Health Assessment Lecture: Respiratory System C

Good assessment skill is paramount in providing quality nursing care. There is the reason why Assessment is the first step in the nursing process and is incorporated in every phase. In assessment nurses can gather pertinent information from the patient's health status so as to have a good overview of the patient's condition to be able to formulate a nursing diagnosis and even help doctors to come up with their medical diagnosis- much more it help the whole health care team.

Thoracic Palpation

The nurse palpates the thorax for tenderness, masses, lesions, respiratory excursion, and vocal fremitus. If the patient has reported an area of pain or if lesions are apparent, the nurse performs direct palpation with the fingertips (for skin lesions and subcutaneous masses) or with the ball of the hand (for deeper masses or

generalized flank or rib discomfort).

RESPIRATORY EXCURSION

Respiratory excursion is an estimation of thoracic expansion and may disclose significant information about thoracic movement during breathing. The nurse assesses the patient for range and symmetry of excursion. The patient is instructed to inhale deeply while the movement of the nurse’s thumbs (placed along the costal margin on the anterior chest wall) during inspiration and expiration is observed. This movement is normally symmetric. 

Posterior assessment is performed by placing the thumbs adjacent to the spinal column at the level of the tenth rib. The hands lightly grasp the lateral rib cage. Sliding the thumbs medially about 2.5 cm (1 inch) raises a small skinfold between the thumbs. The patient is instructed to take a full inspiration and to exhale fully. The nurse observes for normal flattening of the skinfold and feels the symmetric movement of the thorax.

Decreased chest excursion may be due to chronic fibrotic disease. Asymmetric excursion may be due to splinting secondary to pleurisy, fractured ribs, trauma, or unilateral bronchial obstruction.

TACTILE FREMITUS

Sound generated by the larynx travels distally along the bronchial tree to set the chest wall in resonant motion. This is especially true of consonant sounds. The detection of the resulting vibration on the chest wall by touch is called tactile fremitus.

Normal fremitus is widely varied. It is influenced by the thickness of the chest wall, especially if that thickness is muscular. However, the increase in subcutaneous tissue associated with obesity may also affect fremitus. Lower-pitched sounds travel better through the normal lung and produce greater vibration of the chest wall. Thus, fremitus is more pronounced in men than in women because of the deeper male voice. 

Normally, fremitus is most pronounced where the large bronchi are closest to the chest wall and least palpable over the distant lung fields. Therefore, it is most palpable in the upper thorax, anteriorly and posteriorly. The patient is asked to repeat “ninety-nine” or “one, two, three,” or “eee, eee, eee” as the nurse’s hands move down the patient’s thorax. The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand or hands are moved in sequence down the thorax. Corresponding areas of the thorax are compared . Bony areas are not tested.

Air does not conduct sound well but a solid substance such as tissue does, provided that it has elasticity and is not compressed. Thus, an increase in solid tissue per unit volume of lung will enhance fremitus; an increase in air per unit volume of lung will impede sound. Patients with emphysema, which results in the rupture of alveoli and trapping of air, exhibit almost no tactile fremitus. A patient with consolidation of a lobe of the lung from pneumonia will have increased tactile fremitus over that lobe. Air in the pleural space will not conduct sound.