Health Assessment, part 30: Chest Assessment

Hi. I'm Meris, and in this video, I'm going to be talking about the basics of assessing the anterior and posterior chest. I'm going to be following along using our health assessment flashcards. These are available on our website, leveluprn.com, if you want to grab a set for yourself. Or if you prefer digital products, I would invite you to check out Flashables, which is the digital version of all of our flashcards. All right. Let's go ahead and get started.

So first up, we are talking about assessing the anterior chest. And one of the things that we are going to do when we are assessing the chest is we are going to make sure that we are seeing an equal chest expansion. Now, I can do this by just looking at my patient and seeing that they are breathing easily and quietly and that everything looks like it is expanding normally. Or I can take my hands and place them on my patient's rib cage, right at the bottom of their rib cage, and have them take in a deep breath. What you expect to see is that both hands are going to rise equally to the same amount at the same level at the same time, and that when they release that breath that your hands should go in at the same time. We should have equal chest rise and fall, which we can either assess by touching or by just observing with our eyes.

Now, we are also going to look for visible pulsations at the point of maximal impulse, PMI. And the PMI refers to what is the area where we can feel and see the most of the heartbeat, if that makes sense. The point of maximal impulse is going to be the fifth intercostal space at the left midclavicular line. So right down here. That is consistent with the apex of the heart, locating the apex of the heart at the bottom there. That is where we can observe for the actual PMI. We can actually see pulsations in that area. We may need to have our patient lean forward a little bit in order to see that, but it is normal and expected to be able to see pulsations at the PMI. But what I don't expect to see is any sort of abnormal movements such as lifts or heaves. A lift is a small movement, whereas a heave is going to be a strong movement, a much larger movement.

So for instance, if I were to lay my patient down, and I could see some sort of weird swinging motion in their chest when their heart beats, those would be abnormal findings. Those are abnormal movements of the chest. Then I'm going to also palpate for any tenderness, masses, lumps, bumps, things of that nature. I will percuss the anterior chest. And when we talk about percussion, this is where we are taking our fingers, placing it over whatever we're percussing, and then taking our other fingers and tapping it. Tapping will transmit a vibration through our fingers to the structures underneath, and that will create a sound. That sound tells us different things about the underlying structures, and I will discuss with you much more in-depth percussion findings in a later video. But at this point, we would percuss the anterior chest, and then I can auscultate breath sounds. Remember that I'm going to be auscultating anterior and posterior over all lung fields by moving in a side-to-side motion versus going through one lung and then assessing the other. We are always comparing this lung field to that lung field, making sure that they sound the same or that I can identify a deviation from normal.

Then we're going to move on to the posterior chest assessment. And when we are assessing the posterior chest, we're going to do the same thing where we are assessing the skin for any sort of lesions, any sort of lumps or bumps, and for symmetrical chest expansion. I can do that same thing on the posterior chest wall if I want to. But one of the things that I need to be assessing here is the diameter, the ratio of the diameter between the anterior posterior chest and the transverse chest. So what does this mean? It means that an average person is going to have a ratio that is one to two, meaning that from side to side, that patient's chest wall should be about two times the size that it is when measured from front to back. We expect the front-to-back measurement to be skinnier. Think about it. If I turn to the side, you expect to see less of my chest. And if I turn forward, I will appear broader, right? So we're going to assess that diameter ratio with the expectation that we are going to see a normal or an average ratio, which is AP to T. AP:T should be one to two, okay?

Now, if I do see a deviation in this, if I see that we are at one to one, for instance, that my chest is as big AP as it is transverse, this is something called barrel chesting. And barrel chesting is what it sounds like. It's where the chest is going to look more like a barrel rather than kind of a rectangular shoebox. We now have this one to one ratio. So we're really looking more like just a perfect circle. This is a very common finding in emphysema or COPD where we have air trapping. When we chronically trap air, chronically hold on to air, eventually, we are going to end up with this hyperinflation of our lungs that is going to over time increase my chest ratio to the point that I have one to one, or potentially worse, barrel chesting.

So moving on from that, we will again palpate for tenderness or masses. But we're going to do a test on the posterior chest that is called tactile fremitus. And fremitus refers to vibration. Tactile refers to touch or feeling. So tactile fremitus is where I'm going to take either the sides - some people use the sides, the ulnar aspect of their hands - or this topmost part of the palm. I call it the ball of the palm, kind of like the ball of your foot. That's not what it's actually called, but this area right across here. This is how I prefer to do it. And I actually bend my hands out like this so that only this portion is making contact with my patient. What I'm going to do is I'm going to place my hands on the patient's back, and I'm going to ask them to utter a low-frequency word or phrase. And very commonly, the one in [inaudible] world that we love to use is the phrase 99.

So I'm going to tell my patient, "You'll feel me touch. You'll feel me put my hands on your back. And every time I move my palms, I want you to say the words 99." And what's going to happen is that as I move my palms down, I'm going to keep moving down their whole entire lung fields. And I expect that I will hear the vibration with a lot of intensity up high, and that as I move down, I will have decreased intensity of the vibrations on my palm as we move down the patient's chest. Now, it's possible that I could feel increased vibrations. And in that case, this could be indicative of some consolidation or some fluid in the lungs. This could be indicative of an alteration in lung health in some way or another. So if I'm moving my palms down, down, down, and the vibration is increasing, that would be an abnormal finding.

And then I'm going to percuss over the lungs again, and I'm going to assess for costovertebral angle tenderness, CVA. The costovertebral angle refers to the angle or the junction of the costo, the ribs, right, and the vertebra, right, the backbone. So the area where the ribs and the backbone meet at the bottom there is called the costovertebral angle. And what I'm going to do is take my hand and place it directly over the costovertebral angle and take my closed fist and hit my hand pretty firmly. I'm not hitting my patient in the back. I'm hitting my fist that is over my patient's back. Very important distinction.

What I am looking for here is that essentially nothing should happen. My patient shouldn't jump or scream or make any sort of sudden movements. They should report no tenderness at the CVA. If I do that blunt percussion, and they jump or grab or start guarding or, "Oh, my God, that hurts so bad," that could be indicative of some kind of a kidney issue such as a kidney stone, hydronephrosis, any kind of pyelonephritis. Anything that's going on with the kidney could potentially cause CVA tenderness. And then lastly, I'm going to auscultate the breath sounds again in that side-to-side motion. And we will talk more about breath sounds in a later video.

But that is it for this video about the basics of assessing the anterior and posterior chest. I'm so glad you stayed to the end because I'm going to give you some quiz questions to test your knowledge of key facts I provided in this video. Where should the nurse expect to find the patient's point of maximal impulse, PMI? At the fifth intercostal space along the left midclavicular line. What is the expected AP to T ratio? One to two. What is the expected finding when assessing tactile fremitus? Vibration intensity gradually decreases as the hands are moved lower. All right. That is it for this video. I do hope that you found this review to be useful. I'll see you in the next one. Thanks so much, and happy studying.