1. GOOD MORNING
TO
YOU ALL

2. ANTERIOR/POSTERIO
R CHEST
PREPARED BY ESTHER N. RIVERA

4. Thoracic Cage – is the entire/outer structure of the
thorax.
= is a bony structure with a conical shape which is
narrower at the top.
= it provides support and protection for many
important organs
= is constructed of the
 Sternum
 12 pairs of ribs
 12 thoracic vertebrae
 Muscles
 Cartilage
= it is narrower at its superior end and broader at its
inferior end and is flattened from front to back
(Tortora: 222)

5. ANTERIOR THORACIC
LANDMARK

6. 1. Suprasternal notch – is an important
landmark
= a U-shaped indentation located on the
superior border of the manubrium or joint
just above the sternum in between the
clavicles.
2. Sternum – “breastbone”
= flat bone which lies in the center of the chest
anteriorly
= measures about 15 cm (6 inches) in length
= it is attached to the first 7 ribs

7.  3 parts:
a. Manubrium – the superior part
=articulates with the costal cartilage of the 1st and the 2 nd
ribs
b. The body – the middle and the largest part
=articulates directly or indirectly with the costal cartilage of
the 2nd through the 10th ribs
c. Xiphoid process – the inferior and the smallest part
= no ribs are attached to it the xiphoid process provides
attachment for some abdominal muscles
3. Costal Angle - the right and left costal margins form an
angle where they meet at the xiphoid process
= usually 90 degrees or less, this angle increases when the
rib cage is chronically over inflated as its emphysema

8. 4. Manusbriosternal angle or sternal angle
= also called the “angle of Louis”
= this is the articulation of the manubrium and the body of
the sternum and it is continuous with the 2nd rib and
becomes a reference point for counting ribs and
intercostal spaces (Jarvis, 448)
5. Intercostal spaces – are the spaces in between the ribs
6. Ribs – the 12 pairs of ribs give the structural support to
the sides of the thoracic cavity
= constitute the main structures of the thoracic cage
= they are numbered superiorly to inferiorly, the uppermost
pair is number one
= each pair of ribs has a corresponding pair of ICS located
immediately inferior to it

9. = anteriorly, the first 7 pairs articulate with the
sternum by way of costal cartilages
= the first pair of ribs curves up immediately under
the clavicle, so only a small portion of these ribs
and 1st interspaces are palpable
= ribs 2 to 6 are easy to count anteriorly
= ribs 7 to 10 connect to the cartilages of the pair
lying superior to them rather than to the sternum
= 11th and 12th ribs are floating ribs” because they
do not connect to either the sternum or another
pair anteriorly, they are attached posteriorly to
the vertebra and their anterior tips are free and
palpable

10. = posteriorly, each pair of ribs articulates with the
respective thoracic vertebra
= the ribs are more difficult to palpate posteriorly
( :297)
7. Clavicle – or the collar bone
= a slender, doubly curved bone
= it attaches to the manubrium of the sternum to
the acromion of the scapula
= it acts as a brace to hold the arm away from the
top of the thorax and helps prevent shoulder
disclocation

11. POSTERIOR THORACIC
LANDMARK

13. 1. C 7 or vertebra prominens
= the most prominent bony spur protruding at
the base of the neck when the head is
flexed
2. Spinous process
= single projection arising from the posterior
aspect of the vertebral arch
= it alligns with their same numbered ribs only
down to T4
= after T4, the spinous processes angle
downward from their vertebral body and
overlies the vertebral body and rib below

14. 3. Scapula – or the shoulder blades
= they are triangular and are commonly
called “wings”
= it is not directly attached to the axial
skeleton
 2 important processes:
a. Acromion - connects with the clavicle
laterally at the acromioclavicular joint
b. Coracoid – the beaklike
= points over the top of the shoulder and
anchors some of the muscles of the joints
(Jarvis:449)

15. REFERENCE LINE
ANTERIOR CHEST
1.Midsternal line
= passes through
the center of the
sternum
2. Midclavicular line
=an imaginary line
that descends from
the middle of the
clavicle(Smeltzer:447)

16. POSTERIOR CHEST
1. Vertebral line
= also called spinal
line
= overlies the
spinous processes
of the vertebrae
2. Scapular line
= drops from the
inferior angle of the
scapula (Bickley:212)

17. LATERAL CHEST
1. Anterior axillary line
= line extends from
the anterior axillary
fold where the pectoralis
major muscle inserts
2. Posterior axillary line
= continues down from
the posterior axillary fold
where latissimus dorsi
muscle inserts(Smeltzer:477)
3. Midaxillary line
= runs down from the apex
of the axilla and lies between
and parallel to the other
two(Jarvis:450)

18. THE THORACIC CAVITY
Mediastinum – is the middle section of the
thoracic cavity containing the esophagus,
trachea, heart and the great vessels
= the right and the left pleural cavities, on either
side of the mediastinum contains the lungs
Lungs – are two coned-shaped, elastic structure
suspended within the thoracic cavity
(Jarvis:457)
= are paired but not precisely symmetric
structures

19. = the right lung is shorter than the left lung
because of the underlying liver
= the left lung is narrower than the right lung
because the heart bulges to the left
= at the point of the midclavicular line on the
anterior surface of the thorax, the lung
extends approximately to the 6 th rib
= laterally, lung tissue reaches the level of the 8 th
rib

20. = posteriorly, the lung base lies at about the 10 th rib
= the right lung has 3 lobes
= the left lung has 2 lobes (Jarvis:452)
 IN A HEALTHY ADULTS, DURING DEEP
INSPIRATION, THE LUNGS EXTEND DOWN
TO THE 8TH ICS ANTERIORLY AND 12TH
POSTERIORLY
 DURING EXPIRATION, LUNGS RISE TO THE
5TH OR 6TH ICS ANTERIORLY AND 10TH ICS
POSTERIORLY ( :300)

22. TRACHEA
= is a flexible structure that lies anterior to the
esophagus
= begins at the level of the cricoid cartilage in
the neck
= is approximately 10 to 12 cm long (adult)
= help to maintain the shape and prevent its
collapse during respiration ( :301)

23. BRONCHI
= both bronchi are at an oblique position in the
mediastinum and enter the lungs at the hilum
= the right main bronchus is shorter and more
vertical than the left
= the left bronchus is narrower and extends at
more of right angle of the trachea
 The trachea and the bronchi represent “dead
space” in the respiratory system
= they function primarily as a passageway for
both inspired and expired air ( Phipps: 979)

25. LUNGS BORDERS
ANTERIOR
1. Apex – extends slightly above the clvicle
= highest point of lung tissue is 3- 4 cm above the inner
third of the clavicle
2. Base – the broad lung area resting on the diaphragm at
the 6th rib in the midclavicular line (Jarvis: 452)
POSTERIOR
1. C 7 – marks the apex of lung tissue
2. T 10 – usually corresponds to the base
= deep inspiration expands the lungs and their lower border
drops to the level of T12 (Jarvis:450)

26. PREPARATION
INSTRUCTIONS FOR THE PATIENT MUST
BE CLEAR AND WITH COURTESY
1. Draping
2. Position
3. Other provisions to ensure further comfort
• Provide warm room and conducive for examination
= well lighted
= well ventilated
• Provide privacy
• Wash your hands but be sure hands are not cold
• The diaphragm of your stethoscope must warm
• Request your client to empty his/her bladder
• Examination must not be interrupted

27. II. Observe for Chest Configuration
 Does the chest move equally on the two
sides?
 Does breathing appear distressing?
 Is it noisy?
 Is breathing regular?
 Is there any prolongation of expiration?

28. INSPECTION
=Thorax provides information about the musculoskeletal
structure, patients nutritional status, and respiratory
system
= the nurse must observe the skin over the thorax for color and
turgor and for the evidence of loss of subcutaneous
tissue
= it is important to note symmetry, if present
= when findings are recorded, anatomic landmarks are used as
point of reference (Smeltzer:476)
I. observe respiration
1. Rate: normal, above normal. Below normal
2. Rhythm: regular, irregular
3. Depth: normal, deep, shallow
4. Effort: use of accessory muscles

29. II. Observe for Chest Configuration
 Does the chest move equally on the two
sides?
 Does breathing appear distressing?
 Is it noisy?
 Is breathing regular?
 Is there any prolongation of expiration?

30. 1. Barrel chest – results as a result of ossification of
the lungs
= increase in the anteroposterior diameter of the thorax
= patient with emphysema, the ribs are more widely
space and the ICS tend to buldge on expiration
2. Funnel chest (Pectus Excavatum) – occurs when
there is a depression in the lower portion of the
sternum
= this may compress the heart and the great vessels
resulting in murmurs
= may occur with rickets or Marfan’s syndrome

31. 3. Pigeon chest (Pectus Carinatum) – may occur as
a result of displacement of the sternum
= there is an increase in the anteroposterior
diameter
= may occur with rickets, Marfan’s syndrome or
severe kyphoscoliosis
4. Kyphoscoliosis – characterized by elevation of the
scapula and the corresponding S-shaped spine
= this deformity limits lung expansion within the
thorax
= may occur with osteoporosis and other skeletal
disorders that affect the thorax (Smeltzer:476)

33. BREATHING PATTERNS AND RESPIRATORY RATE
Normal adult – 12-19 breaths per minute (rate)
500-500 ml (depth) air moving in and out/respiration
even (pattern)
Ratio of pulse to respiration = 4:1
1. Eupnea – normal breathing at 12-19 breaths/min
2. Bradypnea – slower than normal, less than breaths/min with
normal depth and regular rhythm
= associated with increase ICP, brain injury, and drug
overdose
3. Tachypnea – rapid, shallow breathing, more than 24
breaths/min
= commonly seen in patient with pneumonia, pulmonary
edema. Metabolic acidosis, septicemia, severe pain and
rib fracture

34. 4. Hyporventilation – shallow, irregular breathing
5. Hyperventilation – increased rate and depth of
breathing
= associated with severe acidosis of diabetic, renal
origin (Kausmaul breathing)
6. Apnea – period of cessation of breathing
= time of duration varies
= may occur briefly during other breathing disorders
such as sleep apnea
= if sustained, apnea is life-threatening

35. 7. Cheyne stokes – characterized by alternating
episodes of apnea and periods of deep breathing
= deep respirations become increasingly shallow,
followed by apnea that may last approx. 20 seconds
= the cycle repeats after each apneic period
= associated with heart failure and damage of the
respiratory center (drug-induced, tumor, trauma)
8. Biot’s respiration – or cluster breathing
= periods of normal breathing (3-4 breaths) followed
by varying period of apnea (usually 10 seconds to 1
min)
= CNS disorder (Kozier:1297)

37. TABLE 35-3 POSSIBLE FINDINGS BY INSPECTION IN A PULMONARY EXAMINATION
OBSERVE NORMAL ABNORMAL
General Appearance Quiet respiration Lips puckered when exhaling
Sitting or reclining without difficulty Restless and apprehensive
Skin translucent, appears dry Leans forward with hands or elbows on knees
Nailbeds pink Skin: diaphoretic, dull pale or ruddy
Mucous membranes pink and moist* Cyanosis: skin or mucous membranes have bluish cast
Cyanosis or pallor assessed by establishing an Central cyanosis: results from decreased oxygenation of blood
early individual baseline +
Peripheral cyanosis: result of local vasoconstriction or
decreased cardiac output
Nail clubbing: painless enlargement of terminal phalanges
related to chronic tissue hypoxia
Trachea Midline in neck Tracheal deviation; displacement either lateral, anterior,
posterior
Jugular venous distension
Cough: strong or weak, dry or wet, productive or non-
productive
Sputum production: amount, color, odor, consistency
* Dark-skinned people might have normal bluish-pigmentation mucous membranes.
+ Central cyanosis is relevant to respiratory status. Observe nailbeds, mucous membrane and lips.

38. TABLE 35-3 POSSIBLE FINDINGS BY INSPECTION IN A PULMONARY EXAMINATION
OBSERVE NORMAL ABNORMAL
Rate Eupnea: 12 to 20 Tachypnea: rate> 20 breaths/minute
Bradypnea: rate < 12 breaths/minute
Breathing pattern Minimal effort with inspiration: passive, quiet Hyperpnea: increased breathing depth
expiration
Inspiration/expiration ratio: 1:2 Accessory muscle breathing
Male: diaphragmatic breathing Apnea: total absence of breathing
Female: thoracic breathing Biots: irregular rhythm with periods of apnea
Cheyne-Stokes: cyclical deeper and shallower breaths,
followed by periods of apnea
Kussmaul’s: deep, rapid, and regular breathing
Paradoxical: portion of chest wall moves in during inhalation
and out during exhalation
Stridorous: audible, loud, low-pitched sound with inhalation
and exhalation
Thoracic configuration Symmetric appearance Chest expands unevenly
Muscular development asymmetric
Anteroposterior diameter (AP) less than Barrel chest: AP diameter increased in relation to transverse
transverse diameter diameter
Spine straight Kyphosis: increased thoracic curvature
Scoliosis: increased lateral curvature
Scapulae on same horizontal plane Scapular placement asymmetric

39. PALPATION
= Start palpation by feeling for the position of the
trachea.
= facing to the patient, place two fingers either
side of the trachea (note whether the distance
between the trachea and the sternomastoid
tendons are equal
= at the back of the patient, hook your finger
round the tendon to meet the trachea (maybe
displaced- mass in the neck
= palpates the thorax for tenderness, masses,
lesions, respiratory excursion and vocal
fremitus (Smeltzer:478)

40. Purposes (Bickley:230)
1. Identification of tender areas
2. Assessment of observed abnormalities
3. Further assessment of chest expansion
4. Assessment of tactile fremitus
Identify tender mass
= palpate an area of pain or lesions are
apparent – perform direct palpation with
the fingertips (for the lesion and
subcutaneous masses)

41. = use the ball of the hand for deeper masses or
generalized flank or rib discomfort
Assess any abnormalities
= observe for any masses or sinus tract
(inflammatory, tube-like opening onto the skin
Respiratory Excursion
= an examination of the thoracic expansion and
may disclose significant information about
thoracic movement during breathing
= assess the patient for range and symmetry of
excursion

42. = instruct patient to inhale deeply
while moving the thumbs from
the 10th rib with the fingers
loosely grasping and parallel to
the lateral rib cage.
= slide them medially about 2-2.5 cm
(1 inch) just enough to raise fold
of skin on each side bet. the
thumb and the spine
= watch the distance bet. the thumb
as they move apart during inspiration.
= feel for the range and symmetry
of the rib cage as it expands and
contracts

43. TACTILE FREMITUS
Fremitus – refers to
palpable vibrations
transmitted through
the bronchopulmonary
tree to the chest wall
when the patient speaks
= is the detection of the
resulting vibration on
the chest wall by touch
= normal fremitus varies
= lower pitched sounds
travel
better through the normal
and produce greater
vibration
of the chest wall

44. = the patient is asked
to repeat “99”, “1 2 3”,
or “eee,eee,eee” as you
move your hands down
the thorax
= the vibrations are
detected with the palmar
surfaces of the fingers and
hands or the ulnar aspect
of the extended hands
= hands are moved in sequence down to the thorax
= corresponding areas of the thorax are compared
= BONY AREAS ARE NOT TESTED
= if fremitus is faint, ask patient to say it again more
loudly or in deeper voice (Smeltzer:479)

45. PERCUSSION
= is one of the most important technique of physical
examination
=percussion of the chest sets and the chest wall and
underlying tissues into motion, producing audible
sound and palpable vibrations
Purposes: 1. to detect the resonance or hollowness of
the chest (underlying tissues are air-filled, fluid-filled or
solid)
2. Used to estimate the size and location of certain
structure within the thorax (diaphragm, heart, liver)
= it penetrates only about 5-7cm into the chest therefore
it will not help to detect deep-seated lesions
(Epstein:627)

46.  Posterior
= percussion usually begins with the posterior
thorax
= ideally, the patient is in a sitting position with
the head flexed forward and the arm crossed
on the lap – the position separates the
scapulae widely and exposes more lung area
= proceeds down the posterior thorax,
percussing symmetry areas at 5-6cm (2-2.5
inch) interval (Smeltzer:480)

47. = hyperextend the middle
finger of your left hand
(pleximeter)
= press its distal interphalangeal
joint firmly on the surface
to be percussed
= avoid surface contact by
any part of the hand because
this dampens our vibrations
Note: thumb, 2nd, 4th, 5th fingers
are not touching the chest
= position your right forearm
quite close to the surface, with the hand cocked upward
= the middle finger should be partially flexed, related, and
poised to strike

48. = with a quick sharp
but relaxed wrist
movement, strike the
pleximeter finger
with the right middle
finger or plexor finger
= aim at your distal
interphalangeal joint

49. = strike using the tip
of your plexor finger,
not the finger pad
= your finger should
be almost at right angles
to the pleximeter
A SHORT FINGERNAIL IS RECOMMENDED TO
AVOID SELF-INJURY
WITHDRAW YOUR STRIKING FINGER QUICKLY
TO AVOID DAMPING THE VIBRATIONS YOU
HAVE CREATED (Bickley:224)

50. PERCUSSION SOUNDS
1. Resonance – low-pitched sound heard over
normal lungs
2. Hyperresonance – loud, lower-pitched sound
than normal resonance heard over
hyperinflated lung such as in chronic
obstructive lung disease, acute asthma
3. Tympany – drumlike, loud, empty quality heard
over gas-filled stomach or intestine or
pneumothorax
4. Dull – medium intensity pitch and duration,
heard over areas “mixed” solid and lung tissue
(pneumonia)
5. Flat – soft, high pitched sound of short duration
heard over very dense tissue where air is not
present (Lewis:555)

54. = percuss one side of
the chest and then the
other at each level
= omit the areas over
the scapulae – the
thickness of muscle and
bone alters the percussion
notes over the lungs
(Bickley:225)

55. Anterior
= patient is an upright
position with shoulders
arched backward and
arms at the table
= begin in the supra-
clavicular area and
proceeds downward,
from one intercostal space to the next
= for female patient, it maybe necessary to displace the
breasts with the left hand while percussing with the right
= using both hands, place finger of one on the chest with
fingers separated (Bickley:232)
YOU MAY ASK THE PATIENT TO MOVE HER BREAST FOR
YOU

56. = strike one of them with the terminal phalynx of the
middle finger of the of the other hand
= it must be removed again immediately, otherwise
the resultant sound will be damped
= the striking movement should be a flick of the wrist
and the striking finger should be at right angle to
the other finger
= each side is compared with the equivalent area
from top to bottom
= DO NOT FORGET THE SIDES
= the anterior and lateral thorax is examined with the
patient in supine position
= if patient cannot sit, percussion of the posterior
thorax is performed with the patient positioned on
the side

57. AUSCULTATION
= prefers to use the diaphragm of the
stethoscope
= in thin bony chest, the bell may give a more
airtight fit and is less likely to trap hairs
underneath which produces a crackling sound
(Epstein:628)
= the most important examining technique for
assessing air flow through the
tracheobronchial tree

58. = it involves:
1. Listening to the sounds generated by
breathing
2. Listening for any adventitious (added)
sound
3. If abnormalities are suspected, listening
to the sounds of the patient’s whispered
voice as they are transmitted through the
chest wall

59. = ask patient to take deep breath through the
mouth
= listen to the breath sounds using the same
pattern for percussion, moving from one side to
the other and comparing symmetric areas of the
lungs (Bickley:226)
= listen at least 1 full breath on each location
BE ALERT FOR PATIENT DISCOMFORT DUE
TO HYPERVENTILATION (light-headedness,
faintness)
ALLOW PATIENT TO REST AS NEEDED
(Smeltzer:480)

60. BREATH SOUNDS
= evaluate the presence and quality of normal breath
sounds
= are usually louder in the upper anterior lung fields
1. Vesicular – soft and low-pitched
= they are heard through inspiration, continue without
pause through expiration
= have 3:1 ratio with inspiration longer than expiration
= can be heard over most of both lungs
2. Bronchovesicular – with inspiratory and expiratory
sounds about equal in length, at times separated by
a silent interval differences in pitch and intensity are
often easily detected during expiration

61. = often can be heard in the 1st and 2nd interspaces
anteriorly and between the scapulae
= can be heard over the large airways esp. on the
right
3. Bronchial – louder and higher in pitch
= with a short silence between inspiratory and
expiratory sounds
= expiratory sound last longer than inspiratory
sounds
= can be heard over the manubrium, if heard at
all (Bickley:227)

62. ADVENTITIOUS SOUND
1. Wheezes – rhonchi
= a high-pitched, musical sound similar to a
squeak
= it is heard most commonly during
expiration, but also can be heard during
inspiration
= low-pitched, coarse, loud, low snoring or
moaning sound
=it is heard in narrowed airway diseases
such as asthma, chronic emphysema

63. 2.

64. www.umshp.org/rt/sounds/sounds.html
education.vetmed.vt.edu/Curriculum/VM87
54/respir/sdf/sounds/sounds.htm
www.cvmbs.colostate.edu/clinsci/callan/bre
ath_sounds.htm