Learning Objectives
By the end of this section, you will be able to:
- Analyze how to collect subjective data for assessment of the thorax
- Describe how to collect objective data for assessment of the thorax
- Recall abnormalities found in the thorax assessment
With an understanding of the basic structures and primary functions of the thorax, the nurse collects subjective and objective data to perform a focused chest assessment. Because the thorax contains vital organs including the lungs and heart, it is imperative that the nurse complete a thorough examination and note any abnormalities. Abnormal findings of the thorax may indicate more severe health problems and may affect the body’s ability to transport adequate amounts of oxygen and blood to organs and tissues.
Nursing Assessment: Collecting Subjective Data
The nurse can collect subjective data during the focused thorax assessment by using interview questions, paying particular attention to what the patient is reporting. The interview should include questions regarding any history of or current respiratory health conditions or illnesses, medication use, and any self-reported symptoms. The nurse should consider the patient’s age, gender, family history, race, culture, environmental factors, and current health practices when gathering subjective data.
Obtaining Health History
The information discovered during the interview process guides the physical exam and subsequent patient education. See Table 23.4 for sample interview questions to use during a focused respiratory and thorax assessment.
| Interview Questions | Follow-Up |
|---|---|
| Have you ever been diagnosed with a respiratory condition, such as asthma, COPD, pneumonia, or allergies? Do you use oxygen or peak flow meter? Do you use home respiratory equipment such as CPAP, BiPAP, or nebulizer devices? |
|
| Are you currently taking any medications, herbs, or supplements for respiratory concerns? |
|
| Have you had any feelings of breathlessness (dyspnea)? | Note: If the shortness of breath is severe or associated with chest pain, discontinue the interview and obtain emergency assistance.
|
| Do you have a cough? |
|
Table 23.4 Interview Questions for Subjective Assessment of the Respiratory System and Thorax
Identifying Lifestyle and Health Practices
Chronic respiratory disorders are common, accounting for nearly 7.5 million deaths per year (Glass & Rosenthal, 2018). Though these disorders are not always completely preventable, there are certain modifiable lifestyle factors associated with their development. While obtaining the health history, the nurse should assess for the following factors that may contribute to respiratory disorders:
- tobacco use and/or vaping
- environmental pollution within the home or from occupational exposures
- refusing vaccines (e.g., influenza or COVID-19)
- physical inactivity
- having a higher weight
- poor dietary habits (e.g., limited intake of fruit and vegetables)
Patient Conversations
What If Your Patient Reports Tobacco Use or Vaping?
Scenario: Nurse walks into the patient’s room to obtain a health history. The patient has recently been diagnosed with chronic obstructive pulmonary disease (COPD).
Nurse: Hi, my name is Julie, and I’ll be your nurse today. Can you confirm your name and date of birth before we get started?
Patient: Sure. It’s Jeremy Reed and my birthday is 12/16/1970.
Nurse. Great, thank you. So I see here that you were recently diagnosed with COPD, does that sound right?
Patient: Yeah, it does. My doctor said my lungs are shot from all the smoking and vaping I do. I’ve cut back some over the years but I do still smoke occasionally.
Nurse: I see. It’s great that you’ve cut back. How many years have you been smoking in total?
Patient: I started pretty young so I would say around thirty-five years or so but I only smoke about a pack per week now. I used to smoke a pack a day.
Nurse: That’s definitely an improvement, but have you ever tried quitting smoking completely?
Patient: I tried stopping cold turkey one time but it was terrible. I was super jittery and had to start again like a week later.
Nurse: It’s great that you tried quitting and I would strongly advise that you try quitting again. Smoking is a huge risk factor for respiratory diseases, especially COPD. Continuing to smoke will make your COPD more severe.
Patient: Yeah, I hear you. But it’s so hard to stay motivated to quit. It’s just easier to keep doing things the way I’ve always done them.
Nurse: I understand. If you’re willing to try, I would love to connect you with some resources to help you quit for good. We have access to counselors and support groups here that I think would be really helpful for you.
Patient: Yeah, that actually sounds great. I would really appreciate it!
If the patient is ready to quit, the five successful interventions are the Five As: Ask, Advise, Assess, Assist, and Arrange.
- Ask: Identify and document smoking status for every patient at every visit.
- Advise: In a clear, strong, and personalized manner, urge every user to quit.
- Assess: Is the user willing to make a quitting attempt at this time?
- Assist: For the patient willing to make a quitting attempt, use counseling and pharmacotherapy to help them quit.
- Arrange: Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date.
Nursing Assessment: Collecting Objective Data
A focused thorax and respiratory objective assessment includes interpretation of vital signs; inspection of the patient’s breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds using a stethoscope. The nurse must understand what is expected for the patient’s age, gender, development, race, culture, environmental factors, and current health condition to determine the meaning of the data that are being collected.
Inspecting the Thorax
Inspection of the thorax during a focused respiratory assessment includes observation of chest configuration and symmetry in addition to the patient’s breathing rate, pattern, and effort (Figure 23.13). First, the nurse will perform a visual inspection to observe the patient’s chest for symmetry and overall configuration. The trachea should be midline and the clavicles should be symmetrical to each other. Note the location of the ribs, sternum, clavicle, and scapula, as well as the underlying lobes of the lungs. When the patient breathes, chest movement should be symmetrical during both inspiration and expiration. While inspecting the chest, observe the anterior-posterior diameter and compare it to the transverse diameter. The nurse must assess the shape and size for comparison. The expected anteroposterior-transverse ratio should be 1:2.
Figure 23.13 Landmarks of the anterior, posterior, and lateral thorax are shown. (credit: “Anterior_Chest_Lines.png,” “Posterior_Chest_Lines.png,” and “Lateral_Chest_Lines.png” by Meredith Pomietlo/Chippewa Valley Technical College, CC BY 4.0)
After inspecting the chest for configuration and symmetry, the patient’s breathing pattern should be observed, including obtaining the respiratory rate over a full minute. The normal range for the respiratory rate of an adult is twelve to twenty breaths per minute. Breathing effort should be nonlabored and in a regular rhythm. Observe the depth of respiration and note if the respiration is shallow or deep. Inspiration should last half as long as expiration unless the patient is active, in which case the ratio increases to 1:1.
Palpating the Thorax
Palpation of the chest may be performed to investigate for areas of abnormality related to injury or procedural complications. For example, if a patient has a chest tube or has recently had one removed, the nurse may palpate near the tube insertion site to assess for areas of air leak or crepitus. Crepitus feels like a popping or crackling sensation when the skin is palpated and is a sign of air trapped under the subcutaneous tissues. If palpating the chest, use light pressure with the fingertips to examine the anterior and posterior chest wall. Chest palpation may be performed to assess specifically for growths, masses, crepitus, pain, or tenderness. Confirm symmetric chest expansion by placing your hands on the anterior or posterior chest at the same level, with thumbs over the sternum anteriorly or the spine posteriorly. As the patient inhales, your thumbs should move apart symmetrically.
Life-Stage Context
Respiratory Changes in Older Adults
The function of the lungs tends to decrease with age. Beginning around age thirty-five, lung capacity decreases due to physiological changes including the alveoli losing their shape, diaphragm weakness, thinning ribs, and immune system vulnerability. Though these changes are unavoidable with aging, certain lifestyle changes such as smoking cessation, avoiding air pollution, exercising, and maintaining a healthy body weight may slow the progression.
Abnormalities in Thorax Assessment
Abnormalities in the thorax and respiratory assessment may indicate underlying conditions that can become life-threatening if not treated effectively (Table 23.5). Pursed-lip breathing, nasal flaring, audible breathing, intercostal retraction (the “pulling in” of muscles between the ribs or in the neck when breathing), anxiety, and the use of accessory muscles are signs of respiratory difficulty and should be evaluated quickly to prevent complications or respiratory arrest.
| Abnormal Finding | Description |
|---|---|
| Prolonged expiration |
|
| “Tripod” positioning |
 (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license) |
| Barrel chest |
 (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license) |
| Kyphosis |
 (credit: “Posturalkyphosis.png” by "CarpalTunnelEx"/Wikimedia Commons, Public Domain) |
| Unequal chest expansion |
|
Table 23.5 Abnormal Findings of the Thorax Assessment
Real RN Stories
Assessing Respiratory Distress
Nurse: Jenna, BSN
Clinical setting: Emergency department
Years in practice: 1
Facility location: Inner city of a large metropolitan area in Missouri
I was a new nurse in a very busy emergency department. Between another wave of COVID-19, the flu, and car accidents due to the icy road conditions, we had maintained maximum capacity in the entire hospital for the last several weeks.
After performing a quick assessment on all seven of my patients at the beginning of my shift, I got a call from the charge nurse letting me know that I would be receiving a patient from a local nursing home who was reporting some shortness of breath. Almost immediately after getting off the phone with the charge nurse, EMS called and gave me a quick rundown about the patient’s situation. “Hi, Jenna, this is Gerry with EMS. We just picked up Ms. Smith from her nursing home where she was found hunched over, in a tripod position, on the side of her bed struggling to catch her breath. She reports getting up and going to the bathroom but when she got back to her bed, she couldn’t breathe effectively so she called the nurse. We put her on two liters of oxygen via nasal cannula and her oxygen saturation improved to 93 percent but she’s pretty anxious and breathing heavily, so we’re bringing her to the hospital just in case. See you shortly.”
Upon arrival, Ms. Smith appeared to be feeling better and her oxygen saturation was 96 percent. I performed a quick assessment, hooked her up to the monitor, and went to check on a few of my unstable patients. About an hour later, Ms. Smith’s oxygen alarm started going off. When I glanced at it, I noticed her oxygen saturation was 90 percent so I hurried over to her bed to check out the situation. When I got to her bed, the first thing I noticed was that her nostrils were flaring. Upon further assessment, I also noticed that she had put herself into a tripod position and her breathing was extremely rapid and shallow. I increased her oxygen to six liters and used my stethoscope to auscultate her lungs. I heard crackles and limited air movement. She was clearly struggling to breathe. At this point, I called a rapid response. Almost immediately, my charge nurse and several others came running. We got her stabilized and sent her for a chest x-ray. She was found to have a severe case of pneumonia. This story always reminds me of how we must pay attention to the details, even the little ones, because sometimes patients present stable and can quickly progress to a more unstable serious condition.
