Head & Neck, Assessment of Lungs & Thorax, Assessment of Breast &Axiallae

Areas to be included in the head and neck examination are the skull, face, eyes, ears, nose, mouth, pharynx, and neck. The carotid artery assessment is conducted either as part of the neck examination or with peripheral artery assessment. Inspection and palpation are used throughout this assessment. Auscultation is used if the carotid arteries are assessed as part of this examination. Table 1 containing Figures 27- 20 through 27-34 presents the specific areas of the head and neck to be examined and the normal and key findings of this assessment.

Skull and Face

Assessment of the skull and face involves inspection and palpation. The client’s face has its own unique characteristics influenced by factors such as race, state of health, emotions, and environment.

Eyes

Active client participation is needed for the various eye tests. To prevent client weakness or discomfort, the eye tests are separated by assessment of the eye’s externalanatomic structures. The nurse should practice holding and using the index finger to rotate the dial for the five lens settings of the ophthalmoscope before conducting the examination. The assessment of visual acuity is a simple, noninvasive

procedure that is performed with the use of a Snellen chart (a chart that contains various-sized letters with standardized numbers at the end of each line of letters) (Figure 27-19).The standardized numbers (called the denominator) indicate the degree of visual acuity when the client is able to read that line of letters at a distance of 20 feet.

COMMON ABNORMAL FACIES

• Exophthalmos is the protrusion or bulging of the eye that results from an increased pressure in the eye’s orbit (e.g., from tumor or inflammation).

• Acromegaly is characterized by an elongated head with prominent forehead, nose, and lower jaw and enlarged nose, lips, and ears resulting from excessive growth hormone.

• Cushing’s syndrome is a round or “moon” face with excessive hair growth (mustache and sideburns); it occurs in clients with excessive production of adrenal hormones or in clients taking adrenal hormone medications.

• Clients with chronic renal failure have pale, swollen tissue around their eyes.

• Parkinson’s disease causes decreased facial mobility and expressions, producing a masklike face; results from progressive, degenerative, neurologic disorders.

COMMON REFRACTIVE ERRORS

• Myopia (nearsightedness): elongation of the eyeball or an error of refraction that causes the parallel rays to focus in front of the retina.

• Hyperopia (farsightedness): an error of refraction in which rays of light entering the eye are brought into focus behind the retina.

• Presbyopia (farsightedness): an error of refraction resulting from a loss of elasticity of the lens of the eye.

• Astigmatism: an unequal spherical curve of the cornea that prevents the light rays from being focused directly in a point on the retina.

Figure 27-19 Snellen Chart

COMMON ABNORMAL BREATH ODORS

• Acetone breath (“fruity” smell) is common in malnourished or diabetic clients with ketoacidosis.

• Musty smell is caused by the breakdown of nitrogen and presence of liver disease.

• Ammonia smell occurs during the end stage of renal failure from a buildup of urea.

COMMON LIP LESIONS

• Herpes simplex (cold sores or fever blisters) are painful vesicular lesions that rupture and crust over.

• Chancre (primary lesion of syphilis) is a reddish round, painless lesion with a depressed center and raised edges that appears on the lower lip.

• Squamous cell carcinoma (most common form of oral cancer) usually involves the lower lip and may appear as a thickened plaque, ulcer, or warty growth.

Ears

Physical assessment of the ears consists of auditory screening, inspection and palpation of the external ear, and otoscopic assessment. The nurse should observe the

client for signs of hearing difficulty during the physical examination, such as turning the head, lipreading, and speaking in a loud voice. If the client is wearing a hearing aid, ask if it is turned on, when the batteries were last changed, and if the device causes any irritation to the ear canal.

Nose and Sinuses

Assessment is limited to inspection and palpation of the external nose and nasal passages using a penlight. An examination with a nasal speculum to inspect the nasalchambers is usually performed only by an advanced nurse practitioner because the nasal chambers are lined with respiratory mucosa. Clients with nasal impairments are at risk of developing respiratory infections. Sinus assessment is limited to palpation of the frontal and maxillary sinuses. Transillumination of the sinuses is usually limited to advanced practitioners.

TABLE 1

Assessment of Head and Neck: Normal and Key Findings

Area of Assessment/Normal Findings Skull and Face: Inspect	Key Findings
1. Observe shape and general size of skull and size of head in proportion to body.Rounded, smooth skull contour. 2. Inspect facial features for symmetry, involuntary movements, edema, and masses. Symmetrical facial features andmovement.	1. Enlarged skull size is indicative of hydrocephalus and Paget’s disease. 2. a. Sunken temples, eyes, and cheeks are indicative of dehydration and malnutrition (see ccompanying display for a description of common facies [expression orappearance of face]). b. Puffy, swollen appearance anterior to ear lobes and above angles of the jaw may indicate parotid gland enlargement (e.g., mumps).

Area of Assessment/Normal Findings Eyes: Inspect and Palpate

Key Findings

1. Assess visual acuity. a. Position Snellen chart 20 feet in front of client. b. Remove corrective lenses. c. Instruct client to cover one eye and read lines, starting with top of chart from left to right (Figure 27-20); note the line where the client correctly reads more than half the letters. d. Record results as a fraction sc (without correction), 20/distance number, and the number of letters missed for the eye test. e. Repeat steps a–d for other eye. f. If appropriate, repeat steps a–e with client wearing corrective lenses, record result cc (with correction). Normal vision, based on the Snellen chart, is 20/20 (at a distance of 20 feet the normal eye can read the chart).

1. A value of 20/40 means that a client can read at a distance of 20 feet what a person with normal vision can read at a distance of 40 feet (see the accompanying display for common refractive errors).

Figure 27-20 Assessing Visual Acuity

Figure 27-21 Testing Extraocular Muscle Function. A. Basic Position.

Figure 27-21 Testing Extraocular Muscle Function. B. Normal Resting Position.

Figure 27-21 Testing Extraocular Muscle Function. C. Conjugate Left Lateral Gaze.

Figure 27-21 Testing Extraocular Muscle Function. D. Left Down and Lateral Gaze.

Figure 27-21 Testing Extraocular Muscle Function. E. Right Down and Lateral Gaze.

Figure 27-21 Testing Extraocular Muscle Function. F. Conjugate Right Lateral Gaze.

Figure 27-21 Testing Extraocular Muscle Function. G. Right Up and Lateral Gaze.

Figure 27-21 Testing Extraocular Muscle Function. H. Left Up and Lateral Gaze.

TABLE 1 (continued)

Assessment of Head and Neck: Normal and Key Findings

Area of Assessment/Normal Findings

Key Findings

2. Test extraocular muscle function: a. Instruct client to follow your finger held 6 to 12 inches in front of eyes. Move your finger through the eight vision fields of gaze (Figure 27-21). b. Observe for parallel eye movement. c. Pause during upward and lateral gaze fields to detect involuntary movement of the eyes. d. Note position of the upper eyelid in relation to the iris and eyelid lag as the client’s eyes move from up to down. e. Record results. Eye movements should be symmetrical as both eyes follow the direction of the gaze. The upper eyelidscover only the uppermost part of the iris and are free from nystagmus (involuntary, rhythmical oscillation of the eyes). 3. External anatomic structures (Figure 27-22).

2. Asymmetrical movement or the presence of nystagmus results from local injury to eye muscles and supporting structures or a cranial nerve disorder.

Figure 27-22 External Structures of the Eye

Area of Assessment/Normal Findings

Key Findings

a. Observe upper eyelid. Upper eyelid should overlap iris. b. Check eyes and eyelids for inflammation, crusting, edema, or masses. Eyes and eyelids should be free from inflammation, crusting, edema, or masses. c. Inspect and palpate lacrimal glands and sacs for swelling. If lacrimation is excessive: (1) Check for blockage of the nasolacrimal duct by pressing against inner orbital rim of lacrimal sac. (2) Inspect duct blockage by palpating on the lacrimal sac and observing for regurgitation of fluid. Lacrimal gland should not be palpable. Tears flow freely from the lacrimal gland over the cornea and conjunctiva to the lacrimal duct. d. Inspect conjunctiva and sclera by instructing client to look upward while you depress lower lid with your thumb.Conjunctiva and lens should be transparent and the sclera should be a light yellow color in dark-skinned clients and a white porcelain color in light-skinned clients. e. Inspect cornea, lens, pupil, and iris.Pupils are black, round, and equal in size, 3–7 mm in diameter (see theaccompanying display). The margins of the iris should be intact. f. Test pupillary responses to light and reaction to accommodation in a dimly lit room. (1) Instruct client to look straight ahead. (2) Bring the penlight from the side of the client’s face to directly in front of the pupil (Figure 27-23A). (3) Note the quickness of response to light. (4) Shine light into same eye, observing response of opposite pupil for equality of size (Figure 27-23B). (5) Repeat steps 2–4, opposite eye. (6) Instruct client to gaze at your finger held 4–6 inches from her nose, then to glance at a distant object while you note pupillary reflex. (7) Move the finger toward the bridge of the client’s nose, noting response of both pupils. (8) Record results PERRLA (pupils equal, round, reactive to light and accommodation). Pupil should constrict quickly in direct response to light and the opposite pupil should also constrict. Pupils should be equal in size. Pupillary accommodationcauses constriction in response to objects that are near, and dilation occurs to accommodate distant vision, with symmetrical convergence of eyes.

a. Upper eyelid should not overlap pupil. b. Red lid margins with yellowish scales result from an inflammation of the eyelids (blepharitis). Presence of inflammation, crusting, edema, or masses may indicateacute hordeolum (sty), a painful, red infection of a hair follicle of the eyelashes; chalazion (chronic inflammatory lesion of the meibomian gland); or basal cell carcinoma (papule with a pearly border and a depressed or ulcerated center) of the lower lid. c. Swelling of lacrimal sac indicates dacryocystitis (inflammation) or tumor. Regurgitation of tears through the puncta indicates blockage of lacrimal duct. d. Bright red conjunctiva with crusty drainage occurs with conjunctivitis (contagious infection of the conjunctiva). A pale conjunctiva usually indicates anemia. Bright red patch on the exposed bulbar conjunctiva is a subconjunctival hemorrhage that may result from trauma or sudden increase in venous pressure (e.g., cough orbleeding disorder). e. Opacity of the lens (loss of transparency) occurs with cataracts caused most commonly by aging (senile cataract). Cloudy pupils occur with cataracts. f. Altered pupillary reaction time and equality occur with increased intracranial pressure, lesions involving the third cranial nerve, trauma, or some medications.Pupillary constriction occurs with inflammation of the iris or in response to medication (e.g., pilocarpine or morphine). Pupillary dilation may occur with trauma,neurologic disorders, glaucoma, or in response to medication (e.g., atropine).

Figure 27-23 A. Move penlight from side of client’s face to eye.

Figure 27-23 B. Shine

penlight into the eye and observe response of the opposite pupil.

TABLE 1 (continued)

Assessment of Head and Neck: Normal and Key Findings

Area of Assessment/Normal Findings

Key Findings

4. Test visual fields. a. Stand 2 feet in front of the client. b. Instruct client to cover the right eye, while you cover your left eye, and ask client to look into your eye directly opposite to create one vision field. c. Using the eight directions of gaze (see Figure 27-21), move your finger outside the vision field and slowly bring your finger back midpoint into the vision field for each direction of gaze. When testing the temporal field, bring your finger from behind the client. d. Instruct client to tell you when your finger becomes visible. e. Note if you see the finger before the client does. f. Repeat steps c and d for each field of vision. g. Record results, indicating eye tested. h. Repeat steps b–g with other eye.Consensual peripheral vision should occur when the nurse’s finger comes into the client’s visual field. 5. Inspect fundus with ophthalmoscope. a. Set ophthalmoscope at 0 diopters. b. Instruct client to gaze at a designated point on the far wall, keeping both eyes open during the examination. c. With your right hand, hold the ophthalmoscope 10 inches from the client and use your right eye to examine theclient’s right eye. Rest your left hand on client’s forehead. d. Shine the light on the pupil and locate the red reflex (bright, orange glow). e. Slowly move the ophthalmoscope closer until the retina is seen. While rotating the lens, dial to focus on the internal structures (Figure 27-24). f. Assess the size, color, and clarity of the optic disc. g. Carefully follow the blood vessel central to the optic disc into each of the four quadrants, observing for lesions (hemorrhages or exudates). h. Inspect the appearance of the macula, lateral to optic disc. i. Repeat steps a–h using your left eye and left hand to examine the client’s left eye. j. Record findings.

4. Loss of peripheral vision occurs in glaucoma (a circulatory disturbance that causes an increase in intraocular [aqueousfluid] pressure). 5. Changes in color, size, or clarity of the margins of the optic disc or the identification of lesions should be recorded and reported; a follow-up examination by an ophthalmologist should be scheduled.

Figure 27-24 Landmarks of the Retina

TABLE 1 (continued)

Assessment of Head and Neck: Normal and Key Findings

Area of Assessment/Normal Findings Ears: Inspect and Palpate 1. Examine external ears for placement, symmetry, and color (Figure 27-25).Symmetrical, with upper attachment at level of eye’s corner (lateral canthus), flesh color. 2. Observe auricle for discharge, swelling, and redness, and palpate for lesions or tenderness by moving auricle and pressing on tragus and mastoid process. Firm, smooth, free from lesions and pain. 3. Select largest ear speculum to accommodate the client’s ear canal. Attach speculum to otoscope to inspect the earcanal and eardrum. a. Tip client’s head and straighten ear canal by grasping and pulling the auricle upward, back, and slightly outward. b. Insert the speculum and examine the canal for ear wax, foreign bodies, discharge, scaliness, redness, or swelling. If wax or a foreign body is present, stop theexamination and notify the nursing supervisor. c. Inspect the tympanic membrane by sliding speculum slightly down and forward. If membrane is not visible, gently pull the tragus slightly farther to straighten the canal. d. Identify the color, light reflex, umbo, the short process, and long handle of the malleus. Note perforations, lesions, bulging or retraction of the membrane, dilatation of blood vessels, bubbles or fluid level (Figure27-26). e. Gently withdraw the speculum and repeat procedure in opposite ear. Cerumen, a waxy yellow or brown substance is normal. Ear canal is pinkish and dry. Intact tympanic membrane, translucent or pearly gray. Light reflex is seen at 5 o’clock in right ear and 7 o’clock in left ear.

Key Findings 1.Ears set below lateral canthus occur with congenital anomalies (e.g., Down syndrome). Redness indicates inflammation or fever. Clear or bloody rainage may indicate leakage of cerebrospinal fluid; if present, stop the examination and notify the nursing supervisor immediately. 2. Flaky, scaly skin is seen with seborrhea. Sebaceous cysts are common behind the ear. Keloids (scar tissue) on the ear lobemay result from ear piercing. Yellow or green discharge, itching, or pain occurs with an ear infection (otitis media). 3. Buildup of cerumen, a normal moist, waxy yellow substance that turns hard, dry, and dark yellow-brown when impacted, may cause temporary hearing loss. Swollen or reddened canal with discharge occurs with infection. Nontender, nodular swelling deep in the ear canal suggests osteoma (usually a benign tumor composed of bone tissue). Red, bulging membrane indicates acute purulent otitis media; whitish appearance on tympanic membrane results from pus in the middle ear. Perforations of the eardrum result from infection.

Figure 27-25 External Structures of the Ear

Figure 27-26 Tympanic Landmarks

TABLE 1 (continued)

Assessment of Head and Neck: Normal and Key Findings

Area of Assessment/Normal Findings

Key Findings

4. Test auditory acuity. a. Whispered voice test: (1) Instruct client to occlude one ear with finger and repeat the words when heard. (2) Nurse stands 1–2 feet away from client, out of view to avoid client lipreading, and softly whispers numbers on side of open ear. Increase voice volume until client identifies words correctly. (3) Repeat procedure on other ear. (4) Record results. Client should be able to repeat whispered words. b. Weber test: (1) Strike tuning fork against your fist or pinch the prongs together. (2) Hold the base of the vibrating fork with your thumb and index finger and place the base of the fork on center of top of client’s head (Figure 27-27). (3) Ask client to describe the sound. (4) Record results. Sound perceived equally in both ears; results indicate a “negative” Weber test. c. Rinne test: (1) Vibrate prongs of tuning fork and place base of fork on mastoid process of ear being tested and note the time on your watch until the client no longer hears sound (Figure 27-28A) (2) Move the vibrating fork in front of the ear canal, noting the length of time sound is heard (Figure 27-28B). (3) Record results. (4) Repeat test, opposite ear. Sound heard longer in front of the right auditory meatus than on the mastoid process because air conduction is twice as long as bone.

a. Inability to hear words may indicate a high-frequency hearing loss (e.g., resulting from excessive exposure to loud noises). b. Results “positive” from Weber test when sound lateralizes to affected ear with a unilateral conductive hearing loss. Occurs with impacted cerumen, perforated tympanic membrane, serum or pus in the middle ear, or fusion of the ossicles. Sound can also lateralize to unaffected ear with sensorineural hearing loss. Occurs withinner ear disorders, auditory nerve damage, or results from repeated, prolonged loud noise or effects of ototoxic drugs. c. Bone conduction is equal to or greater than air conduction. Occurs with conductive hearing loss resulting from diseases, obstruction, or damage to outer or middle ear.

Figure 27-27 Weber test: Place the base of the tuning fork on the

top of the client’s head.

Figure 27-28 Rinne test. A. Place the base of the fork on the mastoid

process.

Figure 27-28 Rinne test. B. Place tuning fork in front of ear canal.

TABLE 1 (continued)

Assessment of Head and Neck: Normal and Key Findings

Area of Assessment/Normal Findings

Key Findings

Nose and Sinuses: Inspect, Palpate, and Percuss 1. Inspect the nose for symmetry, deformity, flaring, or inflammation and discharge from the nares. Located symmetrically, midline of the face and is without swelling, bleeding, lesions, or masses. 2. Test patency of each nostril. a. Instruct the client to close the mouth and apply pressure on one naris and breathe. b. Repeat test on opposite naris. Each nostril is patent. 3. Inspect the nasal cavities with a penlight. a. Tilt the client’s head in an extended position. b. Place nondominant hand on client’s head. Using your thumb, lift the tip of the nose. c. With the lit penlight, assess each nostril: note color of anterior nares, nasal septum for deviation, perforation, lesions, or bleeding, and inspect for swelling, discharge. Mucosa is pink or dull red without swelling or polyps. Septum is midline and intact. A small amount of clear watery discharge is normal. 4. Palpate the nasal sinuses (Figures 27-29 and 27-30) by applying gentle, upward pressure on frontal and maxillary areas, avoiding pressure on the eyes. Percuss area with middle or index finger and note the sound. Nontender, airfilled cavities, resonant to percussion.

1. Swollen or broken as a result of trauma or surgery. 2. Air cannot move through the nostril. May occur with a deviated septum, foreign body, upper respiratory infection, allergies, or nasal polyps. 3. Rhinitis, red, swollen mucosa with copious clear, watery discharge occurs with a cold. Discharge becomes purulent if a secondary bacterial infection develops. Pale, edematous mucosa with clear, watery discharge occurs with allergies or hay fever. A normal mucosa with clear, watery nasal discharge that tests positive for glucose following head injury or nasal, sinus, or dental surgery usually indicates the leakage of cerebrospinal fluid. If present, stop the exam and notify the nursing supervisor immediately. 4. Pain or tenderness may be caused by viral, bacterial, or allergic processes that cause inflammation and obstruction,eliciting a dull sound.

Figure 27-29 Palpating Frontal Sinuses

Figure 27-30 Palpating Maxillary Sinuses

TABLE 1 (continued)

Assessment of Head and Neck: Normal and Key Findings

Area of Assessment/Normal Findings

Key Findings

Mouth and Pharynx: Inspect and Palpate 1. Stand 12–18 inches in front of client and smell the breath. Breath should smell fresh. 2. Observe the lips for color, moisture, swelling, or lesions. Instruct client to open mouth. With a tongue depressor, retract the buccal mucosa and note color, hydration, inflammation, or lesions (Figure 27-31). Invert lower lip with your thumbs on inner oral mucosa, note muscle tone; repeat with upper lips using thumbs and index fingers.Lips and mucosa should be pink, firm, and moist without inflammation or lesions. 3. If present, remove dentures. Retract the cheeks with a tongue depressor and inspect gums (gingivae). Note color, edema, retraction, bleeding, and lesions. Palpate the gums with the tongue blade for texture.Gums are pink, smooth moist, and firm. 4. Instruct client to clench teeth. Note position and alignment. Inspect teeth: use tongue depressor to expose the molars. Note tartar, cavities, extraction, and color. Properly aligned, smooth, white, and shiny. 5. Instruct client to protrude the tongue. a. Inspect dorsum of tongue. Note color, hydration, texture, symmetry, presence or absence of fasciculations (Figure 27-32). b. With penlight, inspect sides and ventral surface. Note size, texture, nodules, or ulcerations. c. Grasp tongue with gauze. Gently pull it to one side and palpate the full length of tongue. d. With penlight, inspect floor of mouth, salivary glands, and duct openings. When protruded, tongue lies midline medium red or pink in color, moist and smooth along lateral margins, with free mobility. Ventral surface is slightly rough (taste buds), and dorsum is highly vascular. 6. Inspect the hard and soft palate with penlight. a. Instruct client to extend head backward and hold mouth open. b. Inspect the hard palate (roof of mouth), located anteriorly, and the soft palate, which extends posteriorly to pharynx. Note color, shape, lesions. Palates are concave and pink. Hard palate has ridges; soft palate is smooth. 7. Inspect the pharynx using a tongue depressor and penlight. a. Explain procedure to the client. b. Instruct client to tilt head back and open mouth. c. With your nondominant hand, place tongue depressor on middle third of tongue. With dominant hand, shine light into back of throat. d. Instruct client to say “ah.” Note the position, size, and appearance of tonsils and uvula. e. If palate and uvula fail to rise symmetrically with phonation, inform client about eliciting gag reflex (touch the posterior one-third of tongue with blade tostimulate the gag reflex) and inspect as stated in step 7d. With phonation, the soft palate and uvula rise symmetrically. The pharynx is pink, vascular, lesion-free.

1. Halitosis (foul-smelling breath) occurs with tooth decay or disease of gums, tonsils, or sinuses or with poor oral hygiene (see the accompanying display for common abnormal breath odors). 2. Pale or cyanotic lips may indicate systemic hypoxemia. Dry, cracked lips occur with dehydration or exposure toweather. Swollen lips (angioneurotic edema) result from allergic reactions (e.g., medication or food; see the accompanying display for common lip lesions). 3. Pale gums that bleed easily may indicate periodontal disease or vitamin C deficiency. 4. Chalky white discoloration of teeth’s enamel indicates early formation of dental caries (cavities). Brown or blackdiscoloration indicates formation of caries. 5. Enlarged tongue may indicate glossitis or stomatitis or may occur with myxedema, acromegaly, or amyloidosis. Deep red, smooth surface occurs with glossitis caused by vitamin B12, iron, or niacin deficiency or as a side effect from chemotherapy. Thick white coating with red, raw surface iscandidiasis (thrush) indicating immunosuppression. Lesions on ventral surface or hardened areas or ulcerations on the lateral surface may indicate cancer. 6. Cleft palate (maxillary processes fail to fuse prenatally) is a congenital defect. Red, swollen, tender palates indicate infection. Eroded lesion on hard palate may indicate cancer. 7. Reddened, edematous uvula and tonsillar pillars with yellow exudate indicate pharyngitis. Swollen, gray membranes and tonsillar enlargement may result from acutetonsillitis, infectious mononucleosis, or diphtheria.

Figure 27-31 Inspecting Buccal Mucosa

Figure 27-32 Structures of the Tongue

TABLE 1 (continued)

Assessment of Head and Neck: Normal and Key Findings

Area of Assessment/Normal Findings

Key Findings

Neck: Inspect, Palpate, and Auscultate 1. Inspect for symmetry and musculature. Instruct client to: a. Flex chin to chest and to each side and shoulder to test anterior sternocleidomastoid muscle. b. Hyperextend the neck backward to test posterior trapezia. Muscles are symmetrical with head in central position. Movement through full range of motion withoutcomplaint of discomfort or limitation. 2. Palpate lymph nodes. Instruct the client to relax and flex neck slightly forward. a. Stand in front of client. b. Methodically palpate anterior cervical nodes (Figure 27-33A) and posterior cervical nodes (Figure 27-33B) with fingerpads of middle three fingers in small circles with gentle pressure. c. Note size, shape, mobility, consistency, and tenderness. Lymph nodes should not be palpable. Small, movable nodes are insignificant. 3. Inspect and palpate trachea. a. Note position. b. Place thumbs and index fingers on sides of trachea. Apply gentle pressure and palpate. Midline position above the suprasternal notch. 4. Palpate the thyroid by standing behind the client (Figure 27-34A). Instruct the client to slightly extend neck. (Thyroid can also be palpated standing in front of client; Figure 27-34B.) a. Rest thumbs on nape of neck. b. Place index and middle fingers of both hands on thyroid isthmus and anterior surfaces of lateral lobes. c. Ask client to swallow. You should feel the isthmus rising under your fingers and feel each lateral lobe before and while client swallows. d. Ask client to flex neck forward and to left, and displace thyroid cartilage to right with tips of your left fingers. Note any bulging of gland. e. Palpate with your right hand, placing thumb deep into and behind sternocleidomastoid muscle with index andmiddle fingers in front. Ask client to swallow. Note any enlargement of gland. f. Repeat steps 4d and e on opposite side. g. If gland appears enlarged, place the diaphragm of stethoscope over gland. Note on auscultation a vibration (soft, rushing sound, or bruit). Thyroid cannot bevisualized. It should be smooth, soft, nontender, and should not be enlarged.

1. Pain with flexion or rotation of head is associated with muscle spasm that may be caused by inflammation of muscles, meninges, or diseases of the vertebrae.Prominent lateral deviation of sternocleidomastoid muscles (torticollis) is commonly associated with inflammation of viral myositis or trauma (e.g., sleeping with head in unusual position). Decreased range of motion is commonly associated with degenerative osteoarthritis. 2. Palpable nodes may result from a variety of diseases, most commonly an infectious process or malignancy. 3. Lateral displacement may be caused by a neck or mediastinum mass or pulmonary disorders. 4. Masses or enlargement during swallowing may indicate a goiter (enlarged thyroid gland) or thyroid nodules indicating thyroid disease. Vibrations or bruits heard on auscultation occur with increased turbulence in a vessel and are caused by increased vascularization of the gland (enlarged toxic goiter).

Figure 27-33 Palpating the Cervical Lymph Nodes: A. Anterior Approach.

Figure 27-33 Palpating the Cervical Lymph Nodes. B. Posterior Approach.

Figure 27-34 Palpating the Thyroid: Posterior Approach.

Figure 27-34 Palpating the Thyroid:  Anterior Approach.

Mouth and Pharynx

Physical assessment of the oral cavity includes the breath, lips, tongue, buccal mucosa, gums and teeth, hard and soft palate, and pharynx. If the client is wearing dentures or removable orthodontia, remove these devices before examination to visualize and palpate the gums. The oral cavity can yield significant information regarding the client’s health because systemic diseases may manifest initially in the oral cavity.

Neck

Physical examination of the neck includes the neck muscles, lymph nodes of the head and neck, thyroid gland, and trachea. The lymph nodes are normally not easily palpable. If the client has an enlarged thyroid gland, the blood supply will be increased, causing a fine vibration that can be auscultated with the diaphragm of the stethoscope.

ASSESSMENT OF LUNGS AND THORAX

The number of clients with chronic respiratory problems is increasing. Respiratory disorders are common and rank as the fifth leading cause of death in the United States. They can contribute to physical and lifestyle limitations. In addition, many acute health problems, medical therapies, and surgical interventions adversely affect respiratory function temporarily or permanently. An adequate knowledge of anatomy, physiology, pathophysiology, and various diagnostic tests is needed to assess the client with respiratory problems.

ANATOMY AND PHYSIOLOGY REVIEW

The two purposes of the respiratory system are to provide a source of oxygen for tissue metabolism and to remove carbon dioxide, the major waste product of metabolism. The respiratory system also influences the following functions:

• Acid-base balance

• Speech

• Sense of smell

• Fluid balance

• Thermoregulation

Upper Respiratory Tract

The upper airways consist of the nose, the sinuses, the pharynx (throat), and the larynx ("voice box").

NOSE AND SINUSES

The nose is the organ of smell, with receptors from cranial nerve I (olfactory) located in the upper areas. This organ is a rigid structure that contains two passages separated in the middle by the septum. The upper one third of the nose is composed of bone; the lower two thirds is composed of cartilage, which allows limited movement. The septum and interior walls of the nasal cavity are lined with mucous membranes that have a rich blood supply. The anterior nares (nostrils or external openings into the nasal cavities) are lined with skin and hair follicles, which help keep foreign particles or organisms from entering the lungs. The posterior nares are openings from the nasal cavity into the nasopharynx.

Three bony projections (turbinates) protrude into the nasal cavities from the walls of the internal portion of the nose. Turbinates increase the total surface area for filtering, heating, and humidifying inspired air before it passes into the nasopharynx. Inspired air entering the nose is first filtered by vibrissae in the nares. Particles not filtered out in the nares are trapped in the mucous layer of the turbinates. These particles are moved by cilia (hairlike projections) to the oropharynx, where they are either swallowed or expectorated. Inspired air is humidified by contact with the mucous membrane and is warmed by exposure to heat from the vascular network.

The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Lined with ciliated epithelium, the purposes of the sinuses are to provide resonance during speech and to decrease the weight of the skull.

PHARYNX

The pharynx, or throat, serves as a passageway for both the respiratory and digestive tracts and is located behind the oral and nasal cavities. It is divided into the nasopharynx, the oropharynx, and the laryngopharynx.

The nasopharynx is located behind the nose, above the soft palate. It contains the adenoids and the distal opening of the eustachian tube. The adenoids (pharyngeal tonsils) are an important defense, trapping organisms that enter the nose or mouth. The eustachian tube connects the nasopharynx with the middle ear and opens during swallowing to equalize pressure within the middle ear.

The oropharynx is located behind the mouth, below the nasopharynx. It extends from the soft palate to the base of the tongue and is a shared passageway for breathing and swallowing. The palatine tonsils (also known as faucial tonsils) are located on the lateral borders of the oropharynx. These tonsils also guard the body against invading organisms.

The laryngopharynx is located behind the larynx and extends from the base of the tongue to the esophagus. The laryngopharynx is the critical dividing point where solid foods and fluids are separated from air. At this point, the passageway divides into the larynx and the esophagus.

LARYNX

The larynx is located above the trachea, just below the pharynx at the base of the tongue. It is innervated by the recurrent laryngeal nerves. The larynx is composed of several cartilages. The thyroid cartilage is the largest and is commonly referred to as the Adam's apple. The cricoid cartilage, which contains the vocal cords, lies below the thyroid cartilage. The cricothyroid membrane is located below the level of the vocal cords and joins the thyroid and cricoid cartilages. This site is used in an emergency for access to the lower airways. In this procedure, called a cricothyroidotomy (or cricothyrotomy), an opening is made between the thyroid and cricoid cartilage and results in a tracheostomy. The two arytenoid cartilages, which attach at the posterior ends of the vocal cords, are used together with the thyroid cartilage in vocal cord movement.

Inside the larynx are two pairs of vocal cords: the false vocal cords and the true vocal cords. The opening between the true vocal cords is the glottis. The epiglottis is a leaf-shaped, elastic structure that is attached along one edge to the top of the larynx. Its hinge-like action prevents food from entering the tracheobronchial tree (aspiration) by closing over the glottis during swallowing. The epiglottis opens during breathing and coughing.

Lower Respiratory Tract

The lower airways consist of the trachea; two mainstem bronchi; lobar, segmental, and subsegmental bronchi; bronchioles; alveolar ducts; and alveoli. The tracheobronchial tree is an inverted treelike structure consisting of muscular, cartilaginous, and elastic tissues. This system of continually branching tubes, which decrease in size from the trachea to the respiratory bronchioles, allows gases to move to and from the pulmonary parenchyma. Gas exchange takes place in the pulmonary parenchyma between the alveoli and the pulmonary capillaries.

TRACHEA

The trachea (windpipe) is located in front of (anterior to) the esophagus. It begins at the lower edge of the cricoid cartilage of the larynx and extends to the level of the fourth or fifth thoracic vertebra. The trachea branches into the right and left mainstem bronchi at the carina.

The trachea is composed of 6 to 10 C-shaped cartilaginous rings. The open portion of the С is the back portion of the trachea and contains smooth muscle that is shared with the esophagus. Low pressure must be maintained in endotracheal and tracheostomy tube cuffs to avoid causing erosion of this posterior wall and to avoid creating a tracheoesophageal fistula (abnormal connection between the trachea and the esophagus).

MAINSTEM BRONCHI

The mainstem, or primary, bronchi begin at the carina. The bronchus is similar in structure to the trachea. The right bronchus is slightly wider, shorter, and more vertical than the left bronchus. Because of the more vertical line of the right bronchus, it can be accidentally intubated when an endotracheal tube is passed. Similarly, when a foreign object is aspirated from the throat, it most often enters the right bronchus.

LOBAR, SEGMENTAL, AND SUBSEGMENTAL BRONCHI

The mainstem bronchi further branch into the five secondary (lobar) bronchi that enter each of the five lobes of the lung. Each lobar bronchus is surrounded by connective tissue, blood vessels, nerves, and lymphatics, and each branches into segmental and subsegmental divisions. The cartilage of these lobar bronchi is ringlike and resists collapse. The bronchi are lined with ciliated, mucus-secreting epithelium. The cilia propel mucus up and away from the lower airway to the trachea, where the mucus is either expectorated or swallowed.

BRONCHIOLES

The bronchioles branch from the secondary bronchi and subdivide into smaller and smaller tubes: the terminal and respiratory bronchioles. These terminal and respiratory tubes are less than 1 mm in diameter. They have no cartilage and therefore depend entirely on the elastic recoil of the lung to remain open (patent). The terminal bronchioles do not participate in gas exchange.

ALVEOLAR DUCTS AND ALVEOLI

Alveolar ducts, which resemble a bunch of grapes, branch from the respiratory bronchioles. Alveolar sacs arise from these ducts. The alveolar sacs contain clusters of alveoli, which are the basic units of gas exchange. A pair of healthy adult lungs contains approximately 300 million alveoli, which are surrounded by pulmonary capillaries. Because these small alveoli are so numerous and share common walls, the surface area for gas exchange in the lungs is extensive. In a healthy adult, this surface area is approximately the size of a tennis court. Acinus is a term used to indicate the structural unit consisting of a respiratory bronchiole, an alveolar duct, and an alveolar sac.

In the walls of the alveoli, specific cells (type II pneumocytes) secrete surfactant, a fatty protein that reduces surface tension in the alveoli. Without sufficient surfactant, atelectasis (collapse of the alveoli) ultimately occurs. In atelectasis, gas exchange is reduced because the alveolar surface area is reduced.

LUNGS

The lungs are sponge-like, elastic, cone-shaped organs located in the pleural cavity in the thorax. The apex (top) of each lung extends above the clavicle; the base (bottom) of each lung lies just above the diaphragm (the major muscle of inspiration). The lungs are composed of millions of alveoli and their related ducts, bronchioles, and bronchi. The right lung, which is larger than the left, is divided into three lobes: upper, middle, and lower. The left lung, which is somewhat narrower than the right lung to make room for the heart, is divided into two lobes.

The hilum is the point at which the primary bronchus, pulmonary blood vessels, nerves, and lymphatics enter each lung. Innervation of the chest wall is via the phrenic (pleura) and intercostal (diaphragm, ribs, and muscles) nerves. Innervation of the bronchi is via the vagus nerve.

The pleura is a continuous smooth membrane composed of two surfaces that totally enclose the lung. The parietal pleura lines the inside of the thoracic cavity and the upper surface of the diaphragm. The visceral pleura covers the lung surfaces, including the major fissures between the lobes. These two surfaces are lubricated by a thin fluid that is produced by the cells lining the pleura. This lubrication allows the surfaces to glide smoothly and painlessly during respirations.

Blood flow through the lungs occurs via two separate systems: bronchial and pulmonary. The bronchial system carries the blood necessary to meet the metabolic demands of the lungs. The bronchial arteries, which arise from the thoracic aorta, are part of the systemic circulation and do not participate in gas exchange.

The pulmonary circulation is composed of a highly vascular capillary network. Oxygen-depleted blood travels from the right ventricle of the heart into the pulmonary artery, which eventually branches into arterioles that form the capillary networks. The capillaries are enmeshed around and through the alveoli, the site of gas exchange. Freshly oxygenated blood travels from the capillaries and through the venules to the pulmonary veins and then to the left atrium. From the left atrium, oxygenated blood flows into the left ventricle, where it is pumped throughout the systemic circulation.

Accessory Muscles of Respiration

Breathing occurs through changes in the size of and pressure within the thoracic cavity. Contraction and relaxation of specific skeletal muscles (and the diaphragm) cause changes in the size and pressure of the thoracic cavity. Accessory muscles of respiration include the scalene muscles, which elevate the first two ribs; the sternocleidomastoid muscles, which raise the sternum; and the trapezius and pectoralis muscles, which fix the shoulders. In addition, various back and abdominal muscles are used when the work of breathing is increased.

Respiratory Changes Associated with Aging

Many changes associated with older clients result from heredity and a lifetime of exposure to environmental stimuli (e.g., cigarette smoke, bacteria, air pollutants, and industrial fumes and irritants). Table 27-1 shows the age-related changes in the partial pressure of arterial oxygen (Pao₂).

Respiratory disease is a major cause of acute illness and chronic disability in older clients. Although respiratory function normally declines with age, there is usually little difficulty with the demands of ordinary activity. However, the sedentary older adult often reports feeling breathless during exercise.

It is difficult to determine which respiratory changes in older adults are related to normal aging and which changes are pathologic and associated with respiratory disease or exposure to pollutants. In addition, age-related disorders of the neuromuscular and cardiovascular systems may cause abnormal respiration, even if the lungs are normal.

ASSESSMENT TECHNIQUES

History

Obtaining accurate information from the client is important in determining the type and severity of pulmonary problems.

DEMOGRAPHIC DATA

Age, gender, and race can affect the physical and diagnostic findings related to respiratory function. Many of the diagnostic studies relevant to respiratory disorders (e.g., pulmonary function tests) use these demographic data for determining predicted normal values.

PERSONAL AND FAMILY HISTORY

Medical History

The nurse asks clients about their own respiratory history and that of their family members. The family history is obtained to consider respiratory disorders with a genetic component, such as cystic fibrosis, some lung cancers, and alpha,-antitrypsin deficiency (one risk factor for emphysema). Clients with asthma often have a family history of allergic symptoms and reactive airways. The nurse assesses for a history of infectious disease, such as tuberculosis, and considers that family members may have similar environmental or occupational exposures.

Smoking History

The nurse questions the client about the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances, and he or she notes whether the client has passive exposure to smoke in the home or workplace. If the client smokes, the nurse asks for how long, how many packs a day, and whether the client has quit smoking (and how long ago). The smoking history is documented in pack-years (number of packs smoked per day multiplied by number of years). Because the client may have guilt or denial about this habit, the nurse assumes a nonjudgmental attitude during the interview.

Smoking induces anatomic changes in the large and peripheral airways, and these changes lead to varying degrees of airway obstruction. Men who continue to smoke experience a more rapid decline in their pulmonary function than do non-smokers. The pulmonary function of clients who have quit smoking for 2 or more years appears to decline less rapidly than in clients who continue to smoke.

Medication Use

The nurse asks about medications taken for breathing problems and about drugs taken for other conditions. For example, a cough can be a side effect of the angiotensin-converting enzyme (ACE) inhibitors. The nurse determines which over-the-counter medications (e.g., cough syrups, antihistamines, decongestants, inhalants, and nasal sprays) the client is using.

The use of home remedies also is assessed. The client is asked about past medication use and the reason for its discontinuation. For example, he or she may have used numerous bronchodilator metered dose inhalers but may prefer one particular drug for relieving breathlessness. In addition, some medications for other conditions can cause permanent changes in pulmonary function. For example, clients may have residual pulmonary fibrosis if they received bleomycin (Blenoxane) as chemotherapy for cancer or amiodarone (Cordarone) for cardiac problems.

Allergies

Information about allergies is important to the respiratory history. The nurse determines whether the client has any known allergies to environmental substances such as foods, dust, molds, pollen, bee stings, trees, grass, animal dander and saliva, or medications. The client is asked to explain a specific allergic response. For example, does he or she wheeze, have trouble breathing, cough, sneeze, or experience rhinitis after exposure to the allergen? Has he or she ever been treated for an allergic response? If the client has received treatment for allergies, the nurse asks about the circumstances leading up to the need for treatment, the type of treatment, and the response to treatment.

Travel and Area of Residence

Travel and area of residence may be relevant for a history of exposure to certain diseases. For example, histoplasmosis, a fungal disease caused by inhalation of contaminated dust, is found in the central United States, the Mississippi and Missouri river valleys, and Central America. Coccidioidomycosis, another fungal disease, is found predominantly in the western and southwestern United States, Mexico, and portions of Central America.

DIET HISTORY

An evaluation of the client's diet history may reveal allergic reactions to certain foods or preservatives. Signs and symptoms range from rhinitis, chest tightness, weakness, shortness of breath, urticaria, and severe wheezing to loss of consciousness. The nurse documents in a prominent location of the client's record any known allergies and the specific type of allergic response experienced. The client is asked about his or her usual food intake and whether any symptoms occur with eating. Malnutrition may occur if he or she has difficulty breathing during eating or the food preparation process.

OCCUPATIONAL HISTORY AND SOCIOECONOMIC STATUS

The nurse considers the home, community, and workplace for environmental factors that could cause or contribute to lung disease. Occupational pulmonary diseases include pneumoconiosis, which results from the inhalation of dust (e.g., coal dust, stone dust, silicone dust); toxic lung injury; and hypersensitivity disease (e.g., hypersensitivity to latex). The occupational history includes the exact dates of employment and a brief job description. Exposure to industrial dusts of any type or to the noxious chemicals found in smoke and fumes may cause respiratory disease. Coal miners, stone masons, cotton handlers, welders, potters, plastic and rubber manufacturers, printers, farm workers, and steel foundry workers are among the most susceptible.

The nurse obtains information about the home and living conditions, such as the type of heat used (e.g., gas heater, wood-burning stove, fireplace, and kerosene heater) and exposure to environmental irritants (e.g., noxious fumes, chemicals, animals, birds, and air pollutants). The client is asked about hobbies and leisure activities. Pastimes such as painting, working with ceramics, model airplane building, furniture refinishing, or woodworking may have exposed the client to harmful chemical irritants.

CURRENT HEALTH PROBLEMS

Whether the pulmonary problem is acute or chronic, the chief complaint is likely to include cough, sputum production, chest pain, and shortness of breath at rest or on exertion. During the interview, the nurse explores the history of the present illness, preferably in chronologic order. This analysis of the problem(s) includes the following:

• Onset

• Duration

• Location

• Frequency

• Progressing and radiating patterns

• Quality and number of symptoms

• Aggravating and relieving factors

• Associated signs and symptoms

• Treatments

Cough

Cough is the cardinal sign of respiratory disease. The nurse asks the client how long the cough has persisted (e.g., 1 week, 3 months) and whether it occurs at a specific time of day (e.g., on awakening in the morning, which is common in smokers) or in relation to any physical activity. The nurse determines whether the cough is productive or nonproductive, congested, dry, tickling, or hacking.

Sputum Production

Sputum production is an important symptom associated with coughing. The nurse notes the duration, color, consistency, odor, and amount of sputum. Sputum may be clear, white, tan, gray or, if infection is present, yellow or green.

The nurse describes the consistency of sputum as thin, thick, watery, or frothy. Smokers with chronic bronchitis have mucoid sputum because of chronic stimulation and hypertrophy of the bronchial glands. Voluminous, pink, frothy sputum is characteristic of pulmonary edema. Pneumococcal pneumonia is often associated with rust-colored sputum, and foul-smelling sputum is often found in anaerobic infections such as a lung abscess. Blood in the sputum (hemoptysis) is most commonly noted in clients with chronic bronchitis or bronchogenic carcinoma. Clients with tuberculosis, pulmonary infarction, bronchial adenoma, or lung abscess may expectorate grossly bloody sputum.

Sputum can be quantified by describing its production in terms of measurements such as teaspoon, tablespoon, and cups or fractions of cups. Normally, the tracheobronchial tree can produce up to 3 ounces (90 mL) of sputum per day. The nurse determines whether sputum production is increasing, possibly from external stimuli (e.g., an irritant in the work setting) or an internal cause (e.g., chronic bronchitis or a pulmonary abscess).

Chest Pain

A detailed description of chest pain helps the nurse differentiate pleural, musculoskeletal, cardiac, and gastrointestinal pain. Because the perception of pain is subjective, pain is analyzed in relation to the characteristics described in the history of the present illness. Coughing, deep breathing, or swallowing usually worsens chest wall pain.

Dyspnea

The perception of dyspnea (difficulty in breathing or breathlessness) is subjective and varies among clients. A client's perception may not be consistent with the severity of the presenting problem. Therefore the nurse determines the type of onset (slow or abrupt), the duration (number of hours, time of day), relieving factors (changes of position, medication use, activity cessation), and evidence of audible sounds (wheezing, crackles, stridor).

The nurse tries to quantify dyspnea by asking whether this symptom interferes with activities of daily living (ADLs) and, if so, how severely. For example, is the client breathless while dressing, showering, shaving, or eating? Does dyspnea on exertion occur after walking one block or climbing one flight of stairs?

The nurse asks about paroxysmal nocturnal dyspnea (PND), which involves intermittent dyspnea during sleep, and about orthopnea, which is demonstrated by a shortness of breath that occurs when lying down but is relieved by sitting up. These two conditions are commonly associated with chronic pulmonary disease and left ventricular failure. In PND, the client has a sudden onset of breathing difficulty that is severe enough to awaken the client from sleep.

Physical Assessment

ASSESSMENT OF THE NOSE AND SINUSES

The nurse inspects the client's external nose for deformities or tumors and inspects the nostrils for symmetry of size and shape. Nasal flaring may indicate an increased respiratory effort. To observe the interior nose, the nurse asks the client to tilt the head back for a penlight examination. The nurse may use a nasal speculum and nasopharyngeal mirror for a more thorough examination of the nasal cavity.

The nurse inspects for color, swelling, drainage, and bleeding. The mucous membrane of the nose normally appears redder than the oral mucosa, but it may appear pale, engorged, and bluish gray in clients with allergic rhinitis. The nasal septum is checked for evidence of bleeding, perforation, or deviation. Some degree of septal deviation is common in most adults and appears as an S shape, inclining toward one side or the other. A perforated septum is noted if the light shines through the perforation into the opposite nostril; this condition is often found in cocaine users. Nasal polyps, a common cause of obstruction, appear as pale, shiny, gelatinous structures attached to the turbinates.

The nurse occludes one nare at a time to check whether air moves through the nonoccluded side easily. The nose and paranasal sinuses are palpated to detect tenderness or swelling. Only the frontal and maxillary sinuses are readily accessible to clinical examination because the ethmoid and sphenoid sinuses lie deep within the skull. Using the thumbs, the nurse checks for sinus tenderness by pressing upward on the frontal and maxillary areas; both sides are assessed simultaneously. Tenderness in these areas suggests inflammation or acute sinusitis. Tenderness in response to tapping a finger over these areas also indicates inflammation.

Transillumination of the sinuses may be used to detect sinusitis. In a darkened room, the nurse places the bulb of a penlight on the client's cheek (just under the corner of the eye) and observes for light penetration through the roof of the mouth. Normally, a faint glow of light through the bone outlines the sinus. Transillumination is absent or decreased in sinusitis. However, this test is not conclusive for sinusitis.

ASSESSMENT OF THE PHARYNX, TRACHEA, AND LARYNX

Examination of the pharynx begins with inspection of the external structures of the mouth. To examine the structures of the posterior pharynx, the nurse uses a tongue depressor to press down one side of the tongue at a time (to avoid stimulating the gag reflex). As the client says "ah," the nurse notes the rise and fall of the soft palate and uvula and observes for color and symmetry, evidence of discharge (postnasal drainage), edema or ulceration, and tonsillar enlargement or inflammation.

The neck is inspected for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. Lymph nodes are palpated for size, shape, mobility, consistency, and tenderness. Tender nodes are usually movable and suggest inflammation. Malignant nodes are often hard and are fixed to the surrounding tissue.

The nurse gently palpates the trachea for deviation, mobility, tenderness, and masses. Firm palpation may elicit coughing or gagging. The space on either side of the trachea should be equal. Many pulmonary disorders cause the trachea to deviate from the midline. Tension pneumothorax, large pleural effusion, mediastinal mass, and neck tumors push the trachea away from the affected area, whereas pneumonectomy, fibrosis, and atelectasis cause a pull toward the affected area. Decreased tracheal mobility may occur with carcinoma or fibro-sis of the mediastinum.

The larynx is usually examined by a specialist with a laryngoscope. The nurse may observe an abnormal voice, especially hoarseness, when there are abnormalities of the larynx.

ASSESSMENT OF THE LUNGS AND THORAX

Inspection

Inspection of the chest begins with an assessment of the anterior and posterior thorax. If possible, the client is in a sitting position during the assessment. He or she should be undressed to the waist and draped for privacy and warmth. The chest is observed by comparing one side with the other. The nurse works from the top (apex) and moves downward toward the base while inspecting for discoloration, scars, lesions, masses, and spinal deformities such as kyphosis, scoliosis, and lordosis.

The nurse observes the rate, rhythm, and depth of inspirations as well as the symmetry of chest movement. An impaired movement or unequal expansion may indicate an underlying disease of the lung or the pleura. The nurse observes the type of breathing (e.g., pursed-lip or diaphragmatic breathing) and the use of accessory muscles. In observing respiration, the nurse documents the duration of the inspiratory (I) and expiratory (E) phases. The ratio of these phases (the I/E ratio) is normally 1:2. A prolonged expiratory phase indicates an obstruction of air outflow and is often seen in clients with asthma or chronic obstructive pulmonary disease (COPD).

The nurse examines the shape of the client's chest and compares the anteroposterior (AP) diameter with the lateral diameter. This ratio normally ranges from 1:2 to approximately 5:7, depending on body build. The ratio increases to 1:1 in clients with emphysema, which results in the typical barrel chest appearance.

Normally, the ribs slope downward. However, clients with air trapping in the lungs caused by chronic asthma or emphysema have little or no slope to the ribs (i.e., the ribs are more horizontal).

The nurse also checks for abnormal retractions of the intercostal spaces during inspiration, which indicate airflow obstruction. These retractions may be due to fibrosis of the underlying lung, severe acute asthma, emphysema, or tracheal or laryngeal obstruction.

Palpation

Palpation of the chest occurs after inspection. Palpation allows the nurse to assess respiratory movement symmetry and observable abnormalities, to identify areas of tenderness, and to elicit vocal or tactile fremitus (vibration).

The nurse assesses thoracic expansion by placing the thumbs posteriorly on the spine at the level of the ninth ribs and extending the fingers laterally around the rib cage. As the client inhales, both sides of the chest should move upward and outward together in one symmetric movement, and the nurse's thumbs move apart. On exhalation, the thumbs should come back together as they return to the midline. Decreased movement on one side (unilateral or unequal expansion) may be a result of pain, trauma, or pneumothorax (air in the pleural cavity). Respiratory lag or slowed movement on one side may indicate the presence of a pulmonary mass, pleural fibrosis, atelectasis, pneumonia, or a lung abscess.

The nurse palpates any abnormalities found on inspection (e.g., masses, lesions, bruises, and swelling). The nurse also palpates for tenderness, particularly if the client has reported pain. Crepitus (subcutaneous emphysema) is felt as a crackling sensation beneath the fingertips and should be documented, especially if it occurs around a wound site or if a pneumothorax is suspected. Crepitus indicates that air is trapped within the tissues.

Tactile (vocal) fremitus is a vibration of the chest wall produced when the client speaks. This vibration can be palpated on the chest wall. To elicit tactile fremitus, the nurse places the palm or the base of the fingers against the client's chest wall and instructs him or her to say the number 99. Using the same hand and moving from the apices to the bases, the nurse compares vibrations from one side of the chest with those from the other side. Palpable vibrations are transmitted from the tracheobronchial tree, along the solid surface of chest wall, and to the nurse's hand.

The nurse notes the symmetry of the vibrations and areas of enhanced, diminished, or absent fremitus. Fremitus is decreased if the transmission of sound waves from the larynx to the chest wall is slowed. This situation can occur when the pleural space is filled with air (pneumothorax) or fluid (pleural effusion) or when the bronchus is obstructed. Fremitus is increased over large bronchi because of their proximity to the chest wall. Disease processes such as pneumonia and abscesses increase the density of the thorax and enhance transmission of the vibrations.

Percussion

The nurse uses percussion to assess for pulmonary resonance, the boundaries of organs, and diaphragmatic excursion. Percussion involves tapping the chest wall, which sets the underlying tissues into motion and produces audible sounds. The nurse places the distal joint of the middle finger of the less dominant hand firmly over the intercostal space to be percussed. No other part of the nurse's hand touches the client's chest wall because doing so absorbs the vibrations. The middle finger of the dominant hand then delivers quick, sharp strikes to the distal joint of the positioned finger. The nurse maintains a loose, relaxed wrist while delivering the taps with the tip of the finger, not the finger pad. This technique is repeated two or three times to determine the intensity, pitch, quality, and duration of the sound produced. Long fingernails limit the ability to percuss.

Percussion produces five distinguishable notes. These sounds assist the nurse in determining the density of the underlying structures (i.e., whether the lung tissue contains air or fluid or is solid). Percussion of the thorax is performed over the intercostal spaces because percussing the sternum, ribs, or scapulae yields sound indicating solid bone. Percussion penetrates only 2 to 3 inches (5 to 7 cm), and therefore deeper lesions are not detected with this technique.

Percussion begins with the client sitting in an upright position. The nurse assesses the posterior thorax first and proceeds systematically, beginning at the apex and working toward the base. The apex of the lung extends anteriorly approximately ¾ to 1 ½  inches (2 to 4 cm) above the clavicle. Posteriorly, there is approximately a 2-inch (5-cm) width of lung tissue at the apex.

The nurse assesses diaphragmatic excursion by instructing the client to "take a deep breath and hold it" while percussing downward until dullness is noted at the lower border of the lung. Normal resonance of the lung stops at the diaphragm, where the sound becomes dull; this site is marked. The nurse repeats the process after instructing the client to "let out all your breath and hold." The difference between the two markings or sounds is the diaphragmatic excursion, which may range from 1 to 2 inches (3 to 5 cm). The diaphragm is normally higher on the right because of the location of the liver. Diaphragmatic excursion may be decreased or absent in clients with pleurisy, diaphragm paralysis, or emphysema.

The nurse continues to assess the thorax with percussion of the anterior and lateral chest. The percussion note changes from resonance of the normal lung to dullness at the borders of the heart and liver. The presence of fluid or solid material is indicated by a dull percussion note over lung tissue (as occurs with pneumonia, pleural effusion, fibrosis, atelectasis, and tumors).

Auscultation

Auscultation includes listening for normal breath sounds, adventitious sounds, and voice sounds. Auscultation provides information about the flow of air through the tracheo-bronchial tree and helps the listener to identify fluid, mucus, or obstruction in the respiratory system. The diaphragm of the stethoscope is designed to detect high-pitched sounds.

Auscultation begins with the client sitting in an upright position. With the stethoscope pressed firmly against the client's chest wall (clothing can distort or muffle sounds), the nurse instructs him or her to breathe slowly and deeply through an open mouth. (Breathing through the nose would set up turbulent sounds that are transmitted to the lungs.) A systematic approach is used, beginning at the apices and moving down through the intercostal spaces to the bases. Listening over bony structures is avoided while auscultating the thorax posteriorly, laterally, and anteriorly. The nurse listens to a full respiratory cycle, noting the quality and intensity of the breath sounds. The client is observed for signs of lightheadedness or dizziness caused by hyperventilation during auscultation. If these symptoms occur, the client is told to breathe normally for a few minutes.

NORMAL BREATH SOUNDS

Normal breath sounds are produced as air vibrates while passing through the respiratory passages from the larynx to the alveoli. Breath sounds are identified by their location, intensity, pitch, and duration within the respiratory cycle (e.g., early or late inspiration and expiration). Normal breath sounds are known as bronchial or tubular (harsh hollow sounds heard over the trachea and mainstem bronchi), bronchovesicular (heard over the branching bronchi), and vesicular (a soft rustling sound heard in the periphery over small bronchioles). The nurse describes these sounds as normal, increased, decreased (diminished), or absent.

When bronchial breath sounds are heard peripherally, they are abnormal. This increased sound occurs when centrally generated bronchial sounds are transmitted to an area of increased density, such as in clients with atelectasis, tumor, or pneumonia. When audible in an abnormal location, bronchovesicular breath sounds may indicate normal aging or an abnormality such as pulmonary consolidation and chronic airway disease.

ADVENTITIOUS BREATH SOUNDS

Adventitious sounds are additional breath sounds superimposed on normal sounds, and they indicate pathologic changes in the tracheobronchial tree. Table 27-6 classifies and describes adventitious sounds: crackle, wheeze, rhonchus, and pleural friction rub. Adventitious sounds vary in pitch, intensity, duration, and the phase of the respiratory cycle in which they occur. The nurse documents exactly what is heard on auscultation.

VOICE SOUNDS

If the nurse discovers abnormalities during the physical assessment of the lungs and thorax, the client is assessed for vocal resonance. Auscultation of voice sounds through the normally air-filled lung produces a muffled, unclear sound because sound vibrations travel poorly through air. Vocal resonance is increased when the sound must travel through a solid or liquid medium, as it does in clients with a consolidated area of the lung, pneumonia, atelectasis, pleural effusion, tumor, or abscess.

BRONCHOPHONY. Bronchophony is the abnormally loud and clear transmission of voice sounds through an area of increased density. For assessment of bronchophony, the client repeats the number 99 while the nurse systematically auscultates the thorax.

WHISPERED PECTORILOQUY. Whispered pectoriloquy is the enhanced voice heard through the chest wall. It is much more sensitive than bronchophony and is perceived by having the client whisper the number sequence one, two, three. Whispered words normally sound faint and indistinct. If they are heard loudly and distinctly, the nurse suspects consolidation of lung tissue.

EGOPHONY. Egophony is another form of abnormally enhanced vocal resonance and has a high-pitched, bleating, nasal quality. The nurse auscultates the thorax while the client repeats the letter E. Egophony exists when this letter is heard as a flat, nasal sound of A through the stethoscope. This abnormal sound indicates an area of consolidation, pleural effusion, or abscess.

OTHER INDICATORS OF RESPIRATORY ADEQUACY

The nurse evaluates additional indicators of respiratory adequacy because gas exchange affects all body systems. Some indicators (e.g., cyanosis) indicate immediate oxygenation problems. Other changes (e.g., clubbing, weight loss, unevenly developed muscles) reflect a more long-standing oxygenation problem.

Skin and Mucous Membranes

The skin and mucous membranes are assessed for the presence of pallor or cyanosis, which could indicate inadequate ventilation. Areas to assess include the nail beds and the mucous membranes of the oral cavity. The fingers are examined for clubbing, which would indicate hypoxia of long duration.

General Appearance

The nurse observes the client for muscle development and general body build. Long-term respiratory problems are often associated with an inability to maintain body weight and a loss of general muscle mass. Arms and legs may appear thin or poorly muscled. The muscles of the neck and chest may be hypertrophied, especially in the client with chronic obstructive pulmonary disease (COPD).

Endurance

The nurse observes how easily the client moves and whether he or she is short of breath while resting or becomes short of breath when walking 10 to 20 steps. As the client speaks, the nurse observes how often he or she pauses for breath between words.

Psychosocial Assessment

The nurse assesses aspects of the client's lifestyle that may significantly affect respiratory function. Some respiratory conditions may be worsened by stress. The nurse asks about present life stresses and usual coping mechanisms.

Chronic respiratory illnesses may cause changes in family roles and relationships, social isolation, financial problems, and unemployment or disability. By discussing coping mechanisms, the nurse assesses the client's reaction to these psychosocial stressors and discovers strengths and ineffective behaviors. For example, the client may react to stress with dependence on family members, withdrawal, or noncompliance with interventions. After completing the psychosocial assessment, the nurse assists the client in determining the support systems available to help cope with respiratory impairment.

Diagnostic Assessment

I LABORATORY TESTS

Blood Tests

A red blood cell count provides data regarding the transport of oxygen from the lungs. A hemoglobin deficiency directly affects tissue oxygenation because hemoglobin transports oxygen to the cells and could cause hypoxemia.

Arterial blood gas (ABG) analysis assesses oxygenation (partial pressure of arterial oxygen [Pao₂]), alveolar ventilation (partial pressure of arterial carbon dioxide [Paco₂]), and acid-base balance. Blood gas studies provide valuable information for monitoring treatment results, adjusting oxygen therapy, and evaluating the client's responses to treatment and therapy, such as during weaning from mechanical ventilation.

Sputum Tests

Sputum specimens obtained by expectoration or tracheal suctioning assist in the identification of pathogenic organisms or abnormal cells, such as in a malignancy or a hypersensitivity state. Sputum culture and sensitivity analyses identify bacterial infection with either gram-negative or gram-positive organisms and determine the vulnerability to specific antibiotics. Cytologic examination is performed on sputum to help diagnose malignant lesions by identifying cancer cells. Benign conditions, such as a hypersensitivity state, may also be identified by cytologic testing. Eosinophils and Curschmann's spirals (a mucous form) are often found by cytologic study in clients with allergic asthma.

RADIOGRAPHIC EXAMINATIONS

Standard Radiography

Chest x-ray examinations are performed for clients with respiratory tract disorders to evaluate the present status of the chest and to provide a baseline for comparison with future changes. Standard chest x-ray examinations are performed from posteroanterior (PA; back to front) and left lateral (LL) projections. Portable chest x-ray studies (taken anteroposterior [AP], front to back) cost more, and the films produced are of lower quality and are more difficult for the radiologist to interpret. Consecutive, 10-mm cross-sectional views of the thorax and produces a three-dimensional assessment of the lungs and thorax.

Fat, cystic, and solid tissue can be distinguished with CT. By adding an intravenously injected contrast agent, vessels and other soft tissue structures can be identified. CT is especially valuable in studying the mediastinum, hilar region, and pleural space. The newer high-resolution CT (HRCT) uses 1.5- to 2-mm "slices" to assist in assessing bronchial abnormalities, interstitial disease, and emphysema. Nursing interventions for the client undergoing CT include education about the procedure and determination of the client's sensitivity to the contrast medium (very important for anaphylaxis prevention).

Ventilation and Perfusion Scanning

A ventilation and perfusion scan (V/Q scan) identifies the areas of the lung being ventilated and the distribution of pulmonary blood. It is used primarily to support or rule out a diagnosis of pulmonary embolism.

To perform the study, the physician first injects a radionuclide with the client in a supine position and then takes six perfusion views: anterior, posterior, right and left lateral, and two obliques. If the perfusion scan is normal, there is no reason to continue with the ventilation scan. Otherwise, the client inhales a radioactive gas or radioaerosol, and the lung is scanned continuously—as the gas makes its way into the lungs (the "wash-in" phase), once the gas has reached equilibrium within the lungs, and then while the gas is leaving the lungs (the "wash-out" phase).

The nurse teaches the client about the procedure and explains that the radioactive substance clears from the body in approximately 8 hours.

OTHER NONINVASIVE DIAGNOSTIC TESTS

Pulse Oximetry

Pulse oximetry identifies hemoglobin saturation. Usually hemoglobin is almost 100% saturated with oxygen. The pulse oximeter uses a wave of infrared light and a sensor placed on the client's finger, toe, nose, earlobe, or forehead. Ideal normal pulse oximetry values are 95% to 100%; values may be a little lower in older clients and in clients with dark skin. To avoid confusion with the Pao₂ values from arterial blood gases, pulse oximetry readings are recorded as the Sao₂ (arterial oxygen saturation), or Spo₂.

A pulse oximetry reading can alert the nurse to desaturation before clinical signs occur (e.g., dusky skin, pale mucosa, and nail beds). The nurse considers client movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and fingernail polish as possible causes for low readings. Covering the sensor or changing its positioning could yield better accuracy if too much ambient light is present.

Results lower than 91% (and certainly below 86%) constitute an emergency and necessitate immediate treatment. When the Sao₂ is below 85%, the tissues of the body have a difficult time becoming oxygenated. An Sao₂ of less than 70% is usually life threatening, but in some cases values below 80% may be life threatening. Pulse oximetry is less accurate at lower values.

Pulmonary Function Tests

Pulmonary function tests (PFTs) evaluate lung function and dysfunction and include studies such as lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation. The physician interprets the results by comparing the client's data with normal findings predicted according to age, gender, race, height, weight, and smoking status.

PFTs are useful in screening clients for pulmonary disease even before the onset of signs or symptoms. Serial testing provides objective data that may be used as a guide to treatment (e.g., changes in pulmonary function can support a decision to continue, change, or discontinue a specific therapy). Preoperative evaluation with PFTs may identify the client at risk for postoperative pulmonary complications. One of the most common reasons for performing such tests is to determine the cause of dyspnea. When performed while the client exercises, PFTs help to determine whether dyspnea is caused by pulmonary or cardiac dysfunction or by muscle deconditioning. These tests are also useful for determining the effect of the client's occupation on pulmonary function and for evaluating any related disability for legal purposes.

CLIENT PREPARATION. The nurse prepares the client for PFTs by explaining the purpose of the tests for planning care. He or she is advised not to smoke for 6 to 8 hours before testing. According to institutional policy and procedure, bronchodilator medication is withheld for 4 to 6 hours before the test. The client with respiratory impairment often fears further breathlessness and is usually anxious before these "breathing" tests. The nurse helps to reduce apprehension by describing what will be experienced during and after the testing.

PROCEDURE. PFTs can be performed at the bedside or in the respiratory laboratory. The client is asked to breathe through the mouth only. A nose clip may be used to prevent air from escaping. The client performs different breathing maneuvers while measurements are obtained.

FOLLOW-UP CARE. Because numerous breathing maneuvers are performed during PFTs, the nurse observes for increased dyspnea or bronchospasm after such studies. The nurse documents whether bronchodilator medication was administered during testing and alters the client's medication schedule as indicated.

Exercise Testing

Exercise, or activity in general, increases metabolism and gas transport as energy is generated. These tests are performed on a treadmill or bicycle or by a self-paced 12-minute walking test. The normal client's exercise is limited by hemodynamic factors, whereas the pulmonary client is limited by ventilatory capacity, pulmonary gas exchange compromise, or both. The nurse explains exercise testing and assures the client of close monitoring by trained professionals throughout the test.

Skin Tests

Skin tests are used in combination with other diagnostic data to identify various infectious diseases (e.g., tuberculosis), viral diseases (e.g., mononucleosis and mumps), and fungal diseases (e.g., coccidioidomycosis and histoplasmosis). The presence of allergic hypersensitivity and the status of the immune system can be demonstrated through skin testing. Exposure to the allergen or organism used in testing produces a specific reaction (delayed hypersensitivity reaction) of the client's immune system.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is used in the diagnosis of respiratory system disorders to provide information about the type and condition of the tissues being imaged along any plane inside the body: vertically, horizontally, and diagonally. This costly procedure requires little client preparation other than the removal of all metal objects. Because of the powerful magnets used in MRI, clients with pacemakers, aneurysm clips, inner-ear implants, cardiac valves, or any other metallic foreign objects in the body are not candidates for MRI.

The nurse informs the client of possible claustrophobia and discomfort from lying on a hard, cool table inside the magnet's small cylinder. The nurse instructs the client in the use of relaxation techniques and imagery to help decrease these sensations. Sedation may be necessary in some cases. The nurse explains that the noises heard during the examination are the natural, rhythmic sounds of radiofrequency pulses. These noises may range from barely audible to noticeable.

OTHER INVASIVE DIAGNOSTIC TESTS

Endoscopic Examinations

Endoscopic diagnostic studies to assess respiratory disorders include bronchoscopy, laryngoscopy, and mediastinoscopy. The most common complications are those related to the medications and bleeding.

Thoracentesis

Thoracentesis is used for diagnosis or treatment and involves the aspiration of pleural fluid or air from the pleural space. Microscopic examination of the pleural fluid helps in making a diagnosis. Pleural fluid may be drained to relieve pulmonary compression and the resultant respiratory distress caused by cancer, empyema, pleurisy, or tuberculosis. Thoracentesis is often followed by pleural biopsy to assist in further assessment of the parietal pleura. Thoracentesis also allows the instillation of medications into the pleural space.

CLIENT PREPARATION. Adequate client preparation is essential before thoracentesis to ensure cooperation during the procedure and to prevent complications. The nurse tells the client to expect a stinging sensation from the local anesthetic agent and a feeling of pressure when the needle is inserted. The nurse reinforces the importance of not moving during the procedure (avoiding coughing, deep breathing, or sudden movement) to avoid puncture of the visceral pleura or lung.

These positions widen the intercostal spaces and permit easy access to the pleural fluid. The nurse properly positions and physically supports the client. Pillows are used to make the client comfortable and to provide physical support.

Before the procedure, the nurse checks the client's history for hypersensitivity to local anesthetic agents and checks to make sure the client has signed an informed consent. The entire chest or back is exposed, and the aspiration site is shaved if necessary. The actual site depends on the volume and location of the effusion, which are determined by radiography and physical examination procedures such as percussion.

PROCEDURE. Thoracentesis is usually performed at the bedside, although ultrasonography or computed tomography may be used to guide it. After draping the client and cleaning the skin with a germicidal solution, the physician uses aseptic technique and injects a local anesthetic agent into the selected intercostal space. The nurse keeps the client informed of the procedure while observing for shock, pain, nausea, pallor, diaphoresis, cyanosis, tachypnea, and dyspnea.

The physician advances the short 18- to 25-gauge thoracentesis needle (with an attached syringe) into the pleural space. Gentle suction is applied as the fluid in the pleural space is slowly aspirated. A vacuum collection bottle is sometimes necessary to remove larger volumes of fluid. To prevent re-expansion pulmonary edema, usually no more than 1000 mL of fluid is removed at one time. If a pleural biopsy is to be performed, a second, larger needle with a cutting edge and collection chamber is used. After the physician withdraws the needle, pressure is applied to the puncture site, and a small sterile dressing is applied.

FOLLOW-UP CARE. After thoracentesis, the physician orders a chest x-ray study to rule out possible pneumothorax and subsequent mediastinal shift (shift of center thoracic structure toward one side). The nurse monitors the client's vital signs and auscultates breath sounds while noting absent or diminished sounds on the affected side. The puncture site and dressing are observed for leakage or bleeding. The nurse also assesses for other complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, pyrogenic infection, and tension pneumothorax. The client is encouraged to breathe deeply to promote reexpansion of the lung. The nurse documents the procedure, including the client's tolerance, the volume and character of the fluid removed, any specimens sent to the laboratory, the location of the puncture site, and respiratory assessment findings before, during, and after the procedure.

Lung Biopsy

A lung biopsy is performed to obtain tissue for histologic analysis, culture, or cytologic examination. The physician uses tissue samples to make a definite diagnosis regarding the type of malignancy, infection, inflammation, or lung disease. Biopsy procedures include transbronchial biopsy (TBB) and transbronchial needle aspiration (TBNA), both of which are performed during bronchoscopy; transthoracic needle aspiration (percutaneous approach for areas not accessible by bronchoscopy); and open lung biopsy (in the operating room).

CLIENT PREPARATION. The client may have predetermined ideas about the outcome of the biopsy and may closely associate the terms biopsy and cancer. Therefore the nurse explains what to expect before and after the procedure and explores the client's feelings and fears. To reduce discomfort and anxiety, the physician may prescribe an analgesic or sedative before the procedure. The nurse informs the client undergoing percutaneous biopsy that discomfort is minimized with a local anesthetic agent but that a sensation of pressure may be experienced during needle insertion and tissue aspiration. Open lung biopsy is usually performed in the operating room with the client under general anesthesia, and the usual preoperative preparations apply.

PROCEDURE. Percutaneous lung biopsy may be performed in the client's room or in the radiology department after an informed consent has been obtained. Fluoroscopy, CT, or ultrasonography is often used to better visualize the area undergoing biopsy and to guide the procedure. Positioning of the client is similar to that for thoracentesis. The physician cleans the skin with an antibacterial agent and administers a local anesthetic agent. Under sterile conditions, the physician inserts a spinal-type 18- to 22-gauge needle through the skin into the desired area (e.g., tissue, nodule, or lymph node) and obtains the tissue needed for microscopic examination. The nurse applies a dressing after the procedure.

An open lung biopsy is performed in the operating room. The client undergoes a thoracotomy where lung tissue is exposed. At least two tissue specimens are taken (usually from an upper lobe and a lower lobe site). The surgeon places a chest tube to remove air and fluid so the lung can reinflate and then closes the chest.

FOLLOW-UP CARE. The nurse monitors the client's vital signs and breath sounds every 4 hours for 24 hours and assesses for signs of respiratory distress (e.g., dyspnea, pallor, diaphoresis, and tachypnea). Pneumothorax is a serious complication of needle biopsy and open lung biopsy, and therefore it is important for the nurse to report untoward signs and symptoms promptly. The nurse also monitors for hemoptysis (which may be scant and transient) or, in rare cases, for frank bleeding from vascular or lung trauma.

Assessment of Breast and Axillae

Basic Breast Anatomy

The breast is a complex structure lying on the chest muscles. It is made up of two kinds of tissue - fatty tissue and breast tissue - which consist of ducts, glands for producing milk and supportive tissue. Your breasts may differ in size and are rarely precisely alike.

Lymph nodes are small glands located in chains throughout the body. They act as a defence or filter against infection. The lymph nodes affecting the breast are located in the armpit and close to the breast bone, as well as in the breast tissue. Chest nodes extend from the breast bone up to the collarbone and armpit and lie directly beneath the breast.

Clinical Breast Examination

Clinicians are encouraged to adopt and implement the following standards for performance of the CBE examination. Efforts to encourage widespread dissemination of these standards must be implemented as a partnership between clinicians and health care organizations.

Clinical History

A clinical history that identifies the patient’s personal and family health history is useful in assessing risk of breast cancer. Some women will not report symptoms until asked, and a clinical history provides an important opportunity to seek out this information. This health history can direct attention to potentially relevant symptoms and provides important context for interpreting findings. The clinical guidelines and policy statements of many organizations concerning the performance of screening CBE emphasize the importance of a woman’s individual risk for breast cancer. Furthermore, information on clinical history can help guide follow up. The clinical history also provides an opportunity for the provider to explain the benefits and limitations of the examination, its elements, the time involved, and the related events that occur after the examination (interpretation, reporting, and follow up).

The clinical history should:

• Identify screening practices for breast health, when they were performed, and results. These practices include breast self-examination (BSE), prior CBE, and prior screening and diagnostic mammograms.
• Ask about any breast changes and how they were identified. This includes changes in appearance of skin or nipples, presence of lumps, pain (focal versus general and constant versus cyclic), itching, or staining of garments or bed sheets that would indicate spontaneous nipple discharge.
• Assess risk by asking about age and personal history, including benign breast disease, biopsy, cancer, cosmetic or other breast surgery, history of hormonal therapy, and/or oral contraceptive use, obstetric history, family history, and health promotion habits (eg, exercise, nutrition).

Visual Inspection

Once the clinical history has been completed, the patient’s breasts should be visually inspected. To minimize awkwardness and potential misunderstandings, providers should inform women in advance that a visual inspection will be performed and describe what is being assessed during this part of the examination. The patient should sit with her hands pushing tightly on her hips. This position contracts the pectoralis major muscles and enhances identification of asymmetries. Although adding multiple positions (eg, hands over head and hands at sides) may further assist identification of asymmetries, it does not add substantively to the single position recommended and may reduce time devoted to palpation. When conducting the visual inspection, the provider must view the breasts from all sides and should:

• Assess symmetry in breast shape or contour (subtle changes or differences), and
• Assess skin changes, particularly any skin erythema, retraction or dimpling, and nipple changes. Physical signs associated with advanced breast cancer have been summarized using the acronym BREAST, signifying Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, and Tender breast.

If the clinician is seeing the patient on a regular basis, visual inspection allows the monitoring of changes in appearance over time when observations are compared with previously documented examination. Visual inspection takes only a short amount of time, with the remainder of the examination spent predominately on palpation.

§     Inspection: skin, nipples, discharge.

– Edema

– Erythema

– Ulceration

– Symmetry

– Retraction

§ Palpation

§ Palpate lymph nodes

Palpation
Following the visual inspection, the examiner palpates each breast and nearby lymph nodes. To minimize awkwardness and the potential for misunderstanding, providers should inform women in advance that palpation will be performed and describe what is being assessed during this part of the examination. Palpation provides an opportunity for discussion of the normal variability of breast characteristics and the importance of women becoming familiar with the characteristics of their own breasts. Thoroughness is essential; palpation must examine all breast tissue as well as nearby lymph nodes. Appropriate palpation includes five key characteristics:

• Position: Patients should be sitting for palpation of the axillary, supraclavicular, and infraclavicular lymph nodes. Patients should be lying down for breast palpation, with their ipsilateral hand overhead to flatten the breast tissue on the chest wall, thereby reducing the thickness of the breast tissue being palpated. If this maneuver does not result in a relatively even distribution of breast tissue, the breast should be further centralized by placing a small pillow under the shoulder/lower back on the side of the breast being examined. The tissue being examined needs to be as thin as possible over the chest wall. The examiner must be able to see the full palpation area.

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FIGURE 1 Position of Patient and Direction of Palpation for the CBE. The top figure shows the lateral portion of the breast, and the bottom picture shows the medial portion of the breast. Arrows indicate the vertical strip pattern of examination. (Reprinted with permission from Barton MB, Harris R, Fletcher SW.)

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FIGURE 2 Palpation Technique. Pads of the index, third, and fourth fingers (inset) make small circular motions, as if tracking the outer edge of a dime. (Reprinted with permission from Barton MB, Harris R, Fletcher SW.)

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FIGURE 3 Levels of Pressure for Palpation of Breast Tissue Shown in a Cross-sectional View of the Right Breast. The examiner should make three circles with the finger pads, increasing the level of pressure (subcutaneous, mid-level, and down to the chest wall) with each circle. (Reprinted with permission from Barton MB, Harris R, Fletcher SW.)

• Perimeter: All breast tissue falls within a pentagon shape (as opposed to the traditional perception of the breast as a conical structure). The examiner should use the following landmarks to cover all of this area: down the midaxillary line, across the inframammary ridge at the fifth/sixth rib, up the lateral edge of the sternum, across the clavicle, and back to the midaxilla.
• Pattern of search: The full extent of breast tissue should be searched using a "vertical strip" pattern. (A systematic analysis demonstrated the superiority of the vertical strip search pattern over concentric circle and radial spoke patterns in thoroughness of coverage, as performed by women trained in BSE to examine themselves. The search should be initiated at the axilla. If a mastectomy has been performed, the chest wall, skin, and incision should be included.
• Palpation: The examiner should use the finger pads of the middle three fingers to palpate one breast at a time. Palpate with overlapping dime-sized circular motions. Tissue at and beneath the nipple should be palpated, not squeezed. Squeezing often results in discharge as well as discomfort. Only spontaneous discharge warrants further evaluation. Breast tissue in the upper outer quadrant and under the areola and nipple should be thoroughly searched, as these are the two most common sites for cancer to arise.
• Pressure: As each area of tissue is examined, three levels of pressure should be applied in sequence: light, medium, and deep, corresponding to subcutaneous, mid-level, and down to the chest wall. Adapt the palpation to the size, shape, and consistency of tissue, and accommodate pressure to other factors such as breast size and the presence of breast implants. Providers sometimes lack confidence performing CBE in women with breast implants; implants correctly placed are located behind the tissue of the breast. Therefore, the steps for CBE are exactly the same as in women without implants.

The duration of the examination is intentionally not specified, for several reasons. First, while thoroughness is related to time spent performing CBE, performance time can decrease with increased proficiency. Additionally, a variety of patient factors, such as breast size, tenderness, lumpiness, body weight, and risk factors, can influence the time required to perform a proficient CBE. The committee determined that specifying a uniform time frame would be misleading more often than not and would inappropriately shift the focus of performance away from proficiency and thoroughness.

2. Interpretation and Reporting:

a. Reporting should consist of a summary of the relevant portions of a patient’s history and a description of whether the CBE is interpreted as normal/negative or abnormal. If abnormal, include a description of the visual and palpable findings, including changes in the appearance of skin or nipples, the presence of nipple discharge, the presence of breast masses or palpable asymmetries, and the presence of palpable lymph nodes.

Lead responsibility for implementation: clinicians and health care organizations.

   b. Develop a consistent, standardized lexicon of terms and format for documenting the interpretation and reporting of specific CBE findings.

Lead responsibility for implementation: health care organizations.

The primary function of CBE is to identify abnormalities that warrant further evaluation; CBE alone is not capable of accurately distinguishing benign from malignant status. Interpreting the visual and tactile observations of CBE is complex. A variety of patient characteristics can influence interpretation, including age, parity, tissue density and nodularity, menopausal status, phase of the ovarian cycle, and health history.² For example, bloody nipple discharge during the last trimester of pregnancy or the first 3 months of lactation may be considered a normal physiologic change, but it would be interpreted quite differently in a woman who was not pregnant or lactating. Similarly, skin erythema or lymphedema would not necessarily be cause for further evaluation in a woman having recently undergone radiation therapy of the breast but would certainly require follow up in a woman without such a history. A more common and difficult challenge involves breast lumpiness or nodularity, which varies considerably among women and over time for the same woman. For example, increased nodularity might be normal during the luteal phase of the menstrual cycle, but at other times it might be cause for further examination.

As with the performance of CBE, no standard system exists for interpreting or reporting CBE findings. No standardized terminology exists for describing findings such as degree of nodularity; thickening versus a mass; dimpling of skin; or the size, mobility, shape, or consistency of an abnormality. Thus, even if CBE was performed uniformly to its highest potential sensitivity and specificity, differences in interpretation and how findings are reported limit its potential benefits in guiding further evaluation and permitting earlier treatment of breast cancer. Efforts to improve the interpretation of mammography reporting and subsequent associated management recommendations have resulted in improvements in accuracy and consistency in those areas, but several studies demonstrate the importance of continued system refinement and training.^43–45 Standardization of interpretation and reporting might yield similar positive effects for CBE. Although development of a detailed lexicon for CBE was beyond the scope of this initiative, the committee recommends further development of a system that complements the Breast Imaging Reporting and Data System and its lexicon developed by the American College of Radiology. The framework provided below under Reporting represents an initial step in this process and provides immediate guidance for practice.

Another important byproduct of standardizing interpretation and reporting is the potential to provide data for more accurate estimates of sensitivity and specificity in clinical practice settings. Estimates of false-positive and false-negative results based on reporting and medical records data could be used to provide feedback to health care professionals to improve their proficiency.

Information about the number of cancers first identified by CBE, particularly as a function of age and other population characteristics, could help clarify the role of CBE as a component of early detection and the use of this examination in relationship to other screening modalities.

Interpretation
Interpretation involves three elements: identification of visual and palpable characteristics of the breasts and lymph nodes; accurate assignment of specific, common, descriptive terminology to each characteristic; and determination of appropriate follow-up actions for identified findings. The interpretation and reporting elements described below provide a general framework for identifying all relevant features of a proficient CBE, describing visual and physical findings, and reporting these findings and follow-up recommendations. This framework is general, representing an important initial step in the process of developing a standardized lexicon and patient follow up, as well as a reporting format for CBE. Describing and interpreting findings can be challenging, as when women have highly nodular breasts, for example. The role of CBE, however, is to identify and appropriately describe visual and palpable findings; determination of benign or malignant status can be established only through further evaluation. Clinicians are encouraged to adopt and begin implementing this framework for CBE interpretation and reporting. Development and implementation of a detailed system, as well as analysis of reporting data, must be undertaken as a partnership between clinicians and health care organizations.

In the most general form, the results of CBE can be interpreted in two ways:

• Normal/Negative: No abnormalities on visual inspection or palpation.
• Abnormal: Asymmetrical finding on either visual inspection or palpation that warrants further evaluation and possible referral. Findings will reflect a continuum of possible outcomes, from probably benign to highly suspicious of cancer. Determination of benign or malignant status, however, can be established only through further evaluation.

Reporting
Reporting should include a description of all findings in specific and precise language, regardless of interpretation. In the case of a negative interpretation, description of findings provides a baseline for interpreting future results from visual inspection and palpation. In the case of an abnormal interpretation, a description provides an important guide for follow-up examination.

Reporting should follow the same sequence as the examination itself. The following outline directs providers’ attention to those aspects of the exam that represent unique patient characteristics or abnormalities. To the extent possible, electronic reporting should be encouraged to provide compatibility with existing medical records systems and more efficient analysis of reporting trends. Additional research assessing reporting consistency, feasibility, and systems-related issues should be performed.

How a Breast Abnormality or Change is Assessed

Breast changes are assessed (worked up) in different ways. The process selected will be determined by a woman’s medical history and current symptoms, the doctor’s usual practice and the resources available within the community. Three common situations are demonstrated in the following examples and flow charts. They are typical of the way a breast change is assessed at a breast assessment centre.

Breast Cancer in Men

Men can be diagnosed with breast cancer. About 1% of all breast cancers are found in men. Since it is not a common occurrence, it is not recommended that men be screened for breast cancer on a regular basis.

If you are a man with a breast abnormality or change that is being investigated, this booklet will provide the help and information you need. You will experience the same tests described in “Tests Used to Assess a Screening Abnormality or a Change in the Breast” and you will find many helpful suggestions in the section “Waiting for Your Test Results.” The section “Further Information about Breast Health” will also be useful.

As so few men are diagnosed with breast cancer, it’s difficult to find someone to talk to who has had a similar experience. Most of your support will come from your family and close friends. It is also important for you to have all your questions answered by your doctor or other healthcare providers.