audible respiratory sounds
Normal breath sounds
Bronchial
Bronchovesicular
Vesicular
Abnormal breath sounds 384-386
Adventitious sounds
Infants
Apgar score
Acrocyanosis
Stridor
Common abnormalities
p. 397-398 399-413
Older adults
Decreased chest expansion
Infants and Children
Important assessment information Box 12-11 p.394
Clubbing==think about CV or GI disorders
The end!