Neck, Thorax and Lung Assessment

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PHYSICAL EXAMINATION OF NECK
ANATOMY OF NECK
·         It includes muscles, lymph nodes, trachea, thyroid gland, carotid arteries and jugular veins.
·         Sternocleidomastoid muscles which divide the neck into two triangles. Anterior and posterior triangles.
·         The trachea, thyroid gland, anterior cervical nodes and carotid artery runs parallel to the muscles.
·         The posterior lymph nodes within the posterior triangle.
·         Lymph nodes in the neck that collect lymph from the head and neck structures are grouped serially and referred to as Chains.
Lymph nodes of the head and neck
 Head  
·         Occipital                                  At the posterior base of the skull
·         Post auricular (mastoid)          behind the auricle of the ear or in front of the mastoid process          
·         Preauricular                            In front of the tragus of the ear

Floor of the Mouth
·         Submandibular_                       Along the medial border  of the lower jaw, halfway between the triangle of the jaw and chin
·         Submental-                              Behind the tip of the, mandible in the midline, under the chin.
Neck
·         Superficial Cervical Chain      Along the anterior to the Sternocleidomastoid muscle 
·         Posterior cervical chain          along the anterior aspect of the Trapezius muscle
·         Deep cervical chain                Under Sternocleidomastoid muscle
·         Supraclavicular                   The angle between  the clavicle  and the sternocleidomastoid  muscle

ASSESSING THE NECK
Assessment of the neck observed during usual care and may be recorded by persons.
Equipment: none.
1. Explain the procedure to the client
2. Take co-operation from the client.
3. Observe appropriate infection control procedures.
4. Provide client privacy.
Assessment of neck muscles
Inspect the neck muscles for abnormal swelling or masses.
Ask the client to hold the head erect.

Normal findings:
Muscles equal in size; head centered.

Observe the head movement.
Ask the client to move the chin to the chest.
Move the head back so that the chin points upward (to determine the functions of Trapezius muscles.)
Co- ordinated, smooth movements with no discomforts.

Head flexes 45۠

Head laterally Flexes 70۠

Assess the muscle strength.
Ask the client to turn the head to one side against the resistance of your hand.
Repeat with other side.

Equal strength.

Shrug the shoulders against the resistance of your hands

Equal strength

Assessment of lymph nodes


Palpate the entire neck for enlarged lymph nodes
Palpating neck lymph nodes
·         Face the client, and bend the client’s head forward slightly or toward the side being examined to relax the soft tissue and muscles.
·         Palpate the nodes using the pads of the fingers. Move the fingertips in gentle rotating motion
·         When examining the sub mental and submandibular nodes, place the finger tips under the mandible on the side nearest the palpating the hand, and pull the skin and subcutaneous tissue laterally over the mandibular surfaces so that tissue rolls over the nodes.
·         Palpate subclavicular nodes: ask patient to bend forward and relax shoulders. Palpate by hooking index and third finger over clavicle lateral to sternocleidomastoid muscle
Not palpable.


Assessment of Trachea


Palpate the trachea for lateral deviation. Place your finger tip or thumb on the trachea in the suprasternal notch, and then move your finger laterally to the left and right in spaces bordered by the clavicle, the anterior aspect of the sternocleidomastoid muscle, and the trachea.
Central placement in midline of neck, spaces are equal on both sides.

Assessment of Thyroid gland


Inspect the thyroid gland.
·         Stand in front of the client.
·         Observe the lower half of the neck overlying the thyroid gland for symmetry and visible masses.
·         Ask the client to hyperextend the head and swallow, if necessary, offer a glass of water to make it easier for the client to swallow.

Not visible on inspection.



Gland ascends during swallowing but is not visible.








Thyroid gland
Palpate the thyroid gland for smoothness. Note any areas of enlargement, masses or nodules.
Findings: Lobes may not be palpated.
·         Stand in front of or behind the client, and the client to lower the chin slightly. Lowering the chin relaxes the neck muscles, facilitating the palpation.
Posterior approach:
·         Place hands around the client’s neck, with your finger tips on the lower half of the neck over the trachea.
·         Ask the client to swallow (taking a sip of water if necessary), and feel for any enlargement of the thyroid isthmus as it raises.
·         To examine the right thyroid lobe, have the client lower the chin slightly and turn the head slightly to the right.
·         With your finger displace the trachea slightly to the right. With the right fingers palpate the right thyroid lobe. 
·         Repeat the last step, in reverse to examine the left thyroid lobe.
·         If enlargement of the gland is suspected, auscultate over the thyroid area for a bruit sound created by turbulent blood flow.
·         Use the bell shaped diaphragm of the stethoscope.
Normal findings: absence of bruit.
Document the findings in the client record.

Anterior approach
·         Place the tips of your index and middle fingers over the trachea,
·          Palpate the thyroid isthmus as the client swallows.
·          To examine the right thyroid lobe, have the client lower the chin slightly to the right. With the right fingers displace the trachea slightly to the client’s right.
·          With the left fingers, palpate the right thyroid lobe. To examine the left thyroid lobe, repeat it other way reverse.
·         If enlargement of the gland is suspected, auscultate over the thyroid area for a bruit (a soft rushing sound created by turbulent blood flow) use the bell of the stethoscope.
·         Document findings. 
Thorax and lungs
·         Assessing the thorax and lungs is frequently critical.
·         To assessing the client’s aeration status.
·         The client posture is very important.
·         Health History:  History of allergies
·         H/o smoking, H/o of lung disease in family
·         H/o of frequent and chronic respiratory infections
·         H/o of chest pain or any trauma



Chest shape and size- In adults the thorax is oval. Its anteroposterior diameter is half its transverse diameter. There are several deformities in the chest.
Pigeon chest a deformity caused by Rickets. The characteristics of Pigeon chest are:
·         Narrow transverse diameter,
·         Increased  anteroposterior diameter,
·         Protruding sternum

Funnel chest: It is due to a congenital defect. Characteristics are:
·         Opposite to the pigeon chest.
·         Sternum is depressed.
·         Narrowing of anteroposterior diameter.

Barrel chest: It is seen in clients with thoracic kyphosis and emphysema.

Thoracic kyphosis is an excessive convex curvature of the thoracic spine. The characteristics are: The ratio of the anterioposterior diameter to transverse diameter is 1:1.
NORMAL BREATH SOUNDS
·         Vesicular
·         Broncho- vesicular
·         Bronchial( tubular)
Bronchial breath sound- Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra.
 Bronchial (tubular)
High-pitched, loud, "harsh” sounds created by air moving through the trachea. They located in anteriorly over the trachea; not normally heard over lung tissue. They are louder than vesicular sounds; have a short inspiratory phase and long expiratory phase (1:2 ratio)
Bronchovesicular breath sound- 1st, 2nd intercostal space beside of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung. Moderate intensity and moderate- pitched “blowing” sounds created by air moving through larger airway (bronchi). They locate in between the scapulae and lateral to the sternum at the first and second intercostal spaces
Characteristics: equal inspiratory and expiratory phases (1:1 ratio).
Vesicular breath sound- Most area of lungs. It is soft- intensity, low- pitched,
“Gentle- sighing” sounds created by air moving through smaller airways (bronchioles and alveoli). They locate over peripheral lung and also heard t base of lungs. Characteristics: Best heard on inspiration, which is about 2.5 times longer than the expiratory phase (5:2 ratio)
ASSESSING THE THORAX
First nurse should examine the posterior chest, then the anterior chest.
Position:  sitting or lying for anterior chest examination. Sitting position preferred because it maximizes the chest expansion. Good lighting is very essential.
EQUIPMENTS
·         Stethoscope
·         Skin marker/pencil
·         Centimeter ruler
Explain the procedure to the client. Wash the hands. Provide client privacy. In women, drape the anterior chest when is not being examined.
Enquiry the client has any history of the following:
·         Family history of illness including cancer, Allergies
·         Tuberculosis
·          Lifestyles habits such as smoking
·          occupational hazards
·         Any medications can being taken, Swelling, wheezing, coughs, pain
Assessment of Posterior thorax
Inspect the shape and symmetry of the thorax from posterior and lateral views.

Normal findings:
Anteroposterior to transverse diameter in ratio of 1:2

Inspect the spinal alignment for deformities.
Have the client stand.
From a lateral position, observe the three normal curvatures; cervical, thoracic and lumbar
      To assess the lateral deviation of spine (scoliosis). Observe the standing client from the rear.
      Have the client bend forward at the waist and observe from behind.

Spine vertically aligned


Spinal column is straight, right and left shoulders and hips are at same height
For clients who have no respiratory complaints, rapidly assess the temperature and integrity of all chest skin

Skin intact; uniform temperature.

For clients who do have respiratory problems, palpate all chest areas for bulges, tenderness or abnormal movements.

Avoid deep palpation for pain full areas, especially if a fractured rib is suspected.


Chest wall intact.

No tenderness.

 No masses.

Palpate the posterior chest for respiratory excursion.
Place the palms of both your hands over the lower thorax with your thumbs adjacent to the spine and your finger stretched laterally
Full and symmetric chest expansion.

Ask the client to take deep breath while you observe the movement of your hands and any lag in movement.

When the client takes a deep breath, your thumb should move apart an equal distance and at the same time;
Normally the thumbs separate 3 to 5 cm during deep inspiration.

Palpate the chest for vocal (tactile) fremitus.
The faintly perceptiable vibration felt through the chest wall when the client speaks

Bilateral symmetry of vocal fremitus.
 Fremitus is heard most clearly at the apex of the lungs.

Place the palmar surfaces of your fingertips or the ulnar aspect of your hand or closed fist on the posterior chest, starting near the apex of the lungs.

Low- pitched voices of males are more readily palpated than higher pitched voices of females.


Palpation
Thoracic expansion- Massive hydrothorax, pneumonia, pleural thickening, atelectasis 
Vocal fremitus (tactile fremitus)
Pleural friction fremitus-Cellulose exudation in pleura due to pleurisy, Tuberculosis, pleurisy, uremia, pulmonary embolism  
Ask the client to repeat such words as ”blue moon or “One, two, three.”
Repeat the two steps, moving your hands sequentially to the base of the lungs. Compare the fremitus on both lungs.
Abnormal findings: Increased fremitus (associated with consolidated lung tissue, as seen in pneumonia).
Decreased or absent fremitus seen in pneumothorax.
PERCUSSION OF POSTERIOR THORAX
Percuss diaphragmatic excursion. Complete the findings at each point with the corresponding point on the opposite side of the chest.
Normal findings: Percussion notes resonate, except over the scapula.
Lowest point of resonance is at the Diaphragm.
Excursion is 3 to 5 cm bilaterally in women, 5 to 6 cm in men.
Diaphragm is usually slightly higher on the right side.  By auscultation hear the vesicular and bronchovesicular breath sounds.
AUSCUTATION OF POSTERIOR THORAX
Auscultate chest using diaphragm of stethoscope. Used the systematic Zigzag procedure.
Ask the client to take slow, deep breath through the mouth. Listen each breath sounds during inspiration and expiration.
ABNORMAL FINDINGS- By auscultation hear the adventitious breath sounds.
Name
Description
Cause
Location
Gurgles (rhonchi)
Continuous, low- pitched, coarse gurgling, harsh, louder sounds with a moaning or snoring quality.
Best heard on expiration but can be heard on both inspiration and expiration.
Air passing through narrowed air passages as a result of secretion, swelling, tumors.
Loud sounds can be heard over most lung areas but predominate over the trachea and bronchi
Friction rub
Superficial grating or creaking sounds heard during inspiration and expiration, not relieved by coughing.
Rubbing together of the inflamed pleural surfaces.
Heard most often in areas of greatest thoracic expansion ( lower anterior and lateral chest)
Crackles (rales)
Fine, short interrupted   crackling sounds, alveolar rales are high pitched. Sound can be stimulated by rolling a lock of hair near the ear. Best heard on inspiration   but can be heard on both inspiration and expiration.  May not be cleared by coughing.

Air passing through fluid or mucous in any air passage.

Most commonly heard in the bases of the lower lung lobes.

Wheeze

Continuous, high-pitched, squeaky musical sounds.
Best heard on expiration. Not usually altered by coughing.

Air passing through a constricted bronchus as a result of secretions, swelling, tumors

Heard over all lung fields




   


ASSESSMENT OF ANTERIOR THORAX
INSPECTION:
·         Breathing patterns
·         Coastal angle
Normal findings:
·         Quiet, rhythmic and effortless respirations.
·         Coastal angle is less than 90 degrees.
Palpation of anterior thorax
Place the palms of both your hands on the lower thorax.
With your finger laterally along the lower rib cage and your thumbs along the coastal margins.
Ask the client to take a deep breath while you observe the movement of your hands.  Palpate the tactile fremitus in the same manner as for the posterior chest.
Normal findings: Full symmetric excursion. Thumbs normally separate 3 to 5 cm. same as posterior vocal fremitus. Fremitus normally decreased over heart and breast tissue.
PERCUSSION OF ANTERIOR CHEST
Begin above the clavicles in the Supraclavicular space, and proceed downward to the diaphragm. Compare one side of the lung to the other.
Normal findings
Percussion notes resonate down to the sixth rib at the level of diaphragm but are flat over areas of heavy muscle and bone. Dull on areas over the heart and the liver. Tympanic over the underlying stomach.
5. Abnormal sound
Special areas on percussion in moderate hydrothorax
Auscultate the trachea- Auscultate anterior chest. Use the sequence.
Start from the bronchi between the sternum and the clavicles.  Record the findings in Nurse’s record.
NORMAL FINDINGS
 By Auscultating trachea hear the Bronchial and tubular breath sounds.
 Auscultation of anterior chest hear the Bronchovesicular and Vesicular breath sounds.
Lateral thorax
Position – sitting. Patient should raise arms to improve access to lateral thoracic structures
Techniques used- Inspection, palpation, auscultation. Breath sounds heard are vesicular.


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notes.nursium.com: Neck, Thorax and Lung Assessment
Neck, Thorax and Lung Assessment
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