Assessing the Thorax, Lungs, and Breasts

Skill 3-5

Assessing the Thorax, Lungs, and Breasts

The thorax is composed of the lungs, rib cage, cartilage, and intercostal muscles. A thorough examination of the respiratory system is essential because the primary purpose of this system is to supply oxygen to, and remove carbon dioxide from, the body. Recognizing and identifying normal and abnormal breath sounds, a crucial component of lung assessment, takes practice (Tables 3-1 and 3-2). Assessment of the breasts and axillae is also included in this assessment. Regular clinical breast exam and breast self-exam are not recommended; however, women should be familiar with how their breasts normally look and feel from everyday self-care and promptly report changes to a health care provider (American Cancer Society [ACS], 2020; U.S. Preventive Services Task Force and the American Congress of Obstetricians and Gynecologists, as cited in Johns Hopkins Medicine, n.d.).

Delegation Considerations

Assessment of the patient's thorax, breasts, axillae, and lungs should not be delegated to assistive personnel (AP). However, the AP may notice some items while providing care. The nurse must then validate, analyze, document, communicate, and act on these findings, as appropriate. Depending on the state's nurse practice act and the organization's policies and procedures, the licensed practical/vocational nurses (LPN/LVNs) may perform some or all the parts of assessment of the patient's thorax, breasts, axillae, and lungs. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Bath blanket or other drape
Examination gown
Light source
Stethoscope
PPE, as indicated

Assessment

Complete a health history, focusing on the thorax and lungs. Identify risk factors for altered health by asking about the following:

History of trauma to the ribs or history of lung surgery
Number of pillows used when sleeping
History of persistent cough with or without producing sputum
History of allergies
Environmental exposure to chemicals, asbestos, or smoke
History of smoking (including pack-years)
History of lung disease in family members or self
History of frequent or chronic respiratory infections
Breast discomfort, masses, or lumps, nipple discharge
History of breast disease, biopsy, or surgeries
Menstrual and pregnancy history, breastfeeding

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Ineffective airway clearance
Impaired gas exchange
Altered health maintenance

Outcome Identification and Planning

The expected outcome to achieve in performing an examination of the thorax, lungs, breasts, and axillae is that the assessment is completed without the patient experiencing anxiety or discomfort, the findings are documented, and the appropriate referral is made to the other health care professionals, as needed, for further evaluation. Other outcomes may be appropriate, depending on the specific diagnosis or patient problem identified for the patient.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
3. Close the curtains around the bed and close the door to the room, if possible. Explain the purpose of the thorax, lung, breast, and axillae examination and what you are going to do. Answer any questions.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates cooperation.
4. Help the patient undress, if needed, and provide a patient gown. Assist the patient to a sitting position and expose the posterior thorax.	Having the patient wear a gown facilitates examination of the thorax while maintaining the patient's privacy.
5. Use the bath blanket to cover any exposed area other than the one being assessed.	Use of a bath blanket provides for comfort and warmth.
6. Inspect the posterior thorax. Examine the skin (Figure 1), bones, and muscles of the spine, shoulder blades, and back as well as symmetry of expansion and accessory muscle use during respirations.	Examination provides information about lung expansion and accessory muscle use during respiration. Inspection of skin reveals color, presence of lesions, rashes, or masses.
7. Assess the anteroposterior (AP) and lateral diameters of the thorax.	This assessment helps to detect deformities, such as a barrel chest. Normally, the AP is less than the transverse diameter (1:2 ratio).
8. Palpate over the spine and posterior thorax. Use the dorsal surface of the hand to palpate for temperature. Use the palmar surface of the hand to palpate in a sequential pattern for tenderness, muscle development, and masses (Figure 2).	Palpation may reveal abnormal findings, such as excessively dry or moist skin, muscle asymmetry, masses, tenderness, or vibrations.
9. Assess thoracic expansion by standing behind the patient and placing both thumbs on either side of the patient's spine at the level of T9 or T10 (Figure 3A). Ask the patient to take a deep breath and note movement of your hands (Figure 3B).	Movement should be symmetric bilaterally.
10. As the patient breathes slowly and deeply through the mouth, auscultate the lungs across and down the posterior thorax to the bases of lungs in a sequential pattern, comparing sides (Figure 4).	Lung auscultation assesses for normal breath sounds and for adventitious breath sounds. Abnormal breath sounds indicate respiratory compromise or diseases, such as asthma or bronchitis.
11. Inspect the anterior thorax. With the patient sitting, rearrange the gown so the anterior chest is exposed. Inspect the skin, bones, and muscles as well as symmetry of lung expansion and accessory muscle use.	Examination of the anterior thorax provides information about lung expansion and accessory muscle use during respiration. Inspection of skin reveals color, presence of lesions, rashes, or masses.
12. Palpate the anterior thorax across and down the anterior thorax to the bases of lungs in a sequential pattern (Figure 5). Use the palmar surface of the hand to palpate for temperature, tenderness, muscle development, and masses.	Palpation may reveal abnormal findings, such as excessively dry or moist skin, muscle asymmetry, masses, tenderness, or vibrations.
13. As the patient breathes slowly and deeply through the mouth, auscultate the lungs across and down the anterior thorax to the bases of lungs in a sequential pattern, comparing sides (Figure 6).	Lung auscultation assesses for normal breath and abnormal (adventitious) breath sounds. Abnormal breath sounds indicate respiratory compromise or diseases, such as asthma or bronchitis.
14. If assessment of the breasts is required, inspect the breasts. Ask the patient to rest hands on both sides of the body, then on the hips and finally above the head. With the patient holding each position, inspect the breasts for size, shape, symmetry, color, texture, and skin lesions. Inspect the areola and nipples for size and shape and the nipples for discharge, crusting, and inversion.	This technique evaluates the general condition of the breasts and helps to identify any abnormalities.
15. Palpate the axillae with the patient's arms resting against the side of the body. If any nodes are palpable, assess their location, size, shape, consistency, tenderness, and mobility.	Palpating the axillae helps to detect nodular enlargement, tenderness, and other abnormalities.
16. Assist the patient into a supine position. Place a small pillow or towel under the patient's back and ask the patient to place a hand on the side being examined under the head, if possible.	Positioning facilitates the exam.
17. Wear gloves if there is any discharge from the nipples or if a lesion is present. Palpate each quadrant of each breast in a systematic method, using either the circular, wedge, or vertical strip technique (see Box 3-1). Palpate the nipple and areola and gently compress the nipple between the thumb and forefinger to assess for discharge. Remove gloves, if worn, and perform hand hygiene.	Gloves prevent contact with blood and body fluids. Palpating the breasts evaluates the consistency and elasticity of breast tissue and nipples and for presence of lumps, masses, or discharge. Proper removal of gloves reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
18. Assist the patient into a comfortable position and in replacing the gown. Remove gloves and any additional PPE, if used. Perform hand hygiene. Continue with assessments of specific body systems, as appropriate or indicated. Initiate appropriate referral to other health care providers for further evaluation, as indicated.	Replacing the gown ensures patient comfort. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Additional assessments should be completed, as indicated, to evaluate the patient's health status. Intervention by other health care providers may be indicated to evaluate and treat the patient's health status.

Evaluation

The expected outcomes have been met when the patient has participated in the assessment of the thorax, lungs, breasts, and axillae; the patient has verbalized understanding of these assessment techniques as appropriate; the assessment has been completed without the patient experiencing anxiety or discomfort; the findings have been documented; and the appropriate referrals have been made to the other health care professionals, as needed, for further evaluation.

Documentation

Guidelines

Describe specific findings. Include specific findings for all assessment techniques performed. Note the location of elicited abnormalities. For breast assessment, clock position (using the positioning of the hands of an analog clock) is often used to describe the location of findings.

Sample Documentation

Practice documenting assessment techniques and findings in Lippincott DocuCare.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

When assessing a patient's lungs, you hear short, high-pitched popping sounds on inspiration: Ask the patient to cough and auscultate again. If the sounds remain, suspect fine crackles and ask the patient if they are experiencing any difficulty in breathing or shortness of breath. Crackles may indicate disease, such as pneumonia or heart failure. Document the findings. Continue to assess the patient and notify the appropriate health care providers, as indicated.

Special Considerations

General Considerations

Warm equipment, such as a stethoscope, before using it to prevent chilling the patient.
Warm hands before palpating thorax and breasts to prevent chilling the patient and causing any discomfort.
Attempt to reduce the noise level in the room while auscultating for breath sounds to ensure accuracy in listening. Also, note that the presence of chest hair may mimic the sound of crackles and bumping the stethoscope against clothing may distort the sound.

Infant and Child Considerations

Auscultate a child's lungs before performing other assessment techniques that may cause crying.
Expect to hear breath sounds that are harsher or more bronchial than those of an adult.
Expect use of abdominal muscles during respiration (infants and young children up to school-age).

Older Adult Considerations

Expect to find a reduction in respiratory effort due to age-related changes.
A common finding in the older adult is kyphosis, an exaggerated posterior curvature of the spine causing bowing out of the upper spine (Eliopoulos, 2018; Jensen, 2019).

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Skill 3-5