CHAPTER 19 THORAX  or breastbone, is a flat, narrow bone

approximately 15cm long. It is located at the

median line of the anterior chest wall and is
divided into 3 sections: Manubrium (upper
bone of the sternum that articulates with the
clavicles and first pair of ribs); Body and the
Xiphoid process (a cartilaginous process at the
base of the sternum that does not articulate with
the ribs).

RIBS

ANATOMY

 The respiratory system is divided into upper and

lower respiratory tracts.
1. upper respiratory tracts comprise the
nose, pharynx, larynx and upper trachea.
2. lower respiratory tract is composed of
lower trachea to the lungs.

THORAX  The first 7 pairs of ribs are articulated to the

sternum via the costal cartilage and are called the
VERTEBROSPINAL OR TRUE RIBS.
 THE FALSE RIBS, 8 -10 articulates with the
costal cartilage just above them. The remaining 2
pairs of ribs (11 and 12) are termed FLOATING
RIBS and do not articulate their anterior ends.
The 10th rib is the lowest rib that can be palpated
anteriorly. The 11th rib is palpated on the lateral
thorax and the 12th rib is palpated on the posterior
thorax.
 INTERCOSTAL SPACES – each area
 – is a cone-shaped structure that consists of between the ribs. There are 11 ICS
bones, cartilages and muscles. On the anterior  LUNGS – are cone-shaped organs that
thorax these bones are the 12 pairs of ribs and fill the lateral chamber of the thoracic
sternum. Posteriorly, there are 12 thoracic cavity. The lower outer surface of each
vertebrae and the spinal column. lung is concave where it meets the
convex diaphragm.
STERNUM

VERTICAL REFERENCE LINES

 Anterior chest - midsternal, right and left

midclavicular lines
  Left lung – consists of 2 lobes (upper and
lower).

 Posterior thorax - vertebral line, right and left

scapular lines

PLEURA

 Serous sac
 The PARIETAL PLEURA lines the chest wall
and the superior surface of the diaphragm.
 The VISCERAL PLEURA lines the external
surface of the lungs. Usually, a small amount of
fluid is found in the space between these 2
pleurae.

THORACIC ACTIVITY

TRACHEA
 The trachea is a flexible structure that lie
anterior to the esophagus, and is approximately
10 to 12 cm long in an adult.
 C-shaped rings of hyaline cartilage compose the
trachea; they help to maintain its shape and
prevent its collapse during respiration.
 At the level of the sternal angle, the trachea
bifurcates into the right and left main bronchi.
 The bronchi and trachea represent “dead space” MEDIASTINUM OR INTERPLEURAL SPACE
in the respiratory system, where air is  is the area between the right and left lungs.
transported but no gas exchange takes place.  It extends from the sternum to the spinal column
and contains the heart, great vessels, and trachea,
esophagus and lymph vessels.
LUNGS  The only respiratory structures are the trachea
and pulmonary vasculature.
 Right lung – is broader than the left lung
because of the position of the heart. The right
lung is about 2.5cm shorter than the left lung
because of the upward displacement of the
diaphragm by the liver. It consists of 3 lobes
(upper, middle and lower).
 MECHANICS OF NORMAL INSPIRATION AND
EXPIRATION

BRONCHI
 the trachea bifurcates into the left and right
mainstem bronchi at the level of the 4th or 5th
vertebral [process posteriorly and the sterna
angle anteriorly. ENTERNAL INTERCOSTAL MUSCLES
 The right mainstem bronchus is wider, shorter  are located in the ICS. During inspiration, the
external intercostal muscles elevate the ribs thus
and more vertical than the left. The main stem
increasing the size of the thoracic cavity
bronchi further divide into lobar or secondary
bronchi.
ACCESSORY MUSCLES
 Each lobar bronchus supplies a lobe of the lung.
 are used to accommodate increased oxygen
 The bronchi transport gases as well as trap
demand. These are the scalene,
foreign particles in their mucus.
sternocleidomastoid, trapezius and abdominal
ALVEOLI rectus.

 are the smallest functional unit of the respiratory

system.
INSPECTION
 It is where the gas exchange occurs.
 This aerating surface is about equal to 100 times  Observe use of accessory muscles
the body surface area of an adult.  Trapezius, or shoulder muscles - facilitate
 It has its own blood supply and lymphatic inspiration in acute and chronic airway
drainage obstruction or atelectasis
 Tripod position seen in COPD
 Client leans forward
DIAPHRAGM
 Uses arms to support weight
 which is innervated by the phrenic nerve, is a  Lifts chest to increase breathing capacity
dome-shaped muscle that forms the inferior
border of the thorax. Anteriorly, its right edge is
located at the 5th rib – 5th ICS at the MCL. The
left dome of the diaphragm is at the 6th rib – 6th
ICS at the MCL. On expiration posteriorly, the
diaphragm is located at the level of the 10th
vertebral process and on T12 on inspiration
PHYSIOLOGY 3. INTERNAL RESPIRATION

 is the process by which gases are exchanges

between the pulmonary vasculature and the
body’s tissues.
 CO2 diffuses from the tissue into the blood.

4. CONTROL OF BREATHING

 is influenced by neural and chemical factors.

The pons and medulla are the CNS structures
 Primarily responsible for involuntary respiration.

1. VENTILATION
IDENTIFYING THORACIC LANDMARKS
2. EXTERNAL RESPIRATION
3. INTERNAL RESPIRATION
4. CONTROL OF BREATHING

1. VENTILATION

 The primary function of the respiratory

system is to deliver oxygen to the lungs and
to remove carbon dioxide from the lungs.
 During inspiration, the pressure inside the ANTERIOR
lungs becomes subatmospheric where the
 SUPRASTERNAL NOTCH – with the finger
diaphragm and external ICS muscles
pads of the index finger, feel in the Midsternal
contract. Expiration is a passive process and
line above the manubrium; the depression is the
occurs more rapidly than inspiration. During
suprasternal notch.
expiration, the diaphragm and external ICS
muscles relax, decreasing the volume of the  ANGLE OF LOUIS – with the finger pads, feel
thoracic cavity. The diaphragm rises. for the suprasternal notch and move your finger
pads down the sternum until they reach a
Mechanism of breathing horizontal ridge; this is the angle of Louis or
sternal angle
 RESPIRATION AKA VENTILATION
 Act of breathing
 INSPIRATION
 EXPIRATION

2. EXTERNAL RESPIRATION

 is the process by which gases are exchanged

between the lungs and the pulmonary  COSTAL ANGLE – place your right finger
vasculature. pads on the bottom of the patient’s anterior left
 Oxygen diffuses from the alveoli into the blood rib cage; place your left finger pads on the
and carbon dioxide diffuses from the blood to bottom of the patient’s anterior right rib cage;
the alveoli. move both hands horizontally towards the
 Diffusion is a passive process in which gases sternum until they meet in the midsternal line;
move across a membrane from an area of higher the angle formed by the intersection of the ribs
concentration to an area of lower concentration. creates the costal angle.
 4. Ensure that the light in the room provides sufficient
brightness to adequately observe the patient.
5. Instruct the patient to remove all street clothes from
the waist up and to don an examination gloves.
6. Place the patient in an upright sitting position on the
examination table or for patients who cannot tolerate the
sitting position, rotate the supine bedridden patient from
side to side to gain access to the thorax.
7. Expose the entire area being assessed. Provide a drape
that women can use to cover their breasts when the
 Anterior axillary line – Vertical line drawn
from the origin of the anterior axillary fold and posterior thorax is assessed
along the anterolateral aspect of the thorax. 8. When palpating, percussing or auscultating the
 Midspinal or vertebral line – vertical line anterior thorax of female or obese patient, ask them to
drawn from the midpoint of the spinous process displace the breast tissue. Assessing directly over breast
 Midsternal line – vertical line drawn from the tissue is not an accurate indicator of underlying
midpoint of the sternum structures.
 Posterior axillary line – vertical line drawn
9. Visualize the underlying respiratory structures during
from the posterior axillary fold
the assessment process in order to accurately describe
 Scapular line – vertical line drawn from the
the location of any pathology
inferior angle of the scapula.
10. Always compare the right and left sides of the
anterior and posterior thorax to one another, as well as
POSTERIOR the right lateral thorax and the left lateral thorax.

 VERTEBRA PROMINENCES – flex the neck 11. Use a systematic approach every time the assessment
forward; palpate the posterior spinous processes; is performed. Proceed from the lung apices to the bases,
if 2 processes are palpable, the superior process right to left lateral.
is C7 and the inferior is T1; this landmark is
useful in counting ribs to the level of T4; beyond
T4 the spinous process project obliquely and no Equipments needed:
longer correspond to the rib of the same number
as the vertebral process o Stethoscope
o Centimeter ruler or tape measure
 INFERIOR ANGLE OF SCAPULA – Locate
the inferior border of the scapula; this level o Washable marker
o Watch with second hand
corresponds to the 7th rib or 7th ICS.
 TWELFTH RIB – palpate the lower thorax in
the scapular line. Move your hand laterally to
palpate the free tip of the 12th rib. INSPECTION
Shape of thorax

GENERAL APPROACH 1. Stand in front of the patient

2. Estimate visually the transverse diameter of the
1. Greet the patient and explain the assessment thorax
techniques that you will be using. 3. Move to either side of the patient
4. Estimate visually the width of the
2. Ensure that the examination room is at a warm,
anteroposterior diameter of the thorax
comfortable room temperature to prevent patient chilling
5. Compare the estimates of these 2 visualizations.
and shivering
3. Use a quiet room that will be free from interruptions
Normal Presence of superficial veins

 In the normal adult, the ratio of AP diameter to 1. Stand in front of the patient
the transverse diameter is approx. 1:2 to 5:7. The 2. Inspect the anterior thorax for the presence of
normal adult is wider from side to side than from dilated superficial veins
front to back. The normal thorax is slightly
Normal
elliptical in shape. A barrel chest is normal in
infants and sometimes in the older adult.  Dilated superficial veins are not seen
Abnormal Abnormal
 BARREL CHEST – the ratio of the AP  The presence of dilated superficial veins on the
diameter to the transverse diameter is approx. anterior chest wall.
1:1. The patient’s chest is circular or barrel
shaped in appearance often found in patient with
COPD. Costal angle
 PECTUS CARINATUM/PIGEON CHEST –
is a marked protrusion of the sternum. This 1. Stand in front of the patient
increases the AP diameter of the thorax. 2. In a patient whose thoracic skeleton is easily
 PECTUS EXCAVATUM/FUNNEL CHEST – viewed, visually locate the costal margins
is a depression in the body of the sternum. This 3. Estimate the angle formed by the costal margins
indentation can compress the heart and cause during exhalation and at rest. This is the costal
myocardial disturbances. The AP diameter of the angle
chest decreases. 4. In a heavy or obese patient, place your fingertips
 KYPHOSIS/HUMPBACK – is an excessive on the lower anterior borders of the thoracic
convexity of the thoracic vertebrae. skeleton.
 SCOLIOSIS – is a lateral curvature of the 5. Gently move your fingertips medially to the
thorax or lumbar vertebrae. xiphoid process
6. As your hands approach the midline, feel the
ribs as they meet at the apex of the costal
margins. Visualize the line that is created by
Symmetry of chest wall
your fingers as they move up the floating ribs
1. Stand in front of the patient toward the sternum. This is the costal angle.
2. Inspect the right and left anterior thoraxes Approximate this angle
3. Note the shoulder height. Observe any
Normal
differences between the 2 sides of the chest wall
such as the presence of masses.  The costal angle is less than 90 degrees during
4. Move behind the patient exhalation and at rest. The costal angle widens
5. Inspect the right and left posterior thoraxes slightly during inhalation due to the expansion
comparing right and left sides of the thorax.
6. Note the position of the scapula
Abnormal

Normal  A costal angle greater than 90 degrees

 The shoulders should be at the same height. The

scapula should be the same height bilaterally. Angle of the ribs
There should be no masses.
1. Stand in front of the patient
Abnormal 2. In a patient whose thoracic skeleton is easily
 Having one shoulder or scapula higher than the viewed, visually locate the midsternal area.
other 3. Estimate the angle at which the ribs articulate
 Presence of a visible mass with the sternum
 4. In a heavy or obese patient, place your fingertips Respirations
on the midstream area
5. Move your fingertips along a rib laterally to the A. RATE
anterior axillary line. Visualize the line that is 1. Stand I front of the patient
created by your hand as it traces the rib. 2. Observe the patient’s breathing without stating
Approximate this angle what you are doing because the patient may
change the RR if aware that you are watching
Normal
the chest rising and falling.
 The ribs articulate at a 45-degree angle with the 3. Count the number of respiratory cycles that the
sternum patient has for 1 full minute.
4. A respiratory cycle consists of one inhaled and
Abnormal one exhaled breath.
 An angle greater than 45 degrees is considered Normal
abnormal. Patients with particular respiratory
pathology may have ribs that are nearly  In the resting adult, the normal RR is 12 to 20
horizontal and perpendicular to the sternum. breaths per minute. This is EUPNEA or
normal breathing.
Abnormal
Intercostal spaces
 TACHYPNEA – a RR greater than 20 breaths
1. Stand in front of the patient
per minute
2. Inspect the ICS throughout the respiratory cycle
 BRADYPNEA – a RR lesser than 12 breaths
3. Note any bulging of the ICS and any retractions.
per minute
Normal  APNEA – is the lack of spontaneous
respirations for 10 or more seconds.
 There should be an absence of retractions and
bulging of the ICS.
Abnormal B. PATTERN

 The presence of retractions which can occur 1. Stand in front of the patient
during inspiration 2. While counting the RR, note the rhythm or
The presence of bulging of the ICS which can pattern of the breathing for regularity or
occur during expiration. irregularity.
Normal
Muscles of respirations  Regular and even in respirations

1. Stand in front of the patient Abnormal

2. Observe the patient’s breathing for a few  CHEYNE – STROKES RESPIRATIONS
respiratory cycles, paying close attention to the
anterior thorax and the neck
3. Note all of the muscles that are being used by
the patient.
Normal

 No accessory muscles are used in normal

breathing
occur in crescendo-decrescendo patterns
Abnormal interspersed between periods of apnea that can
last 15 to 30 seconds. It is a regular irregular
 The use of accessory muscles respiratory pattern.
  BIOT RESPIRATIONS/ATAXIC  HYPERPNEA
RESPIRATIONS

 is an example of an irregularly irregular is a breath that is greater in volume than the

respiratory pattern. In an irregularly resting tidal volume. RR is normal and the
irregular rhythm, there is no identifiable pattern is even.
pattern to the respiratory cycle. There is an
absence of a crescendo and decrescendo BREATHING PATTERNS
pattern. Deep and shallow breaths occur at
random intervals interspersed with short and
long pauses
 APNEUSTIC RESPIRATIONS – are
characterized by a prolonged gasping during
inspiration followed by a very short, inefficient
expiration which last 30 to 60 seconds.
 AGONAL RESPIRATIONS – are irregularly
irregular respirations. They are of varying depths
and patterns.

C.DEPTH  AIR TRAPPING – is an abnormal

respiratory pattern with rapid, shallow
1. Stand in front of the patient respirations and forced expirations
2. Observe the relative depth with which the  KUSSMAUL’S RESPIRATIONS – are
patient draws a breath during inspiration characterized by extreme increased depth
Normal and rate of respirations. These respirations
are regular and the inspiratory or expiratory
 The normal depth of inspiration is no processes are both active.
exaggerated and effortless  SIGHING – is characterized by normal
Abnormal respirations interrupted by a deep inspiration
and followed by a deep expiration. It may be
 HYPOVENTILATION/SHALLOW accompanied by an audible sigh. Sighing is
VENTILATION pathological if it occurs frequently.

D. SYMMETRY
1. Stand in front of the patient
2. Observe the symmetry with which the chest rises
and falls during the respiratory cycle.
Normal
chest wall is moved minimally during  The healthy adult’s thorax rises and falls in
inspiration and expiration unison in the respiratory cycle. There is no
paradoxical movement.
Abnormal 3. Note for which part of the respiratory cycle each
is used.
 Unilateral expansion of either side of the thorax.
Hoover’s Sign is the paradoxical inward Normal
movement of the lower ICS during inspiration.
 Most patients inhale and exhale through the nose
This occurs when the diaphragm is flat instead
of its normal dome shape. Abnormal

 Continuous mouth breathing

E. AUDIBILITY  Patients may breathe through a stoma or
tracheostomy
1. Stand in front of the patient  PURSED-LIP BREATHING – is performed
2. Listen for the audibility of the respirations by patients who need to prolong the expiration
Normal phase of the respiratory cycle. It appears that the
patient is trying to blow out a candle or is
 A patient’s respirations are normally heard by preparing for a kiss.
the unaided ear a few centimeters from the
patient’s nose or mouth
Sputum
Abnormal
1. Ask the patient to expectorate a sputum sample
 Hear audible breathing when standing a few feet
2. If the patient is unable to expectorate, ask the
from the patient. Upper airway sounds may also
patient for a recent sputum sample from a
be heard.
handkerchief or tissue.
3. Note the color, odor, amount and consistency of
the sputum
F. PATIENT POSITION
Normal
1. Ask the patient to sit upright for the respiratory
assessment  A small amount of sputum is normal in every
2. View the patient either before or after the individual. The color is light yellow or clear.
assessment and note the assumed position for Normal sputum is odorless. Depending on the
breathing. Ask if the assumed position is hydration of the patient, the sputum can be thick
required for respiratory comfort. or thin.
3. Note if the patient can breathe normally when in
Abnormal
a supine position
4. Note if pillows are used to prop the patient  COLORS: mucoid, yellow or green, rust or
upright to facilitate breathing. blood-tinged, black and pink
Normal  ODOR: foul-smelling sputum
 AMOUNT: large
 The healthy adult breathes comfortably in a  CONSISTENCY: very thick sputum; thin
supine, prone or upright position consistency
Abnormal

 ORTHOPNEA – is difficulty breathing in ASSESSING PATIENTS WITH RESPIRATORY

positions other than upright. ASSISTIVE DEVICES
A. OXYGEN
G. MODE OF BREATHING
1. Stand in front of the patient
2. Note whether the patient is using the nose,
mouth or both to breathe
  Mode of delivery: nasal cannula, face mask
 Percentage of oxygen that is being
E. MECHANICAL VENTILATION
delivered: 25%, 40%
 Flow rate of the oxygen: 2 liters per minute
 Humidification provided and oxygen
warmed
B. INCENTIVE SPIROMETER

Type of ventilator
FiO2 setting
Mode used: assist, intermittent mandatory
ventilation
 Frequency of use  Amount of positive and expiratory pressure
 Volume achieved: 1000 ml  Rate and tidal volume
 Number of times patient reaches goal with  Peak inspiratory pressure
each use  Temperature of the humidification
C. ENDOTRACHEAL TUBE  Alarm sets
F. PULSE OXIMETER

 Size of ETT
 Nasal or oral insertion Determine the monitor’s setting
 Tube secured to the patient The monitor’s alarms are on. The
 Length of the ETT as it exits the nose or approximate limits are set
mouth  If using the probe on a nail, the patient’s
 Cuffs inflated or deflated mail polish has been removed
D. TRACHEOSTOMY TUBE  If using the probe on the ear, the skin is
intact and earrings are not interfering
G. PEAK FLOW METER

 Patient is seated while performing the

 Size of tracheostomy tube
maneuver
 Cuff present; if yes, cuff inflated or deflated
 Indicator line is lowered to the baseline level
 Tracheostomy ties secure the tube
 Patient exhales as deeply as possible while
maintaining a firm seal with the lips around
the mouthpiece.
  Patient does not obstruct the exhalation 8. Repeat steps 2-6 for the left lateral thorax.
outlet.
PALPATION
PULSATIONS
Normal:
GENERAL PALPATION
 No pulsations should be present
 assesses the thorax for pulsations, masses,
Abnormal
thoracic tenderness and crepitus
 Presence of pulsations on the thorax
To perform anterior palpation:
1. Stand in front of the patient
2. Place the finger pads of the dominant hand on MASSES
the apex of the right lung (above the clavicle)
3. Using light palpation, assess the integument of Normal:
the thorax in that area  No masses should be present
4. Move the finger pads down to the clavicle and
palpate Abnormal:
5. Proceed with the palpation, moving down to
each rib and ICS of the right anterior thorax.  Masses are present
Palpate any area of tenderness last.
6. Repeat the procedure on the left anterior thorax.
THORACIC TENDERNESS
Normal:
To perform posterior palpation:
 No thoracic tenderness present
1. Stand behind the patient
2. Place the finger pads of the dominant hand on Abnormal:
the apex of the right lung
 Presence of thoracic tenderness which may
3. Using light palpation, assess the integument of
cause fractured ribs
the thorax in that area
4. Move the finger pads down to the first thoracic
vertebra and palpate
5. Proceed with the palpation, moving down to CREPITUS
each thoracic vertebra and ICS of the right Normal
posterior thorax
6. Repeat the procedure on the left posterior thorax  Crepitus should be absent
Abnormal

To perform lateral palpation:  The presence of crepitus, also referred as

subcutaneous emphysema. It is usually felt
1. Stand to the patient’s right side earliest in the clavicular region.
2. Have the patient lift the arms overhead
3. Place the finger pads of the dominant hand
beneath the right axillary fold
4. Using light palpation, assess the integument of
the thorax in that area
5. Move the finger pads down to the first rib
beneath the axillary fold
6. Proceed with the palpation, moving down to
each rib and ICS of the right lateral thorax
7. Move to the patient’s left side
 THORACIC EXPANSION 5. Ask the patient to exhale
6. Observe the movement of the thumbs as they
assesses the extent of chest expansion and the symmetry
return to the midline.
of chest wall expansion
Normal
To perform ANTERIOR THORACIC EXPANSION:
 The thumbs separate an equal amount from
the spinal column or xiphoid process
(distance) and remain in the same plane of
the 10th spinous vertebra or costal margin
(direction). The normal distance for the
thumbs to separate during thoracic
expansion is 3 to 5 cm.
Abnormal
1. Stand directly in front of the patient. Place the  Unilateral decreased thoracic expansion.
thumbs of both hands on the costal margins and  Bilateral decreased thoracic expansion
pointing towards the xiphoid process. Gather a  Displacement of thumbs from the 10th spinal
small fold of skin between the thumbs to assist vertebra region.
with the visualization of the results of this
technique.
2. Lay your outstretched palms on the anterolateral
TACTILE FREMITUS/ VOCAL FREMITUS
thorax
3. Instruct the patient to take a deep breath is the palpable vibration of the chest wall that is
4. Observe the movement of the thumbs, both in produced by the spoken word. This technique is useful in
direction and in distance assessing the underlying lung tissue and pleura. The
5. Ask the patient to exhale anterior, posterior and lateral chest walls are assessed. 3
6. Observe the movement of the thumbs as they different aspects of the hand can be used to perform this
return to the midline. skill: The palmar bases of fingers, the ulnar aspect of the
hand and the ulnar aspect of a closed fist.

To perform POSTERIOR THORACIC

EXPANSION

How to perform:
1. Stand directly behind the patient. Place the
thumbs of both hands at the level of the 10th 1. Firmly place the ulnar aspect of an open hand on
spinal vertebra, equidistant from the spinal the patient’s right anterior apex
column and approximately 1 – 3 inches apart. 2. Instruct the patient to say the words “99” or
Gather a small amount of skin between the “1,2,3” with the same intensity every time you
thumbs as directed for anterior expansion. place your hand on the thorax.
2. Place your outstretched palms on the 3. Feel any vibration on the ulnar aspect of the
posterolateral thorax hand as the patient phonates. If no fremitus is
3. Instruct the patient to take a deep breath palpated, you may need to have the patient speak
4. Observe the movement of the thumbs, both in more loudly
direction and in distance
 4. Move your hand to the same location on the left TRACHEAL POSITION
anterior thorax.
5. Repeat steps 2 and 3
6. Compare the vibrations palpated on the right and
left apices
7. Move the hands down 2 to 3 inches and repeat
the process on the right and then on the left.
Ensure that your hand is in the ICS in order to
avoid the bony structures. Minimal or no
fremitus will be felt over the rib because they lie
on top of the lungs.
8. Continue this process down the anterior thorax
to the base of the lungs
9. Repeat this procedure for the lateral chest wall To assess the position of the trachea:
and compare symmetry. Either do the entire 1. Place the finger pad of the index finger on the
right then the entire left thorax or alternate right
patient’s trachea in the suprasternal notch
and left at each ICS. 2. Move the finger pad laterally to the right and
10. Repeat this procedure for the posterior chest gently move the trachea in the space created by
wall. the border of the inner aspect of the
Normal sternocleidomastoid muscle and the clavicle.
3. Move the finger pad laterally to the left and
 Normal fremitus is felt as a buzzing on the ulnar repeat the procedure.
aspect of the hand. The fremitus will be more
pronounced near the major bronchi and the Another method by which the trachea can be
trachea and will be less palpable in the periphery palpated:
of the lung. The diaphragm is approximately at 1. Gently place the finger pad of the index finger in
the level of T10- T12 posteriorly and it is the midline of the suprasternal notch
slightly higher on the right because of the 2. Palpate for the position of the trachea.
presence of the liver.
Normal
Abnormal
 The trachea is midline in the suprasternal notch
 increased tactile fremitus
 Decreased or absent tactile fremitus Abnormal
 A high diaphragm level is abnormal
 Tracheal deviation to the affected side
 PLEURAL FRICTION FREMITUS – is a
 Tracheal deviation to the unaffected side
palpable grating sensation that feels more
pronounced on inspiration when there is an
inflammatory process between the visceral and
parietal pleurae. PERCUSSION
 TUSSIVE FREMITUS – is the palpable GENERAL PERCUSSION
vibration produced by coughing
 RHONCHAL FREMITUS – is the coarse To percuss ANTERIOR THORACIC
palpable vibration produced by the passage of PERCUSSION:
air through thick exudates in large bronchi or the 1. Place the patient in an upright sitting position
trachea. with the shoulders back.
2. Percuss 2 or 3 strikes along the right lung apex
3. Repeat this process at the left lung apex
4. Note the sound produced from each percussion
strike and compares the sounds from each. If
different sounds are produced or if the sound is
not resonant then abnormality is suggested.
 5. Move down approximately 5 cm or every other resonance is normal in thin adults and in patients
ICS, and percuss that area with decreased musculature.
6. Percuss in the same position on the contralateral
Abnormal
side
7. Continue to move down until the entire lung has  The presence of hyper resonance in the majority
been percussed. of adults is abnormal. Hyper resonance is
To percuss POSTERIOR THORACIC percussed in air-filled spaces. It can be elicited
PERCUSSION: in pneumothorax, emphysema, and asthma.

1. Place the patient in an upright sitting position

with a slight forward tilt. Have the patient bend DIAPHRAGMATIC EXCURSION
the head down and fold the arms in front at the
waist. These actions move the scapula laterally
and maximize the lung area that can be
percussed.
2. Percuss the right lung apex located along the top
of the shoulder. Approximately 3 percussion
strikes should be struck along the area.
3. Repeat the process on the left lung apex
4. Note the sound produced from each percussion
strike and compares the sound from each. If
different sounds are produced or if the sound is
not resonant, then pathology is suggested.
5. Move down approximately 5 cm or every other
provides information on the patient’s depth of
ICS and percuss that area.
ventilation. This is accomplished by measuring the
6. Percuss in the same position on the contralateral
distance the diaphragm moves during inspiration and
side
expiration.
7. Continue to move down the thorax until the
entire posterior lung field has been percussed.
1. Position the patient for posterior thoracic
percussion
To perform LATERAL THORACIC PERCUSSION 2. With the patient breathing normally, percuss the
right lung from the apex (resonance) to below
1. Place the patient in an upright sitting position the diaphragm (dull). Note the level at which the
with hands and arms raised directly overhead. percussion note changes quality to orient your
This position allows for the greatest exposure of assessment to the patient’s percussion sounds. If
the thorax. full posterior thoracic percussion has already
2. Either percuss the entire right lateral thorax and been performed, then this step can be eliminated.
then the entire left lateral thorax or alternate 3. Instruct the patient to inhale deeply as possible
right and left sides. Start to percuss in the ICS and hold that breath.
directly below the axilla. 4. With the patient holding the breath, percuss the
3. Note the sound produced from that strike. right lung in the scapular line from below the
4. Percuss approximately 5 cm below the original scapula to the location where resonance changes
location or about every other ICS. to dullness
5. Percuss down to the base of the lung. 5. Mark this location and tell the patient to exhale
and breathe normally.
6. When the patient has recovered, instruct the
Normal patient to inhale as deeply as possible, exhale
fully and hold this exhaled breath.
 Normal lung tissue produces a resonant sound.
7. Repercuss the right lung below the scapula in the
The diaphragm and the cardiac silhouette emit
scapular line in a caudal direction. Mark the spot
dull sounds. Rib sounds are flat. Hyper
where resonance changes to dullness.
8. Measure the distance between the 2 marks.
 9. Repeat steps 1 – 8 for the left posterior thorax. 7. Continue to move the stethoscope down
approximately 5cm or every other ICS,
Normal
comparing contralateral sides. Remember to
 The measured distance for diaphragmatic visualize the anatomic topography of the chest
excursion is normally 3 to 5 cm. The level of the during auscultation.
diaphragm on inspiration is T12 and T10 on
expiration. The right side of the diaphragm is
usually slightly higher than the left To perform POSTERIOR THORACIC
AUSCULTATION:
Abnormal

 A diaphragmatic excursion that is less than 3

cm.
 A high diaphragm level

ASCULTATION

the aim of respiratory auscultation is to identify

the presence of normal breath sounds, abnormal lung
sounds, adventitious lung sounds and adventitious
pleural sounds.
1. Place the patient in an upright sitting position
To perform ANTERIOR THORACIC with a slight forward tilt, head bent down and
AUSCULTATION: arms folded in front at the waist. These actions
move the scapula laterally and maximize the
lung area that can be auscultated.
2. Place the stethoscope firmly on the patient’s
right ling apex. Ask the patient to inhale and
exhale deeply and slowly every time the
stethoscope is felt on the back.
3. Repeat this process on the left lung apex.
4. Move the stethoscope down approximately 5 cm
or every other ICS and auscultate in that area.
5. Auscultate in the same position on the
contralateral side.
6. Continue to move inferiorly with the
1. Place the patient in an upright sitting position
auscultation until the entire posterior lung has
with the shoulders back
been assessed.
2. Instruct the patient to breathe only through the
mouth. Mouth breathing, when compared to To perform LATERAL THORACIC
nasal breathing decreases air turbulence, which AUSCULTATION:
can interfere with the interpretation of breath
sounds. Have the patient inhale and exhale 1. Place the patient in an upright sitting position
deeply and slowly every time the stethoscope is with the hands and arms slightly directly
felt or when instructed to do so. overhead.
3. Place the stethoscope on the apex of the right 2. Auscultate the entire right thorax first then the
lung and listen for one complete respiratory entire left thorax or auscultate the right and left
cycle lateral thoraxes by comparing side to side. The
4. Note the sound that is auscultated stethoscope should initially be placed in the ICS
5. Repeat on the left apex directly below the axilla.
6. Note the breath sound auscultated in each area 3. Instruct the patient to breathe only through the
and compares one side to the other mouth. Have the patient inhale and exhale
 deeply and slowly every time the stethoscope is was found during percussion or palpation or in
felt on the lateral thorax. which adventitious breath sounds were heard.
4. Note the sound that is auscultated and continues 2. Place the stethoscope in the appropriate location
to move the stethoscope inferiorly on the patient’s chest
approximately every 5 cm or every other ICS 3. Instruct the patient to say the words “99” or “1,
until the entire thorax has been auscultated 2, 3” every time the stethoscope is placed on the
chest or when told to do so.
4. Auscultate the transmission of the patient’s
Breath sounds spoken word.

Normal

 Air rushing through the respiratory tract during To perform EGOPHONY:

inspiration and expiration generates different 1. Repeat steps 1 and 2 from the bronchophony
breath sounds in the normal patient. There are 3 procedure
distinct types of normal breath sounds: 2. Instruct the patient to say the sound “ee” every
1. Bronchial or Tubular sounds time the stethoscope is placed on the chest or
2. Vesicular sounds when told to do so.
3. Bronchovesicular sounds 3. Auscultate the transmission of the patient’s
Abnormal spoken word.

 Breath sounds that are considered not normal

can either be abnormal or adventitious breath To perform WHISPHERED PECTORILOQUY:
sounds. Adventitious breath sounds are
superimposed sounds on the normal bronchial, 1. Repeat steps 1 and 2 from the bronchophony
bronchovesicular and vesicular breath sounds procedure
 6 Adventitious breath sounds are: 2. Instruct the patient to whisper the words “99” or
1. Fine crackles “1, 2, 3” every time the stethoscope is placed on
2. Coarse crackles the chest or when told to do so.
3. Sonorous wheeze 3. Auscultate the transmission of the patient’s
4. Sibilant wheeze spoken word.
5. Pleural friction rub
6. Stridor
Voice sound
Normal
Voice sounds
 The normal finding when performing tests for
Assessment will reveal whether the lungs are bronchophony, egophony and whisphered
filled with air, fluid or are solid. This auscultation need pectoriloquy is an unclear transmission or
be performed only if an abnormality is detected during muffled sounds
auscultation.
Abnormal
3 techniques by which voice sounds can be assessed:
Positive or present voice sounds are:
1. Bronchophony  BRONCHOPHONY: clear transmission of
2. Egophony “99” or “1, 2,3” with increased intensity
3. Whispered pectoriloguy  EGOPHONY: transformation of “ee” to “ay”
with increased intensity; the voice has a nasal or
bleathing quality
To perform BRONCHOPHONY:
 WHISPHERED PECTORILOQUY: clear
1. 1.Position the patient for posterior, lateral or transmission of “99” or “1, 2,3” with increased
anterior chest auscultation. The area to be intensity.
auscultated will be that in which an abnormality
GERONTOLOGICAL CONSIDERATIONS: CHAPTER 21: HEART AND PERIPHERAL
VASCULATURE
1. ANATOMIC CHANGES
- Degeneration of the intervertebral discs HEART
- Stiffening of ligaments and joints
- Calcification of the costochondral cartilage  the major pumping organ of the body. In resting
- Muscles atrophy and diaphragm flattens out adult, the heart contracts 60 – 100 times while
- Most have barrel chest and some kyphosis pumping 4 – 5 liters of blood per minute.
 It is located in the thoracic cavity between the
2. ALVEOLAR GAS EXCHANGE lungs and above the diaphragm in an area known
- The lung’s decreased elastic recoil causes as mediastinum
the closure of the airways for a portion of  It is about the size of a clenched fist and weighs
the respiratory cycle. This occurs approximately 255g in women and 310g in men.
particularly in the lower lobes of the lungs.  The heart can be described as an inverted cone.
- Loss of lung tissue and alveolar capillaries  The anterior chest area that overlies the heart
and pulmonary thickening and great vessels is called the precordium.
 The right side of the heart pumps blood to the
3. REGULATION OF VENTILATION lungs for gas exchange (pulmonary circulation);
- Medulla is less sensitive to changes in the left side of the heart of the heart pumps
carbon dioxide and oxygen levels which blood to all other parts of the body (systemic
normally trigger the respiratory apparatus. circulation).
- Neural output to respiratory muscles is  The large veins and arteries leading directly to
decreased and away from the heart are referred to as the
great vessels.
4. LUNG DEFENSE MECHANISM
- There is less ciliary activity which increases Parts:
susceptibility to infection o Base - uppermost portion which includes the left
- Cough reflex decreases and right atria as well as the aorta, pulmonary
arteries and superior vena cava and inferior cava
o Apex – lower portion which extends into the left
thoracic cavity covering the heart to appear as if
it is lying on the right ventricle.

Chambers of the heart:

o Right and Left atria – interatrial septum
o Right and Left ventricle – interventricular
septum
o Right atria – is the collection point for the
blood returning from the systematic circulation
for deoxygenation in the lungs.
o Left atria – receives freshly oxygenated blood
via the 4 pulmonary veins which are the only
veins in the blood that carry oxygenated blood
Heart valves:
o Atrioventricular valve(AV valves) – prevent it
from prematurely entering the ventricles
o Tricuspid valve – named from its 3 flaps/cusps;
AV valve between the RA and RV
o Bicuspid/mitral valve – named from its 2 flaps
or cusps; AV valve between LA and LV
Pericardium  This electrical activity can be measured and
recorded by electrocardiography (ECG, also
 Is a tough, inextensible, loose-fitting, fibroserous
abbreviated a EKG), which records the
sac that attaches to the great vessels and
depolarization and repolarization of the cardiac
surrounds the heart.
muscle.
 A serous membrane lining, the parietal
 The phases of the ECG are known as P, Q, R, S,
pericardium, secretes a small amount of
and T.
pericardial fluid that allows for smooth, friction-
free movement of the heart. This same type of
serous membrane covers the outer surface of the
heart and is known as the epicardium.
 The myocardium is the thickest layer of the
heart, made up of contractile cardiac muscle
cells.
 The endocardium is a thin layer of endothelial
tissue that forms the innermost layer of the heart
and is continuous with the endothelial lining of
blood vessels.

ELECTRICAL CONDUCTION OF THE HEART

Pathways

 The SA Node is located in the posterior wall of

the right atrium near the junction of the superior
and inferior vena cava.  P wave: Atrial depolarization; conduction of the
 The SA Node generates impulses (at a rate of impulse throughout the atria.
60-100 per minute) that are conducted over both  PR interval: Time from the beginning of the
atria, causing them to contract simultaneously atrial depolarization to the beginning of
and send blood into the ventricles. ventricular depolarization, that is, from the
 The current initiated by the SA Node, is beginning of the P wave to the beginning of the
conducted across the atria to the atrioventricular QRS complex.
(AV) node.  QRS complex: Ventricular depolarization (also
atrial repolarization); conduction of the impulse
 The AV node slightly delays incoming electrical
throughout the ventricles, which then triggers
impulses from the atria and then relays the
contraction of the ventricles; measured from the
impulse to the AV bundle (bundle of His) in the
beginning of the Q wave to the end of the S
upper interventricular septum.
wave.
 The electrical impulse then travels down the
 ST segment: Period between ventricular
right and left bundle branches and the Purkinje
depolarization and the beginning of ventricular
fibers in the myocardium of both ventricles,
repolarization.
causing them to contract almost simultaneously.
 T wave: Ventricular repolarization; the
 Although the SA Node functions as the
ventricles return to a resting state.
“pacemaker of the heart,” this activity shifts to
 QT interval: Total time for ventricular
other areas of the conduction of system, such as
depolarization and repolarization, that is, from
the Bundle of His, if the SA Node cannot
the beginning of the Q wave to the end of the T
function.
wave; the QT interval varies with heart rate.
Electrical activity  U wave: May or may not be present; if present,
it follows the T wave and represents the final
 Electrical impulses, which are generated by the phase of ventricular repolarization.
SA Node and travel throughout the cardiac
conduction circuit, can be detected on the
surface of the skin.
 THE CARDIAC CYCLE HEART SOUNDS
The cardiac cycle refers to the filling and Normal Heart Sounds
emptying of the heart’s chamber. The cardiac cycle has
two phases: diastole (relaxation of the ventricles, known S1 (“Lub”)
as filling) and systole (contraction of the ventricles,  May be heard over the entire precordium but is
known as emptying). heard best at the apex (left MCL, fifth ICS)
Diastole  Is the result of closure of the AV valves (the
mitral and tricuspid valves)
 During ventricular diastole, the AV valves are  Usually heard as one sound but may be heard a
open and the ventricles are relaxed. This causes two sounds
higher pressure in the atria than in the ventricles  If heard as two sounds, the first component
(early or protodiastolic filling) represents mitral valve closure (M1); the second
 Near the end of ventricular diastole, the atria component represents tricuspid closure (T1)
contract and complete the emptying of blood out
of the upper chambers by propelling it into the S2 (“Dub”)
ventricles.  Heard best at the base of the heart
 This final active filling phase is called  Results from closure of the semilunar valves
presystole, atrial systole, or sometimes the (aortic and pulmonic) and correlates with the
“atrial kick.” beginning of the diastole
 Usually heard as one sound but may be heard as
two sounds
Systole  If S2 is a two distinct sounds, the first
 The filling phases during diastole result in a component represents aortic valve closure (A2)
large amount of blood in the ventricles, causing and the second component represents pulmonic
the pressure in the ventricles to be higher than in valve closure (P2)
the atria.  If S2 is heard as two distinct sounds, it I called a
 This causes the AV valves (mitral and tricuspid) split S2.
to shut. Closure of the AV valves produces the  A splitting of S2 may be exaggerated during
first heart sound (S1), which is the beginning of inspiration and disappear during expiration.
systole. Extra Heart Sounds
 This valve closure also prevents blood from
flowing backward (regurgitation) into the atria  S3 and S4 are referred to as diastolic filling
during ventricular contraction. sounds, which result from ventricular vibration
 At this point in systole, all four valves are closed secondary to rapid ventricular filling.
and the ventricles contract (isometric  If present, S3 can be heard early in diastole, after
contraction). S2.
 There is now high pressure inside the ventricles,  S4 also results from ventricular vibration but,
causing the aortic valve to open on the left side contrary to S3, the vibration is secondary to
of the heart and the pulmonic valve to open on ventricular resistance (noncompliance) during
the right side of the heart. Blood is ejected atrial contraction.
rapidly through these valves.  If present, S4 can be heard late in diastole, just
 With ventricular emptying, the ventricular before S1.
pressure falls and the semilunar valves close.  S3 is often termed ventricular gallop, and S4 is
This closure produces the second heart sound called atrial gallop.
(S2), which signals the end of systole.
Murmurs
 After closure of the semilunar valves, the
ventricles relax.  Blood normally flows silently through the heart.
There are conditions, however, that can create
turbulent blood flow in which a swooshing or
 blowing sound may be auscultated over the  The pulse should normally have a smooth, rapid
precordium. upstroke that occurs in early systole and a more
 Conditions that contribute to turbulent blood gradual down stroke.
flow include:
1. Increased blood velocity
2. Structural valve defects Jugular and Venous Pulse Pressure
3. Valve malfunction
4. Abnormal chamber openings  There are two sets of jugular veins: internal and
external.
 The internal jugular veins lie deep and medial to
Cardiac output (CO) the sternocleidomastoid muscle.
 The amount of blood pumped by the ventricles  The external jugular veins are more superficial;
during a given period of time (usually 1 minute) they lie lateral to the sternocleidomastoid muscle
and is determined by the stroke volume (SV) and above the clavicle.
multiplied by the heart rate (HR): SV x HR =  The jugular veins return blood to the heart from
CO the head and neck by way of the superior vena
 The normal adult cardiac output is 5 to 6 L/min. cava.
 Right-sided heart failure raises pressure and
Stroke volume volume, thus raising jugular venous pressure.
 The amount of blood pumped from the heart
with each contraction (stroke volume from the
left ventricle is usually 70 mL) HEALTH ASSESSMENT
 Influenced by several factors:
 Preload (degree of stretch of the heart
muscle before contraction)
 Afterload (the pressure against which
the heart muscle has to eject blood
during contraction)
 Synergy of contraction
 Compliance, or dispensability, of the
ventricles
 Contractility, or force of contractions, of
the myocardium

NECK VESSELS
Carotid Artery Pulse

 The right and left common carotid arteries

extend from the brachiocephalic trunk and the
aortic arch, and are located in the groove
between the trachea and the right and left
sternocleidomastoid muscles.
 They supply the neck and head, including the
brain, with oxygenated blood.
 The carotid artery pulse is a centrally-located
arterial pulse.
 Because it is close to the heart, the pressure
wave pulsation coincides closely with
ventricular systole.
 COLLECTING OBJECTIVE DATA: PHYSICAL
EXAMINATION
Preparing the Client

 Explain that they will need to expose the anterior

chest.
 Explain that it is necessary to assume several
different positions for this examination.
 Explain that you will need to place the client in
the supine position with the head elevated to
about 30 degrees during auscultation and
palpation of the neck vessels and inspection,
palpation, and auscultation of the precordium.
 Explain to the client the necessity to assume a
left lateral and sitting-up and leaning-forward
position so that you can auscultate for the
presence of any abnormal heart sounds.
 Explain that you will be listening to the heart in
a number of places and that this does not
necessarily mean that anything is wrong.
Equipment
o Stethoscope with a bell and diaphragm
o Small pillow
o Penlight or movable examination light
o Watch with second hand
o Centimeter rulers (two)
 THE 5 CARDIAC LANDMARKS AND ITS
LOACTION

The mitral area correlates anatomically with the apex of

the heart. The aortic and pulmonic area correlates
anatomically with the base of the heart.
 chambers of your heart beat too fast, causing the
bottom chambers to also beat faster than normal.
Atrial flutter impedes your heart's ability to
pump blood effectively throughout your body.
 Premature ventricular contraction - are extra
heartbeats that begin in one of your heart's two
lower pumping chambers (ventricles). These
extra beats disrupt your regular heart rhythm,
sometimes causing you to feel a fluttering or a
skipped beat in your chest.
 Heart block - is an abnormal heart rhythm
where the heart beats too slowly, which results
in the electrical signals being partially or totally
blocked between the upper chambers (atria) and
lower chambers (ventricles). Heart block is also
called atrioventricular (AV) block.

 Atrial fibrillation - is an irregular and often

rapid heart rate that occurs when the two upper
chambers of your heart experience chaotic
electrical signals. The result is a fast and
irregular heart rhythm. The heart rate in atrial
fibrillation may range from 100 to 175 beats a
minute.
 Atrial flutter - is a type of abnormal heart
rhythm, or arrhythmia. It occurs when the upper
 insufficiency or ventricular failure (normal in
children and young adults).

Mitral and Tricuspid Area (S4)

 An S4 heart sound or atrial diastolic gallop is
late diastolic filling sound associated with atrial
contraction. An S4 can be either left or right
sided and it is best heard in the mitral or
tricuspid area. S4 is a late diastolic filling sound
that occurs just before S1.
S4 Heart sound (Atrial or Presystolic Gallop)
Examination:
1. Place the bell of the stethoscope lightly over the
GERONTOLOGICAL CONSIDERATIONS mitral area
 Decreased size of heart muscle 2. Place the bell of the stethoscope lightly over the
tricuspid area
 Atria and ventricles become fibrotic and
3. Auscultate for 10 to 15 seconds for a left or right
sclerotic
sided S4.
 Decreased cardiac output
Timing: Late Diastole
 Change in heart position
Causes: Pulmonic stenosis, hypertension,
 Obesity
coronary artery disease, aortic stenosis or
 Vessels become fibrotic and rigid forceful atrial contraction dune to resistance to
ventricular filing late in diastole resulting from
left ventricular hypertrophy.
ABNORMAL HEART SOUNDS
Murmurs
Mitral and Tricuspid Are (S3)
 are distinguished from heart sounds by their
 Auscultation of the mitral and tricuspid areas is longer duration. It may be classified as:
repeated for low – pitched sounds specifically a. Innocent – which are always systolic
for S3 or ventricular systolic gallop or extra and are associated with any other
heart sound. An S3 is an early diastolic filling abnormalities
sound that originates in the ventricles and is best b. Functional – which are associated with
heard at the apex of the heart. high-output states
c. Pathological – which are related to
S3 Heart sound (Venticular Gallop)
structural abnormalities.
Examination:  Murmurs are produced by turbulent blood
flow in the following situation:
1. Place the bell of the stethoscope lightly over the a. Flow across a partial obstruction
mitral landmark. When the S3 originates in the b. Increased flow through normal
left ventricle, it is best heard with the patient in a structures
left lateral decubitus position and exhaling. c. Flow into a dilated chamber
2. When originating in the right ventricle, an S3 d. Backward or regurgitate flow across
can best be heard by placing the bell of the incompetent valves.
stethoscope lightly over the 3rd or 4th ICS at the e. Shunting of blood out of a high pressure
left sterna border. chamber or artery through an abnormal
3. Auscultate for 10 to 15 seconds for a left or right passageway.
sided S3.  7 characteristics of murmurs
Timing: End diastole a. Location – area where the murmur is
Causes: Over distention of the ventricles during heard the loudest (e.g. mitral, pulmonic,
the rapid filling segment of diastole or mitral etc)
 b. Radiation – transmission of sounds from Normal: No pericardial friction rub should be
the specific valves to other adjacent auscultated
anatomic areas. E.g.: Mitral murmurs Abnormal: Pericardial friction rub is present.
can often radiate to the axilla.
c. Timing – phase of the cardiac cycle in
which the murmur is heard. Murmurs CHAPTER 23: ABDOMEN
can be either systolic or diastolic. If a
murmur occurs simultaneously with the COMPETENCIES
pulse, it is a systolic murmur. If it does  Demonstrate the techniques of gastrointestinal
not, it is a diastolic murmur. Murmurs assessment.
can be further be characterized as  Relate abnormal physical gastro-intestinal
pansystolic or holosystolic meaning that findings to pathological processes.
the murmur is heard throughout all of  Outline the gastrointestinal variations associated
systolic. Murmurs can be characterized with the aging process.
as early, mid, or late systolic or diastolic
murmurs. ANATOMY AND PHYSIOLOGY
d. Intensity – Loudness or intensity. The  Abdominal cavity
murmur is recorded with the grade over
 Peritoneum
the roman numeral “VI” to show the
 Abdominal vasculature
scale being used.
e. Quality – harsh, rumbling, blowing or ABDOMEN
musical
f. Pitch- high, medium or low. Low –
pitched murmurs should be auscultated
with the bell of the stethoscope whereas
high – pitched murmurs should be
auscultated with the diaphragm of the
stethoscope
g. Configuration – pattern that the murmur
makes over time. The configuration of a
murmur can be described as crescendo
(soft – loud), descrescendo (loud – soft),
crescendo – descrescendo (soft to loud
to soft) and plateau (sound is sustained).
 Bordered superiorly by the costal margins
 Inferiorly by the symphysis pubis and inguinal
Pericardial Friction rub
canals
 When inflamed pericardial surfaces rub together,  Laterally by the flanks
they produce a characteristic high – pitched  Four quadrants - right upper quadrant (RUQ),
friction noise of grating or scratchy quality right lower quadrant (RLQ), left lower quadrant
known as pericardial friction rub. (LLQ), left upper quadrant (LUQ)
 Two imaginary lines (vertical/midline;
Examination: horizontal/lateral)
1. Position the patient so that he or she is reclining  Regions commonly used - epigastric, umbilical,
in the sitting position, in the knee-chest hypogastric or suprapubic
position or leaning forward.
Right Upper Quadrant
2. Auscultate from the sternum (3rd to 5th ICS) to
the apex with the diaphragm of the stethoscope  Ascending and transverse colon
for 10 to 15 seconds  Duodenum; gallbladder; hepatic flexure of
3. Characterize any sound according to location, colon; liver
radiation, timing, quality and pitch  Pancreatic head; pylorus; right adrenal gland
  Right kidney; right ureter Health history

Right Lower Quadrant  Patient profile

- Age
 Appendix  Child to young adult: appendicitis
 Ascending colon; cecum  Adult: peptic ulcers, cholecystitis,
 Right kidney diabetes mellitus
 Right ovary and tube - Gender
 Right ureter  Female: gallbladder disease
 Right spermatic cord  Male: GI cancers, cirrhosis, duodenal
ulcers
Left Upper Quadrant
 Common Chief Complaints
 Left adrenal gland  Nausea and vomiting
 Left kidney  Diarrhea or constipation
 Left ureter  Appetite
 Pancreas, spleen, stomach  Abdominal distension
 Transverse descending colon  Abdominal pain
o Visceral
Left Lower Quadrant o Parietal
o Referred
 Left kidney
 Increased eructation or flatulence
 Left ovary and tube  Bowel elimination
 Left ureter  Characteristics of Chief Complaint
 Left spermatic cord  Quality
 Descending and sigmoid colon  Quantity
Abdominal Wall Muscles  Associated manifestations
 Aggravating factors
 Three muscle layers from back, around flanks, to  Alleviating factors
front: external and internal abdominus oblique,  Setting
transverse abdominus  Timing
 Abdominal wall muscles: protect internal  Medical
organs; allow normal compression of internal - Abdomen specific
organs during functional activities - Nonabdomen specific
 Surgical
Internal Anatomy
- GI procedures
 Parietal peritoneum; visceral peritoneum
 Different body systems
- Gastrointestinal Past Health History
- Reproductive (female)
- Lymphatic and urinary  Communicable diseases
 Solid viscera: liver, pancreas, spleen, adrenal  Allergies
glands, kidneys, ovaries, uterus  Injuries and accidents
 Hollow viscera: stomach, gallbladder, small
intestine, colon, bladder
Family Health History
 Palpation of abdominal viscera depends on:
location, structural consistency, size  Malignancies of stomach, liver, pancreas, colon;
peptic ulcer disease, diabetes mellitus, irritable
 Viscera normally not palpable
bowel syndrome, colitis
- Pancreas; spleen; stomach gallbladder, small
intestine
 Vascular structures: abdominal aorta; right and
left iliac arteries
Social History - Palpation

 Alcohol use
 Drug use
Inspection
 Travel history
 Home and work environments
 Hobbies and leisure activities
 Economic status

Health Maintenance Activities

 Sleep
 Diet
 Exercise
 Stress management
 Use of safety devices
 Health check-ups

COLLECTION OF OBJECTIVE DATA

 As part of a comprehensive health examination

 To explore gastrointestinal complaints
 To assess abdominal pain, tenderness, or masses
 To monitor the client postoperatively
 Auscultate after inspection and before
percussion
 Palpate last
Preparing the Client

 Empty the bladder

 Remove clothes and put on a gown
 Lie supine with the arms folded across the chest
or resting by the sides
 Drape the client
 Breathe through the mouth; take slow, deep
breaths
Equipment:
o Small pillow or rolled blanket
o Centimeter ruler
o Stethoscope (warm the diaphragm and bell)
o Marking pen

ASSESSMENT OF THE ABDOMEN

 Order of assessment Auscultation

- Inspection USING THE DIAPHRAGM OF A WARM
- Auscultation STETHOSCOPE, APPLY LIGHT PRESSURE TO
- Percussion AUSCULTATE FOR BOWEL SOUNDS FOR UP TO 5
MINUTES IN EACH QUADRANT. USE THE BELL
TO AUSCULTATE FOR VASCULAR SOUNDS.

Palpation
LIGHT PALPATION PRECEDES DEEP
Percussion PALPATION TO DETECT TENDERNESS AND
SUPERFICIAL MASSES. DEEP PALPATION IS
PERCUSSION NOTES WILL VARY FROM
USED TO DETECT MASSES AND SIZE OF
DULL TO TYMPANIC, WITH TYMPANY
ORGANS.
DOMINATING OVER THE HOLLOW ORGANS.
THE HOLLOW ORGANS INCLUDE THE WATCH THE CLIENT’S FACIAL EXPRESSIONS
STOMACH, INTESTINES, BLADDER, AORTA, AND AND BODY POSTURE CAREFULLY TO HELP
GALLBLADDER. DULL PERCUSSION NOTES ASSESS PAIN. EXAMINE TENDER AREAS LAST.
WILL BE HEARD OVER THE LIVER, SPLEEN, NEVER USE DEEP PALPATION OVER TENDER
PANCREAS, KIDNEY, AND UTERUS. PERCUSS ORGANS IN CLIENTS WITH POLYCYSTIC
FROM AREA OF TYMPANY TO DULLNESS TO KIDNEYS. AFTER RENAL TRANSPLANT, OR
LOCATE BORDERS OF SOLID VISCERAS. AFTER HEARING AND ABNORMAL BRUIT. USE
DEEP PALPATION WITH CAUTION.
 PADIATRIC VARIATIONS
ABDOMEN

 Contour and size

– -Prominent/ cylindrical (protuberant)
when erect, flat when supine. Superficial
veins may be present in infants.
 Abdominal movement
– -Rises with inspiration in synchrony
with chest; may have visible pulsations
in epigastric region.
Liver progesterone which are released from the
 Border ovaries.
- Normal, shortened liver span on percussion.  The female breast is an accessory reproductive
May not extend below costal margin. organ with two functions:
- INFANT and CHILDREN: Liver may be - to produce and store milk that provides
felt 1-3 cm below costal margin; may nourishment for newborns and to aid in
descend with inspiration. sexual stimulation.
 The male breast has no functional capability.
Spleen
 For purposes of describing the location of
 Border assessment findings, the breasts are divided into
– INFANT and CHILDREN: Spleen may four quadrants by drawing horizontal and
be felt 1-3 cm. below costal margin. vertical imaginary lines that intersect at the
nipple.
 The upper outer quadrant, which extends into the
GERONTOLOGICAL VARIATIONS axillary area, is referred to as the Tail of Spence
- Most breast tumors occur in this quadrant.
 Decline in appetite and at risk for nutritional  Lymph nodes are present in both male and
imbalance. female breasts. These structures drain lymph
 Dilated superficial capillaries visible. from the breasts to filter out microorganisms and
 Abdomen is softer and organs are more return water and protein to the blood.
easily palpated owing to a decrease in tone
of abdominal musculature.
 Decreased production of saliva, decreased
peristalsis, decreased enzymes, weaker
gastric acid
 Gastric mucosa and parietal cell
degeneration results in a loss of intrinsic
factor, which decreases absorption of
vitamin B12.
 Bowel sounds 5-30 sounds/min.
 Shortened liver span on percussion due to a
decrease in liver size after age 50 years.
 Liver border is more easily palpated.
 Decrease nerve sensation to lower bowel
contribution to constipation.
EXTERNAL BREAST ANATOMY

 The skin of the breasts is smooth and varies in

CHAPTER 20: BREAST
color depending on the client’s skin tones.
 The nipple, which is located in the center of the
breast, contains tiny openings of the lactiferous
STRUCTURE AND FUNCTION
ducts through which milk passes.
 The breasts are paired mammary glands that lie  The areola surrounds the nipple (generally 1 to 2
over the muscles of the ACW, anterior to the cm radius) and contains elevated sebaceous
pectoralis major and serratus anterior muscles. glands (Montgomery glands) that secrete a
 Depending on their size and shape, the breasts protective lipid substance during lactation.
extend vertically from the second to the sixth rib Smooth muscle fibers in the areola cause the
and horizontally from the sternum to the mid- nipple to become more erectile during
axillary line. stimulation.
 The male and female breasts are similar until  The nipple and areola typically have darker
puberty, when female breast tissue enlarges in pigment than the surrounding breast. Their color
response to the hormones estrogen and ranges from dark pink to dark brown, depending
 on the person’s skin color. The amount of 2. Fibrous tissue – provides support for the
pigmentation increases with pregnancy, then glandular tissue largely by way of bands called
decreases after lactation. Cooper’s ligaments (suspensory ligaments).
These ligaments run from the skin through the
breast and attach to the deep fascia of the
muscles of the anterior chest wall.
3. Fatty tissue – the glandular tissue is embedded
in the fatty tissue. This subcutaneous and
retromammary fat provides most of the
substance to the breast, determining the size and
shape of the breasts.
 The functional capability of the breast is
not related to size but rather to the
glandular tissue present.
 The amount of glandular, fibrous, and
fatty tissue varies according to various
factors including the client’s age, body
build, nutritional status, hormonal cycle,
and whether she is pregnant or lactating.

INTERNAL BREAST ANATOMY

Female breasts consist of three types of tissue:
1. Glandular tissue – constitutes the functional LYMPH NODES
part of the breast, allowing for milk production.  The major axillary lymph nodes consist of the
Glandular tissue is arranged in a circular fashion anterior (pectoral), posterior (subscapular),
from the nipple. Each lobe contains several lateral (brachial), and central (mid-axillary)
lobules in which the secreting alveoli (acini nodes.
cells) are embedded in grape-like clusters.
 The anterior nodes drain the anterior chest wall
-Mammary ducts from the alveoli converge into
and breasts.
a single lactiferous duct that leaves each lobe
 The posterior chest wall and part of the arms are
and conveys milk to the nipple. The slight
drained by the posterior nodes.
enlargement in each duct before it reaches the
 The lateral nodes drain most of the arms, and the
nipple is called the lactiferous sinus. The milk
central nodes receive drainage from the anterior,
can be stored in the lactiferous sinus (or
posterior, and lateral lymph nodes.
ampullae) until stimulated to be released from
the nipple.  A small proportion of the lymph also flows into
the infraclavicular or supraclavicular lymph
 nodes or deeper into nodes within the chest or Family history
abdomen.
 History of breast cancer in the family?
Lifestyle and health practices

 Are you taking any hormones, contraceptives, or

antipsychotic agents?
 Exposure to radiation?
 What is your typical daily diet?
 Alcohol consumption? Tobacco?
 How much coffee or cola do you consume each
day?
 Any regular exercise? Type of bra do you wear
when exercising?
 Do you examine your own breasts? How?
 When was your last breast examination by a
health care provider?

COLLECTING SUBJECTIVE DATA

 When interviewing clients, especially females,

about the breasts, keep in mind that this topic
may evoke a wide spectrum of emotions from
the client.
 Explore your own feelings regarding body
image, fear of breast cancer, and the influence of
the breasts on self-esteem.
 Male with gynecomastia or cancer of the breast
may be embarrassed to have what they consider
a “female condition”
History of present health concern

 Lump or swelling? Where? When did you first

notice it? Has the lump grown? Any other
associated problems?
 Any lump/swelling in the underarm area?
 Any redness, warmth, or dimpling of the
breasts?
Personal Health History COLLECTING OBJECTIVE DATA

 Pain in the breasts? Use COLDSPA to explore General Approaches

the symptoms.
 Instruct patient to neither use creams, lotions or
 Any prior breast disease? Surgery? Biopsy? powders nor shave the underarms 24-28 hours
Breast implants or breast trauma? prior to examination.
 Menarche? Have you experienced menopause?  Encourage the patient to express any anxieties
 Have you given birth to any children? Age when and concerns about the physical examination
you have your first child?  Inform the patient that the examination should
 LMP (Last Menstrual Period) not be painful but maybe uncomfortable at
times.
 Adopt a non-judgmental and supportive attitude.
  Be aware on the impact of culture on breast Normal
assessment and self-examination.
 Breast and axillae are flesh-colored and the
 Instruct patient to remove any jewelry.
 Areolar areas nipples are darker in pigmentation.
 Ensure room temperature is warm
 Pigmentation is enhanced during pregnancy.
 Warm hands with warm water or by rubbing
 Moles and nevi are normal variants.
them together prior to assessment.
 Terminal hair maybe present in the areolar areas.
During assessment
Abnormal
 Inform patient of what you are going to do
before you do it.  Inflamed breast – Peau d’ orange
 Do health teaching
 Keep areas not assessed appropriately draped
 Always compare right and left breast.
 Wear gloves if patient has any discharge.
 Position the patient uncovered to the wrist,
facing you.
 Instruct the patient to let her arms relax by her
sides
 Inspect the breast, axilla, areolar areas and  Striae
nipples for color, vascularity, thickening, edema,
size, symmetry, contour, lesions or masses and
exudates.
 Repeat the sequence with the patient’s arms
raised over her head. This will accentuate
retraction (tissue drawn back) if present.
 Repeat inspection with patient pressing hands on
the hips which will contract the pectoral
muscles.
 Have the patient lean forward to allow the breast
to hang freely away from the chest wall and B. VASCULARITY
repeat the inspection sequence.
 OBSERVE THE ENTIRE SURFACE OF
EACH BREAST FOR SUPERFICIAL
VASCULAR PATTERNS.
Normal

 Superficial vascular patterns are diffuse and

symmetrical.
Abnormal

A. COLOR

 INSPECT THE BREASTS, AREOLAR

AREAS, AND AXILLAE FOR COLORATION
C. THICKENING OR EDEMA E. CONTOUR
 ASSESS BREASTS FOR CONTOUR
 OBSERVE THE BREASTS, AXILLAE AND  COMPARE THE BREASTS TO EACH
NIPPLES FOR THICKENING OR EDEMA OTHER
Normal Normal
 Thickening or edema is not found in the breast,  The breast is normally convex, without
axillae or nipples flattening, retractions, or dimpling.
Abnormal Abnormal

 Dimpling of the breast

D. SIZE AND SYMMETRY

 OBSERVE THE BREASTS, AXILLAE, F. LESIONS OR MASSES

AREOLAR AREAS, AND NIPPLES FOR  INSPECT THE BREAST, AXILLAE,
SIZE & SYMMETRY. AREOLAR AREAS AND NIPPLES FOR
Normal LESIONS & MASSES.
Normal
 Breast on the side of the dominant arm are being
larger.  The breast, axillae, areolar areas and nipples are
 Nipples should point upward and laterally, or free of masses, tumors and primary or secondary
they may point outward and downward. lesions.
Abnormal Abnormal
 Assymetrical  Dermatitis

 Inversion  Lesion
  Advanced cancer Breast palpation

PALPATION IS PERFORMED IN A SEQUENTIAL

MANNER:
1. Supraclavicular and infraclavicular lymph nodes
2. Breast, with patient in sitting position:
a) Arms at side
b) Arms raised over the head
3. Axillary lymph nodes region.
4. Breast, with the patient in sitting position.
G. DISCHARGE
 OBSERVE FOR SPONTANEOUS
DISCHARGE FROM THE NIPPLES OR Supraclavicular & Infraclavicular
OTHER AREAS OF THE BREASTS.
 Have the patient seated and uncovered to the
Normal waist.
 Encourage the patient to relax the muscles of the
 Non-pregnant/ non lactating- no discharge head and neck.
 Pregnant- yellow discharge or colostrum  Flex the patient’s head to relax the
 Lactation- white discharge of breast milk sternocleidomastoid muscle.
Abnormal  Standing in front of the patient, in a bilateral and
simultaneous motion, place the finger pads over
 Galactorrhea the patient’s clavicles, lateral to the tendinous
portion of the sternocleidomastoid muscle.
 Using the rotary motion of the palmar surfaces
of the fingers, probe deeply into the scalene
triangles in order to palpate the supraclavicular
and infraclavicular lymph nodes.
Normal

 Palpable lymph nodes less than 1 cm. in

 Blood coming out from the nipple diameter are usually normal and
clinically insignificant, provided that
there are no additional enlarged lymph
nodes found in other regions such as the
axilla. Palpation should not elicit pain.

BREASTS: PATIENT IN SITTING POSTION

 Supernumerary nipples  Place the patient in a sitting position with arms

at side.
 Stand to the patient’s right side, facing the
patient.
 Using the palmar surfaces of the fingers of the
dominant hand, begin the palpation at the outer
quadrant of the patient’s right breast.
 In small-breasted patient, the dominant hand can
palpate the tissue against the chest wall, but if
the breasts are pendulous, use a bimanual
technique of palpation.
  Palpate in a downward fashion, sweeping from c) Subscapular posterior nodes
the outer quadrants to the sternal border of the
breast,
Normal

 Palpation should not elicit significant tenderness,

although the breasts and especially the nipples
may become full and slightly tender
premenstrually.
- At the anterior edge of the latissimus dorsi
muscle
AUXILLIARY LYMPH NODE REGION

 Stand at the patient’s right side, facing the d) Pectoral (anterior)

patient.
 Tell the patient to take a deep breath and relax
the shoulders and arms.
 Using you left hand, adduct the patient’s right
arm so that it is close to the chest wall. Your
fingers will be positioned behind the pectoral
muscles.
 Gently roll the tissue against the chest wall and
axillary muscles as you work downward. - Behind the lateral edge of the pectoralis
major muscle
Locate and palpate the 4 axillary lymph nodes
Normal
a) Brachial (lateral) Nodes
 Palpable lymph nodes less than 1 cm are
usually considered normal and clinically
insignificant.
 Palpation should not elicit pain.
Abnormal

- At the inner aspect of the upper part of the

humerus, close to the axillary vein.

b) Central (midaxillary)

 Enlarged axilliary node

BREAST: PATIENT IN SUPINE POSITION

 Keep the patient uncovered to the waist.

 Instruct the patient to assume a supine position.
- At the thoracic wall of the axilla
 If the breasts are large, place a small towel or
folded sheet under the patient’s right shoulder.
 Stand at the right side of the patient.
 Using the palmar surfaces of the fingers, palpate
the right breasts by compressing the mammary
tissues gently against the chest wall.
 Examine the right breast from the left side of the
examining table to allow the examination to be
done with the sensitive ball of the finger rather
than the insensitive part of the fingertips.
 The palpation is completed in the inner outer
quadrant.
 Start the examination in the lower inner quadrant
where there is less breast tissue. Also note sub
mammary fold.

f. Palpation must include the tail of Spence, periphery and

areola.

 The right hand stays in the central position of the g. Don gloves and compress the nipple to express any
breast while the left hand defines the outer discharge.
boundary of the breast glandular tissue. The
glandular tissue is denser and is to be h. Repeat procedure on opposite breasts.
distinguished from the softer fatty tissue.

 The glandular tissue is kneaded between the

hands as the examination progresses in a
clockwise direction.

 The position of the right and left hand is

changed as the examination progresses to avoid
crossing the hands.
 ABNORMALITIES NOTED ON PALPATION OF screening or diagnostic mammography or during
THE BREAST a clinical breast examination.
 Ultrasound uses sound waves and picks up the
echoes to created images and allows imaging the
breast from any orientation.
Needle Aspiration

 The withdrawal of fluid or tissue from a cavity

via a hollow needle with an aspirator tube
attached to an end.
Thermography

 Measuring the regional temperature of a body

part or organ.
 Malignant lesions are often warmer than
nonmalignant areas and are called “hot spots”.
Cancerous Tumors  The new blood vessels that form up a
malignancy light up red, yellow or white and the
 These are irregular, hard, not defined masses normal tissues or benign tumors show up in
that may be fixed or mobile. green or blue.
 They are not usually tender and unusually occur
after age 50.
Fibroadenomas

 are common benign (non-cancerous) breast

tumors made up of both glandular tissue and
stromal (connective) tissue.
 Fibroadenomas are most common in women in
their 20s and 30s, but they can be found in
women of any age. They tend to shrink after a
woman goes through menopause.
Benign Breast Disease

 Also called fibrocystic breast disease

 Benign Breast Disease is marked by round,
elastic, defined, tender, and mobile cysts.
 The condition is most common from age 30 to
menopause, after which it decreases.

DIAGNOSTIC TECHNIQUES
Mammography

 Is the process of using low-dose X-rays to

examine the human breast.
Ultrasonopraphy

 This is used by physicians to evaluate breast

abnormalities that have been found with
 CHAPTER 24 MUSULSOSKETAL to another bone, while tendons connect
muscle to bone.
ANATOMY AND PHYSIOLOGY
D. CARTILAGE
Purposes: - An avascular, dense, connective tissue that
 To support body position and to promote covers the ends of opposing bones.
mobility. - Its resilience allows the muscle to withstand
 To protect underlying soft organs and allows for increased pressure and tension.
mineral storage,
 It produces select blood components (platelets,
red blood cells and white blood cells.

A. BONES
Purposes:
a. For mobility and weight-bearing function.
b. Protection of underlying organs and tissues
Divisions:
a. Central – axial skeleton
b. Peripheral – appendicular skeleton
E. LIGAMENTS
- Are strong, fibrous, connective tissue that
B. MUSCLES connects bones to each other at the joint level
and encase the joint capsule.
Characteristics and Functions
- It supports purposeful joint movement and
a. Cardiac & smooth muscles / Involuntary prevent joint movement that is detrimental to
-the individual has no conscious control over the that type of joint.
initiation and termination of the muscle
contraction.
b. Skeletal Muscle / voluntary/ largest type
-provides for mobility by exerting a pull on the
bones near a joint. It also provides for body
contour and contributes to overall body weight.
c. Tendons
- Attaches muscles to the bone

F. BURSAE
- These are sacs that are filled with fluid
- Acts as cushion between two nearby surface to
reduce friction.

- A tendon (or sinew) is a tough band of

fibrous connective tissue that usually
connects muscle to bone and is capable of
withstanding tension.
- Tendons are similar to ligaments; both are
made of collagen. Ligaments join one bone
 - A bursa is a small fluid-filled sac made of white COLLECTING SUBJECTIVE DATA
fibrous tissue and lined with synovial
membrane. Bursa may also be formed by a
synovial membrane that extends outside of the
joint capsule. [8] It provides a cushion between
bones and tendons and/or muscles around a
joint; bursa are filled with synovial fluid and are
found around almost every major joint of the
body.
G. JOINTS
- A union between two bones.
- Secure the bones firmly together but allow for
some degree of movement between the two
bones.
- A joint or articulation (or articular surface) is the
location at which bones connect. They are
constructed to allow movement (except for skull,
sacral, sternal, and pelvic bones) and provide
mechanical support, and are classified
structurally and functionally

General Considerations
1. Assist the patient in a comfortable position.
2. Be clear in your instruction to the patient of you
are asking the patient to perform a certain body
movement or to assume a certain position.
Demonstrate the desire movement if necessary.
3. Notify the patient before touching or
manipulating a certain body part.
4. Inspection, palpation, ROM and muscle testing
are performed on the major skeletal muscles and
joints of the body in cephalocaudal, proximal to
distal manner.
5. Examine non-affected part before examining an
affected area.
6. Avoid unnecessary or excessive manipulation of
body part.
 b. Ask the patient to walk on the toes and then on
the heels of the feet.
c. Ask the patient to walk by placing one foot in
front of the other, in a “heel-to-toe” fashion
(tandem walking)
d. Instruct the patient to walk forward, then
backward.
e. Instruct the patient to ambulate forward a few
steps with the eyes closed.
f. Observe the patient during transfer between the
standing and sitting position.
Normal
COLLECTING OBJECTIVE DATA: PHYSICAL
 Walking is initiated in one smooth, rhythmic
EXAMINATION
fashion.
Preparing the Client  The patient remains erect and balanced during
all stages of gait.
 Be sure that the room is at a comfortable
temperature and provide rest periods as  The arms swing freely at the side of the torso but
necessary. in opposite direction to the movement of the
legs. OR
 Provide adequate draping to avoid unnecessary
exposure of the client yet adequate visualization  Prior to turning, the head and neck turn toward
of the part being examined. the intended direction, followed by the rest of
the body.
 Explain that you will ask the client frequently to
change positions and to move various body parts  The patient should be able to transfer easily to
against resistance and gravity. various positions.

Physical Assessment
TEMPOROMANDIBULAR JOINT (TMJ)
 Observe gait and posture.
Inspection and Palpation
 Inspect joints, muscles, and extremities for size,
symmetry, and color.  Inspect and palpate the TMJ. Have the client sit;
 Palpate joints, muscles, and extremities for put your index and middle fingers just anterior to
tenderness, edema, heat, nodules, or crepitus. the external ear opening. Ask the client to open
 Test muscle strength and ROM of joints. the mouth as widely as possible.
 Compare bilateral findings of joints and  Test ROM. Ask the client to open the mouth and
muscles. move the jaw laterally against resistance. Next,
 Perform special tests for carpal tunnel syndrome. as the client clenches the teeth, feel for
contraction of the temporal and masseter
Assessment Procedure muscles to test the integrity of CN V (trigeminal
nerve)
GAIT  Stand in front of the patient.
Inspection  Inspect the right and left temporomandibular
 Observe the client’s gait as the client enters the joints (CN VII)
room.
 Assess for the risk of falling backward in the
older or handicapped client by performing the
“nudge test.” Stand behind the client and put
your arms around the client while you gently
nudge the sternum.
a. Instruct the patient to walk normally across the
room.
c. Palpate the temporomandibular joints:  Test ROM of the thoracic and lumbar spine. Ask
 Place your index and middle fingers over the the client to bend forward and touch the toes.
joint Observe for symmetry of the shoulders, scapula,
 Ask the patient to open and close the mouth and hips.
 Feel the depression into which your fingers  Sit behind the client, stabilize the client’s pelvis
move with an open mouth. with your hands, and ask the client to bend
 Note the smoothness with which the mandible sideways (lateral bending), bend backward
moves. toward you (hyperextension), and twist the
 Note any audile or palpable click as the mouth shoulders one way then the other.
opens.  Sit behind the client, stabilize the client’s pelvis
with your hands, and ask the client to bend
d. Assess ROM. Ask the patient to: sideways (lateral bending), bend backward
 Open the mouth as wide as possible toward you (hyperextension), and twist the
 Push out the lower jaw shoulders one way then the other.
 Move the jaw from side to side
SHOULDERS, ARMS, AND ELBOWS
e. Palpate the strength of the masseter and temporalis
muscle s as the patient clenches the teeth (CN V). Inspection and palpation
 It is normal to hear or palpate a click when the  Inspect anteriorly and posteriorly for symmetry,
mouth opens. The mouth can open 3 – 6 cm with color, swelling, and masses. Palpate for
ease. The lower jaw protrudes without deviating tenderness, swelling, or heat. Anteriorly palpate
to the side and moves 1 – 2 cm with lateral the clavicle, acromioclavicular joint,
movement. subacromial area, and the biceps. Posteriorly
palpate the glenohumeral joint, coracoid area,
trapezius muscle, and the scapular area.
STERNOCLAVICULAR JOINT
ELBOWS
Inspection and palpation
 Inspect elbows in both flexed and extended
 With client sitting, inspect the sternoclavicular positions.
joint for location in midline, color, swelling, and  Ask the client to perform the following
masses. Then palpate for tenderness or pain. movements to test ROM, flexion, extension,
pronation, and supination.

CERVICAL, THORACIC, AND LUMBAR SPINE

WRIST
 Observe the cervical, thoracic, and lumbar
 Inspect wrist size, shape, symmetry, color, and
curves from the side, then from behind. Have the
swelling. Then palpate for tenderness and
client standing erect with the gown positioned to
nodules.
allow an adequate view of the spine. Observe for
 Ask the client to bend the wrist down and back
symmetry noting differences in height of the
(flexion and extension)
shoulders, iliac crest, and buttock creases.
 Test for carpal tunnel syndrome. Perform
 Palpate the spinous processes and the
Phalen’s test. Ask the client to rest elbows on a
paravertebral muscles on both sides of the spine
table and place the backs of both hands against
for tenderness or pain.
each other while flexing the wrist 90 degrees
 Test ROM of the cervical spine by asking the
with fingers pointed downward and wrists
client to touch the chin to the chest (flexion) and
dangling. Have the client hold this position for
to look up at the ceiling (hyperextension).
60 seconds.
 Test lateral bending. Ask the client to touch each
 Perform test for Tinel’s sign. Use your finger to
ear to the shoulder on that side.
percuss lightly over the median nerve.
 Evaluate rotation. Ask the client to turn the head
 Test for thumb weakness. Ask the client to raise
to the right and left.
thumb up from plane of the palm.
  Ask the client to stretch the thumb so that its pad  If you notice swelling, perform the bulge test to
rests on the pad of the little finger pad. determine if the swelling is due to accumulation
of fluid or soft-tissue swelling. With the client in
supine position, use the ball of your hand firmly
HANDS AND FINGERS to stroke the medial side of the knee upward,
three to four times, to displace any accumulated
Inspection and Palpation fluid. Then press on the lateral side of the knee
 Inspect size, shape, symmetry, swelling, and and look for a bulge on the medial side of the
color. Assess the metacarpophalangeal joints by knee.
squeezing the hand from each side between your Test ROM. Ask the client to
thumb and fingers.
 Ask the client to spread the fingers apart  Bend each knee up (flexion) toward buttocks or
(abduction), make a fist (adduction), bend the back.
fingers down (flexion), and then up  Straighten the knee (extension/hyperextension).
(hyperextension), move the thumb away from  Walk normally.
the fingers and then touch the thumb to the base  Test for pain and injury.
of the small finger.

ANKLES AND FEET

HIPS
Inspection and Palpation
Inspection and Palpation
 Inspect position, alignment, shape, and skin.
 With the client standing, inspect symmetry and  Palpate the toes from the distal end proximally,
shape of the hips. With the client supine, ask the noting tenderness, swelling, bony prominences,
client to: nodules, or crepitus of each interphalangeal
o Raise extended leg joint.
o Flex knee up to chest while keeping  Assess the metatarsophalangeal joints by
other leg extended. squeezing the foot from each side with your
o Move extended leg away from midline thumbs and fingers. Palpate each metatarsal,
of body as far as possible and then noting swelling or tenderness. Palpate the
toward midline of body as far as plantar area (bottom) of the foot, noting pain or
possible (abduction and adduction) swelling.
o Bend knee and turn leg inward (rotation)  Test ROM
and then outward (rotation)
o Ask the client to lie prone and lift
extended leg off table. Alternatively, ask
the client to stand and swing extended
leg backward.

KNEES
Inspection and Palpation

 With the client supine then sitting with knees

dangling, inspect for size, shape, symmetry,
swelling, deformities, and alignment.
 Palpate for tenderness, warmth, consistency, and
nodules. Begin palpation 10 cm above the
patella, using your fingers and thumb to move
downward toward the knee.