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Structure of the card|o vascu|ar system

The heart is a Iour chambered hollow muscular organ. The heart lies
within the thorax between lungs in the mediastinal space. Its beating is oIten
palpable at the IiIth intercostal space. The heart is composed oI three layers, the
thin inner lining endocardium; a layer oI muscle , myocardium; a Iibrous outer
layer the epicardium .The heart is surrounded by pericardium. The inner
visceral layer oI the pericardium is in contact with the epicardium and the outer
parietal layer is in contact with the mediastinum. A small amount oI the
pericardial Iluid lubricates the space between the pericardial layers.
The heart is divided vertically by the septum.This creates a right and
leIt atrium and a right and leIt ventricle
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The right atrium receives the venous blood Irom the inIerior and
superior venacava and the coronary sinus.The bllod then passes through the
tricuspid valve into the right ventricle. With each contraction the right ventricle
pumps blood through the pulmonic valve into the pulmonary artery. Blood
Ilows to the leIt atrium by way oI the pulmonary veins. It then passes through
the mitral valve and into the leIt ventricle. As the heart contracts the blood is
ejected through the aortic valve into the aorta and thus enters the hogh pressure
systemic circulation
Cardiac valves The 4 valves oI the heart serve to keep blood Ilowing in a
Iorward direction . The cusps oI the mitral and the tricuspid valves are attached
to thin strands oI the Iibrous tissue termed chordae tendineae. Chordae are
anchored in the papillary muscles oI the ventricles.

The conduction system is specialised nerve tissue responsible Ior
creating and transporting the electrical impulse or action potential.This impulse
initiates depolarisation and subsequently cardiac contraction. The electrical
impulse is initiated by the sino atrial node which is the pace maker oI the heart.
E ach impulse generated at the SA node travels swiItly through the muscle
Iibers oI the atria by the inter nodal pathways and cell to cell conduction.
Mechanical contraction oI the atria Iollows the depolarisation oI the cells.
The electrical travels Irom the atria to the AV node. The excitation moves
through the bundle oI his and the leIt and right bundle branches. The action
potential diIIuses widely through the walls oI both the ventricles by means oI
purkinje Iibers. The eIIicient ventricular conduction system delivers the impulse
within 0.12 seconds. This triggers a uniIorm ventricular contraction .
The cardiac cycle starts with depolarisation oI SA node. Its climax is
ejection oI blood into the pulmonary and systemic circulations. It ends with
repolarisation when the contractile Iiber cells and the conduction pathway
cellsregain their resting polarised condition. During systole there is an absolute
reIractory period during which cardiac muscle does not respond to any stimuli.
AIter this period cardiac muscle gradually recovers its excitability and a relative
reIractory period occurs by early diastole.
Depolarisation triggers mechanical activity. Systole, contraction oI the
myocardium , results in ejection oI the blood Irom the cardiac chamber.
Relaxation oI the myocardium , diastole,allows Ior Iilling oI the chamber.
Cardiac output is the amount oI blood pumped by each ventricle in one minute.
It is calculated by multiplying the amount oI blood ejected Irom the ventricle
with the heart beat , the stroke volume |SV| by the heart rate |HR| per minute.
A careIul health history and physical examination should aid the nurse in
diIIerentiating symptom that reIlect a cardio vascular problem Irom problems oI
other body systems
Past health history
Many illnesses can aIIect the cardio vascular system directly or indirectly.
The patient should be questioned about a history oI chestpain, shortness oI
breath, alcoholism or excessive drinking , anaemia, rheumatic Iever ,
streptococcal sore throat, congenital heart disease, stroke, syncope ,hyper
tension , thrombophlebitis, intermittent claudication , varicosities and edema .
An assessment oI the patients current and past use oI medications should be
made. A medication assessment should list the name oI the drug and the
patient`s understanding oI its purpose and side eIIects. Drugs that may
adversely aIIect the cardiovascular system also should be assessed.
Surgery and other treatments
The patient should also be asked about speciIic treatments , past surgeries
or hospital admissions related to cardio vascular problems
Functional health patterns
Health perception- health management pattern.
The nurse should ask about the presence oI cardio vascular risk Iactors. Major
risk Iactors include elevated serum lipids, hypertension , cigarette smoking,
sedentary liIestyle and diabetes mellitus should be included. II the patient
smokes the number oI packyears oI smoking (number oI packs smoked per day
multiplied by the number oI years the patient has smoked) should be estimated.
The alchohol use should also be recorded. The use oI habit Iorming drugs
including recreational drugs should also be noted. A question about patient`s
allergies is appropriate. The patient also should be asked whether an
anaphylactic reaction has ever been experienced. ConIirmed illnesses oI blood
relatives can highlight any hereditary or Iamilial tendencies toward coronary
artery disease, peripheral vascular disease, hypertension, bleeding , cardiac
disorders, diabetes mellitus , atherosclerosis and stroke. Finally a Iamily health
history oI non cardiac conditions like asthma, renal disease , obesity should be
assessed because they can aIIect the cardiovascular system.
utritional metabolic pattern
Being under weight or overweight may indicate potential cardiovascular
problems. The amount oI salt, saturated Iats and triglycerides in the patient`s
diet should be determined.
Elimination pattern
The patient on dieuretics may report increased urinary
elimination.Problems with constipation should be investigated and documented.
Straining at stool should be avoided in a patient with cardiovascular problems
Activity exercise pattern
The beneIit oI exercise to cardiovascular health is indisputable, with
sustained aerobic exercise being most beneIicial The nurse should enquire about
the types oI exercise done, the duration and Irequency oI each and the
occurrence oI any unwanted eIIects.Any symptoms indicative oI cardiovascular
problems such as light headedness, chest pain, shortness oI breath, or
claudication during exercise should be noted. The patient should also be
questioned about any limitation in activities oI daily living as a result oI
cardiovascular problem. Such problems are oIten associated with Iatigue and
depression, which are symptoms oI cardiac disease.
Sleep-rest pattern
Although there are many possible causes cardiovascular problems are oIten
the cause Ior interrupted sleep. Paroxysmal nocturnal dyspnea are associated
with advanced heart Iailure.Many patients with heart Iailure may need to sleep
with their head elevated on pillows.
Cognitive-perceptual pattern
Any pain associated with the cardiovascular system such as chest pain and
claudication should be reported. Caediovascular problems such as arrhythmias,
hypertension, and stroke may cause problems with vertigo, langiage and
Self perception - self concept pattern
II a cardiovascular event is oI acute origin , the patient`s selI perception
may be aIIected. Invasive diagnostic and palliative procedures oIten lead to
body image concerns Ior the patient. When the cardiovascular disease is chronic
in nature the patient may not be able to identiIy the cause but can oIten describe
the inability to keep up previous level oI activity accomplishments. This too
may aIIect the patient`s selI esteem. ThereIore it is very essential to ask about
the eIIects oI illness on the patient.

Role relationship pattern
The patient`s sex race and age are all related to cardiovascular health and
thereIore important basic inIormation.In addition discussing the patient`s
marital status , role in the household, number oI children and their ages, living
environment and signiIicant others assists the nurse in identiIying strengths and
support systems in patient`s liIe.
Sexuality and reproductive system
The patient should be asked about the eIIect oI the cardiovascular
problem on sexual patterns and satisIaction. It is common Ior a patient to have a
Iear oI sudden death during sexual intercourse, causing a major alteration in
sexual behaviour. Fatigue or shortness oI breath may curtail sexual activity
Impotence may be a symptom oI peripheral vascular disease and is a side eIIect
oI some medications used in the treatment oI cardio vascular problems. Many
medications used to treat cardiovascular problems particularly those used to
treat hypertension can result in impotence. This side eIIect may cause non
compliance with medical treatment.
Coping- stress tolerance pattern
The patient should be asked to identiIy areas that cause stress or anxiety.
Behaviours such as explosive , rapid speech and emotions such as anger and
hostility have been associated with a risk oI cardiac disease. InIormation about
support systems such as Iamily , extended Iamily and Iriends, psychologists and
religious groups may provide excellent resources Ior plan oI care.
Values - belief pattern
Some patients may attribute their illness as a punishment Irom god;
others may Ieel that a higher power may assist them. InIormation about a
patient`s values and belieIs will help the nurse intervene during periods oI
crisis.It is also important to determine whether the proposed plan oI care causes
any conIlict with the patient`s value system.

A physical examination is perIormed to conIirm some oI the data obtained in
the health history. The nurse observes the patient`s general appearance and
perIorms a Iocussed cardiac physical examination that includes the evaluation
oI the Iollowing .
O EIIectiveness oI the heart as a pump
O Filling volumes and pressures
O Cardiac output
O Compensatory mechanisms
Inspection of the skin
Examination oI the skin begins during the evaluation oI the patients general
appearance and continues throughout the assessment. The common Iindings
associated with the cardio vascular disease are as Iollows.
Pallor- is caused by lack oI oxyhemoglobin. It is a result oI anemia or
decreased arterial perIusion. Pallor is best observed around the Iinger
nails, lips and oral mucosa. In patients with dark skin the nurse observes
the palms oI the hands and soles oI the Ieet.
Peripheral cyanosis- This is a bluish tinge ,most oIten oI the nails and
skin oI the nose ,lips earlobes and extremities. This suggests decreased
blood Ilow to a particular area, which allows more time Ior the
haemoglobin molecule to become desaturated. This may occur normally
in peripheral vasoconstriction associated with a cold environment in
patient`s with anxiety or in disease states such as heart Iailure.
Central cynasosis- It denotes serious cardiac disorders like pulmonary
edema and congenital heart disease in which venous blood passes through
pulmonary circulation without being oxygenated
anthelasma may be observed along the nasal portion oI one or both the
eyelids and may indicate elevated cholesterol levels
Reduced skin turgor occurs with dehydration and aging
Temperature and moistness are controlled by the autonomic nervous
system. Normally the skin is warm and dry. Under stress the hands may
become cool and moist. In cardiogenic shock sympathetic nerve system
stimulation causes vasoconstriction and the skin becomes cold and
clammy. During an acute MI diaphoresis is common
Ecchymosis is associated with the blood outside oI the blood vessels and
is usually caused by trauma. Patients who are receiving anticoagulant
therapy should be careIully observed Ior unexplained ecchymosis.In
these patients excessive bruising indicates prolonged clotting times
caused by an anticoagulant dosage that is too high
Wounds ,scars, and tissue surrounding the implanted devices should also
be examined. Wounds are assessed Ior adequate healing and any scars
Irom previous surgeries are noted. The skin surrounding a pacemaker or
implantable cardioverter or deIibrillator generator is examined Ior
thinning ,which could indicate erosion oI the device through the skin.

Check either the BP or pulse Iirst. II the BP is high measure it again later
in the examination . Count the radial pulse with your Iingers or the apical
pulse with the stethoscope at cardiac apex.
The systemic arterial BP is the pressure exerted on the walls oI
the arteries during ventricular systole and diastole.The average normal BP
usually sited is 120/80mm oI Hg. An increase in above the upper normal
level is called hypertension and decrease in BP below normal level is
called hypotension.
Pulse pressure: The diIIerence between the systolic and diastolic
pressures is called pulse pressure. Pulse pressure which is normally 30 to
40 mm Hg indicates how well the patient maintains cardiac output. The
pulse pressure increases in conditions that elevate stroke volume (anxiety,
exercise , bradycardia) ,reduce systemic vascular resistance (Iever) , or
reduce distensibility oI the arteries ( atherosclerosis ,aging ,
hypertension). Decreased pulse pressure reIlects reduced stroke volume
and ejection velocity (shock, HF, hypovolemia , mitral regurgitation) or
obstruction to the blood Ilow during systole( mitral or aortic stenosis). A
pulse pressure oI less than 30 mm Hg indicates decreased cardiac output
and requires Iurther cardiac assessment .
Postural blood pressure changes : Postural hypotension occurs
when the BP decreases signiIicantly aIter the patient assumes an upright
posture. It is usually accompanied by dizziness , light headedness or
syncope. Although there are many cause Ior postural hypotension the
three most common causes in patients with cardiac problems are a
reduced volume oI Iluid or blood in the circulatory

Radial pulse is commonly used to assess heart rate. With the pads pI the
index and middle Iinger press radial artery until maximum pulsation is
Ielt. The normal heart rate is between 60 to 100 beats per minute.

Arterial pulses
Factors to be evaluated in examining the pulse are rate ,rhythm
quality, conIiguration oI the pulse wave and quality oI the arterial vessels.
Pulse rate: The normal pulse rate varies Irom a low oI 50 bpm in
healthy athletic young adults to rates well in excess oI 100 bpm aIter
exercise or during times oI excitement. Anxiety usually raises pulse rate
during physical examination. II the rate is higher than expected , it is
appropriate to reassess it at the end oI the physical examination when the
patient is more relaxed.
Pulse rhythm: II the pulse rhythm is irregular the heart rate should be
counted by auscultating the apical pulse Ior one Iull minute while
simultaneously palpating the radial pulse. Any discrepancy between the
contractions heard and pulses Ielt are noted. Disturbances in rhythm
oIten result in a pulse deIicit, a diIIerence between the apical rate and the
peripheral rate . Pulse deIicits commonly with atrial Iibrillation and atrial
Ilutter, premature ventricular contractions and varying degrees oI heart
Pulse quality: The quality or amplitude oI the pulse can be described as
absent , diminished , normal or bounding . It should be assessed
bilaterally. Scales can be used to assess the strength oI the pulse. The
Iollowing oI an example oI 0 to 4 scale.
0 pulse not palpable or absent
1 weak thready pulse , diIIicult to palpate , obliterated with
2 diminished pulse cannot be obliterated.
3 easy to palpate , Iull pulse , cannot be obliterated.
4 strong bounding pulse , may be abnormal

Observe the rate, rhythm ,eIIort and depth oI breathing . Count the
number oI respirations in one minute either by visual inspection or by
subtly listening over the patients trachea with your stethoscope during
examination oI head , neck and chest.
Average oral temperature is 37degree c. In the early morning hours it
may Iall as low as35.8 and in late aIternoon it may increase to 37.3.
Rectal temperature are higher than oral temperature by average oI 0.4 to
0.5 degree centigrade. Axillary temperature are lower than oral
temperature by approximately 1 centigrade.

Inspect clubbing of fingers.
Clubbing ( diIIuse enlargement oI terminal The normal nail bed angle
is 160 degree. Flattening oI angle and clubbing ( diIIuse enlargement oI
terminal phalanges) occur with congenital cyanotic heart disease and
cor pulmonale
Capillary refill
With the patient`s hand near the level oI his or chest , check capillary
reIill. This is an index oI peripheral perIusion and cardiac output.
Depress and blanch nailbeds , release and note the time Ior color return.
Usually the color returns within a Iraction oI a second ReIill lasting more
than 1 to 2 seconds signiIies vasoconstriction and decreased cardiac
output( hypo volemia, shock, heart Iailure) The hands are cold clammy
and pale.
Radial and ulnar pulse
. In the peripheral vascular assessment , assess the ulnar and radial pulses.
The radial pulse is palpated in the medial area oI the wrist ( thumb side)
The ulnar artery is palpated at the opposite side oI the wrist. BeIore a
radial artery is punctured or cannulated allen test is perIormed to assess
blood Ilow to hand and ensure that it is adequate.
Femoral arteries
Palpate Iemoral artery just below the inguinal ligament halIway between
the pubis and anterior superior iliac spine. Press Iirmly and then slowly
release noting the pulse taps under tips. Auscultate the site Ior a bruit. A
bruit occurs with turbulent blood Ilow indicating partial occlusion.
Popliteal pulse
It is more diIIuse pulse and can be diIIicult to localise with the leg
extended but relaxed , anchor the nurse`s thumb on the knee and curl the
nurse`s Iingers around the popliteal Iossa , press Iingers Iorward to
compress the artery against the bone. OIten a normal popliteal pulse is
impossible to palpate.
Dorsalis pedis and posterial tibial
Dorsalis pedis is assessed to determine Ilow to the limb but also to
assess adequacy oI cardiac output to extremities It is palpated on the
upper aspect on the Ioot. Posterial tibial pulse is located behind medial
malleolus ( inner ankle oI the lower leg)


ugular venous pulsations
Right sided heart Iunctions can be estimated by observing the pulsations
oI the jugular veins oI the neck and the central venous pressure, which reIlects
right atrial or right ventricular end diastolic pressure. Pulsations oI the internal
jugular vein are most commonly assessed. II they are diIIicult to see the
pulsations oI the external jugular vein should be noted. These veins are more
superIicial and visible just above the clavicles adjacent to sternocleido mastoid
muscle. The external jugular veins are Irequently distended while patient lies
supine on the examining table or bed. As the patients head is elevated distention
oI the vein normally disappears. The veins normally are not apparent iI the
patient`s head is elevated more than 30 degrees.. Obvious distention oI the veins
with the patient`s head elevated 45 to 90 degrees indicate an abnormal increase
in the volume oI the venous system. This occurs with right sided HF less
commonly with obstruction oI the blood Ilow in the superior venacava and
rarely with acute massive pulmonary embolism .Unilateral distension oI the
external jugular vein is due to local cause ( kinking or aneurysm) Full extended
external jugular vein above 45 degree signiIy increased CVP as with heart
ugular venous pressure
Think oI jugular vein as a CVP manometer attached directly to the right atrium.
We can read the CVP at highest level oI pulsations . Hold a vertical ruler on the
sternal angle . Align a straight edge to the level oI venous pulsations. Hold a
vertical ruler on the sterna angle. Align a straight edge on the ruler like a T
square, and adjust the level oI horizontal straight edge to the level oI pulsation.
Read the level oI intersection on the vertical ruler. Normal jugular venous
pulsation is 2cm or less above vertical angle. Elevated pressure is alevel oI
pulsation that is more than 3 cm above the sterna angle while at 45 degree this
occurs without heart Iailure.
epato jugular reflex
II venous pressure is elevated or iI heart Iailure is suspected, perIorm hepato
jugular reIlex. Position the patient comIortably supine and instruct him or her to
breath quietly through open mouth. Hold the right hand on the right upper
quadrant oI the cliemt`s abdomen just below the rib cage. Watch the level oI
jugular pulsation as nurse push in with her hand. Exert Iirm sustained pressure
Ior 30 seconds . This empties venous blood out oI the liver sinusoids and adds
its volume to the venous system . II the heart is able to pump this additional
volume, jugular vein will rise Ior a Iew seconds then recede back to previous
levels.II heart Iailure is present the jugular veins will elevate and stay elevated
as long as nurse push
eart inspection and Palpation
1. Aortic area- It is the second intercostals space to the right oI the sternum.
To determine the correct intercostals space, start at the angle oI Louis by
locating the bony ridge near the top oI the sternum, at the junction oI the
body and the manubrium. From this angle locate the second intercostals
space by sliding one Iinger to the leIt or right oI sternum. Subsequent
intercostals spaces are located Irom this point by palpating down the rib
2. Pulmonic area- second intercostals space to the leIt oI the sternum.
3. Erb`s point- Third intercostals space to the leIt oI the sternum
4. Right ventricular or tricuspid area- Fourth and IiIth intercostals spaces to
the leIt oI the sternum
5. LeIt ventricular or apical area-The point oI maximal impulse, the location
on the chest where heart contractions can be palpated.
6. Epigastric area Below the xiphoid process
For most oI the examination patient lies supine with the head oI the bed
slightly elevated.
Each area oI the precordium is inspected and then palpated. Anormal
impulse that is distinct and located over the apex oI the heart is called apical
impulse.It may be observed in young people and older people who are thin.
The apical is normally located and auscultated in the leIt IiIth intercostal
space. In many cases the apical impulse is normally Ielt as a light pulsation
one to two cm in diameter.It is Ielt at the onset oI the Iirst heart sound and
lasts Ior only halI oI systole.The nurses uses the palm oI the hand to locate
the apical pulse initially and the Iingerpads to assess its size and quality. An
apical impulse below the IiIth intercostals space or lateral to the
midclavicular line usually denotes ventricular enlargement Irom leIt
ventricular Iailure. Normally the apical is palpable in only one intercostals
space palpability in one or more intercostals spaces denote leIt ventricular
enlargement. II the apical impulse can be palpated in two distinctly separate
areas and the pulsations movements are paradoxical (not simultaneous) a
ventricular aneurysm may be suspected. Abnormal turbulent blood Ilow
within the heart may be palpated with the palm oI the hand as a purring
sensation. This phenomenon is called a thrill and is associated with a loud
murmer. A thrill is always indicative oI signiIicant pathology within the
heart. Thrills also may be palpated over vessels when blood Ilow is
signiIicantly and substantially obstructed and over the carotid arteries iI
aortic stenosis is present or iI aortic valve is narrowed.
Chest percussion
Normally only the leIt border oI the heart can be detected by
percussion.It extends Irom the sternum to the midclavicular in the third to
the IiIth intercostals space.The right border lies under the right margin oI the
sternum and is not detectable.Enlargement oI the heart to either the leIt or
usually can be noted.In people with thick chests obesity or emphysema, the
heart may lie so deep in the thoracic surIace that not even its leIt border can
be notedunless the heart is enlarged. In such unless the nurse detects a
displaced apical impulse and suspects cardiac enlargement percussion is

Cardiac auscultation
eart sounds. : The normal heart sounds s1 and s2 are produced primarily by
the closing oI the heart valves. The time between s1 and s2 corresponds to
systole. This is normally shorter than the time between s2 and s1 (diastole). As
the heart rate increases the diastole shortens.
- The first heart sound .
Closure oI the mitral and tricuspid valves creates Iirst heart sound(s1)
although vibration oI the myocardial walls also may contribute to this sound.
Although s1 is heard over the entire precordium, it is heard best at the apex
oI the heart.its intensity increases when the valve leaIlets are made rigid by
calcium in the rheumatic heart disease and in any circumstance in which
ventricular contraction occurs at a time when the valve is caught wide open (
when a premature ventricular contraction interrupts the normal cardiac
cycle. ) S
varies in intensity Irom beat to beat when atril contraction is not
synchronous with ventricular contraction. Because the valve may be Iully
opened or partially closed on one beat and open on the next one due to
irregular atrial activity. S
is easily identiIiable and serves as the point oI
reIerence Ior the remaining cardiac cycle.
Second heart sound
Closing oI the aortic and pulmonic valves produces the second heart
sound. (s
) Although these two valves close almost simultaneously, the
pulmonic valve usually lags behind. . ThereIore under certain circumstances
the two components oI the second sound maybe heard separately. ( split s
) .
The splitting is more likely to accentuate on inspiration and to disappear on
exhalation. S
is most audible at the base oI the heart.
Gallop sounds .
II the blood Iilling the diastole is impeded during diastole as occurs in
certain disease conditions then a temporary vibration occurs in the diastole
that is similar to although usually similar to S
and S
. The heart sounds
then come in triplets and have the acoustic eIIects oI a galloping horse; they
are called gallops. This may occur early in diastole during the rapid Iilling
phase oI the cardiac cycle or later at the time oI atrial contraction. Gallop
sounds are very low Irequency sounds and may be heard only with the bell
oI the stethoscope placed very lightly against the chest .They are heard best
at the apex although occasionally when emanating Irom the right ventricle,
they may be heard to the leIt oI sternum. A gallop sound occurs during rapid
ventricular Iilling is the third heart sound S
. It may represent a normal
Iinding in the children and young adults. Such a sound is heard in patients
who have myocardial disease or in those who have HF or in patients whose
ventricles Iail to eject all oI their blood during systole. An s
Gllop is heard
with the patient lying on the leIt side A gallop sound that occurs during
atrial contraction is called Iourth heart sound S
. An S
is oIten heard when
the ventricle is enlarged or hypertrophied and thereIore resistant to Iilling .
Such a circumstance may be associated with CAD hypertension or stenosis
oI the aortic valve. On rare occasions all 4 heart sounds are heard with a
single period oI cardiac contraction, ejection reIilling and resting, reIerred to
as cardiac cycle, giving rise to what is called a cardiac rhythm.
Snaps and clicks
Stenosis oI the mitral valve resulting in the rheumatic heart disease gives
rise to an unusual high pitched sound very early in diastole that is best heard
along the leIt sterna border. The sound is caused by the high in the leIt
atrium with abrupt displacement oI rigid mitral valve. The sound is called an
opening snap. It occurs too long aIter S
to be mistaken Ior a split S
and too
early in diastole to be mistaken Ior a gallop. It almost always is associated
with the murmer oI mitral stenosis and is speciIic to this disease
Murmurs are created by turbulent Ilow oI blood. The causes oI turbulence
may be a critically narrowed valve, a malIunctioning valve that allows
regurgitant blood Ilow, a congenital deIect oI the ventricular wall , a deIect
between the aorta and the pulmonary artery, or an increased Ilow oI blood
through a normal structure ( eg , with Iever , pregnancy, hyperthyroidism)
Murmurs are characterised and consequently described by several
characterestics including their timing in the cardiac cycle, location in the
chest wall, intensity, pitch, quality and pattern oI radiation.
Friction rub
In pericarditis a harsh ,grating sound that can be heard in both systole
and diastole is called a Iriction rub. It is caused by abrasion oI the pericardial
surIaces during cardiac cycle . Because a Iriction rub may be conIused with a
murmur care should be taken to identiIy the sound and to distinguish it Irom
murmurs that may be heard in both systole and diastole.A pericardial Iriction
rub can be heard best using the diaphragm oI the stethoscope with the patient
sitting up and leaning Iorward.
Auscultation Procedure.
During auscultation the patient remains supine and the examining room
is quiet as possible.A stethoscope with a diaphragm and a bell is essential Ior
an accurate auscultation oI the heart.
Using the diaphragm oI the stethoscope the examiner starts at the apical
area and progresses upward along the leIt sterna border to the pulmonic and
aortic areas . During auscultation the patient remains supine and the
examining room is quiet as possible.A stethoscope with a diaphragm and a
bell is essential Ior an accurate auscultation oI the heart.
Using the diaphragm oI the stethoscope the examiner starts at the apical
area and progresses upward along the leIt sterna border to the pulmonic and
aortic areas . Alternatively the examiner may begin the examination at the
aortic and pulmonic areas and progress downward to the apex to the heart.
Initially S
is identiIied and evaluated with respect to the intensity and
splitting . Next S
is identiIied and its intensity and any splitting is noted.
AIter concentrating on S
and S
2 ,
examiner listens Ior extra sounds in
systole and diastole. The examiner again proceeds to move the stethoscope
to all the designated areas oI the precordium, listening careIully Ior these
sounds. Finally the patient is turned on the leIt side and the stethoscope is
placed on the apical area where an S
or an S
and a mitral murmur are more
readily detected.
The primary Iunction oI the respiratory system is gas exchange which
involves the transIer oI oxygen and carbondioxide between the
atmosphere and the blood. The respiratory system is divided into two
parts upper respiratory tract and lower respiratory tract.
Upper respiratory tract
The nose made oI the bone and cartilage, is divided into two nares by the
nasal septum. The interior oI the nose is shaped into two rolling
projections called turbinates that increase the surIace area Ior warming
and moistening air. The internal nose opens directly into the sinuses. The
nasal cavity connects with the pharynx , a tubular passageway that is sub
divided Irom above downwards into three parts the nasopharynx , the
oropharynx , and the laryngopharynx.
The olIactory nerve endings are located in the rooI oI the nose. The
adenoids and tonsils which are small masses oI lymphatic tissue , are
Iound in the nasopharynx and the oropharynx respectively. The epiglottis
is a small Ilap oI tissue at the base oI the tongue. During swallowing the
epiglottis covers the larynx , preventing solids and liquids Irom entering
the lungs. A condition such as a stroke that alters the swallowing ability
may impair the Iunction oI the epiglottis, thus predisposing to aspiration.
AIter passing through the oropharynx, air moves through the
laryngopharynx and the larynx where the vocal cords are located and
then down into the trachea . The trachea is a cylindrical tube about 5
inches ( 10 to 12 cm) and 1 inch ( 1.5 to 2.5 cm) in diameter. The support
oI U shaped cartilages keeps the trachea open but allows the adjacent
esophagus to expand Ior swallowing. The trachea biIurcates into the right
and leIt mainstem bronchi at a point called the carina. The carina is
located at the level oI the manubriosternal junction, called the angle oI
Louis. The carina is highly sensitive and touching it during suctioning
causes vigorous coughing
Once air passes the carina, it is in the lower respiratory tract . The main
stem bronchi , pulmonary vessels and nerves, and nerves enter the lungs
through a slit called the hilus . The right mainstem bronchus. For this
reason , aspiration is more likely in the right lung than in the leIt lung.
The main stem bronchi subdivide several times to Iorm the lobar ,
segmental and subsegmental bronchi. Further divisions Iorm the
bronchioles. Beyond these lie the alveolar ductsand alveolar sacs . The
bronchioles are encircled by smooth muscles that constrict and dialate in
response to various stimuli.. No exchange oI oxygen or carbondioxide
takes place until air enters the respiratory bronchioles. The area oI the
respiratory tract Irom the nose to the respiratory bronchioles serves only
as a conducting pathway and is thereIore termed the anatomic dead
space.. This space must be Iilled with every breath, but the air that Iills it
is not available Ior gas exchange. AIter moving through the conducting
zone, air reaches the respiratory bronchioles and alveoli. Alveoli are
small sacs that Iorm the Iunctional unit oI the lungs . The alveoli are
interconnected by pores oI Kohn, which allow movement oI air Irom
alveolus to alveolus. Bacteria can also move through these pores resulting
in an extension oI respiratory inIection to previously noninIected areas.
The alveolar capillary membrane is very thin and is site oI gas exchange.
Subjective data
Past health history
The nurse should determine the Irequency oI the upper respiratory
problems. For eg; colds ,sore throats, sinus problems, allergies and iI
weather changes aIIect these problems. The patient with allergies
should be questioned about possible precipitating Iactors such as
medications, pollen, smoke, or pet exposure. Charecterestics oI the
allergic reaction such as runny nose, wheezing, scratchy throat,or
tightness in the chest and severity should be determined.
A history oI prior respiratory problems, such as asthma , COPD,
pneumonia and tuberculosis should also be elicited. Respiratory
symptoms are oIten maniIestations oI problems that involve other
body systems. ThereIore the patient should be asked iI there is a
history oI other health problems in addition to those involving
respiratory system. For eg , the patient with cardiac dysIunction may
experience dyspnea (shortness oI breath) as a consequence oI
congestive cardiac Iailure. The patients with HIV inIection may
experience Irequent respiratory inIections because immune Iunction
is compromised.
The patient should be questioned about prescription and over the counter drugs
used to manage respiratory problems, such as antihistamines , bronchodialators,
corticosteroids , cough suppressants and antibiotics. InIormation about the
reason Ior taking the medications , its name , the doze, and Irequency, length oI
time taken , its eIIect, and any side eIIects should be obtained. II the patient is
using oxygen to ease a breathing problem, the amount , the method oI
administration and eIIectiveness oI therapy should be documented.
Surgery or other treatments.
The nurse should determine whether the patient has been hospitalised Ior a
respiratory problem. II so the dates therapy , and current status oI the problem
should be recorded. T he nurse should ask about the use and results oI
respiratory treatments such as nebulizer, humidiIier, and airway clearance
modalities .
Functional health problems
The patient should be asked iI there has been a perceived change in health status
within last several days , months, years. In COPD lung Iunction decrease
slowly in many years. II dyspnea is present the nurse should determines iI it
occurs at rest or with physical exertion.
The nurse should explore iI patient has diIIiculty in breathing in certain position
or iI relieI oI dyspnea can be obtained by assuming a diIIerent position.
II a cough is present the nurse should evaluate the quality oI the cough. For
eg.a loosing sounding cough indicates the presence oI secretions a dry hacking
cough indicates airway irritation or obstruction aharsh barky cough suggests
upper airway obstruction. From inhibited vocal cord movement related to
subglottic edema .The nurse should assess whether the cough is weak or strong
or whether it is productive or unproductive oI secretions Also determine the
onset and chronicity oI cough.
Sputum production
II the patient has a productive cough the Iollowing characterestics oI the sputum
should be evaluated amount color consistency and odor. The amount should be
quantiIied in teaspoons , table spoons or cups per day. The nurse should not any
recent increases or decreases in the amount. The normal color is clear or slightly
whitish. II the patient is a cogarrette smoker the sputum is usually clear to grey
with occasional specks oI brown. The patient with COPD may exhibit clear ,
whitish or slightly yellow sputum, especially in the morning on rising. Changes
in consistency oI sputum to thick , thin, Irothy should be noted. These changes
may indicate dehydration, postnasal drips, or sinus drainage, or possible
pulmonary edema. Normally sputum should be odourless. A Ioul order indicate
the presence oI lung abscess , bronchiectasis, or an inIection caused by certain
micro organisms. Smoking should be contraindicated in the case oI excessive
sputum production because it interIeres with ciliary action, increases bronchial
secreations, causes inIlammation and hyperplasia oI the mucous membranes and
reduces production oI surIactant. Thus smoking impairs bronchial drainage.
When a person stops smoking the sputum volume decreases and resistance to
inIections increases
.Chest pain
Chest pain associated with pulmonary conditions may be sharp, stabbing, and
intermittent, or it may be dull aching and persistant. The pain usually is located
where the pathologic process is located but it can also be reIerred elsewhere ,
Ior eg, to the neck, back or abdomen. Chest pain occurs with pneumonia,
pulmonary embolismwith lung inIarction, and pleurisy. It also may be a late
symptom oI bronchogenic carcinoma. In carcinoma the pain is dull and
persistant because cancer has invaded the chest wall, mediastenum and spine.
Wheezing is oIten the common Iinding in person with bronchioconstriction or
airway narrowing. It is a high pitched musical sound heard mainly on
expiration. Clubbing oI Iingers is a sign oI lung disease that is Iound in patients
with chronic hypoxic conditions , chronic lung inIections or malignancies oI
the lung. This Iinding is initially maniIested as sponginess oI the nail bed and
loss oI the nail bed angle
Hemoptysis is a symptom oI both pulmonary and cardiac diseases The most
common causes are pulmonary inIection, Ca oI lungs, abnormalities oI heart or
lung vessels, pulmonary artery or vein abnormalities, pulmonary embolus and
Cyanosis is a bluish coloring oI skin, avery late indication oI hypoxia. The
presence or absence oI hypoxia is determined by amount oI unoxygenated
haemoglobin in the blood. A patient with anemia rarely maniIests cyanosis and
a patient with polycythemia may appear cyanotic even iI adequately
oxygenated. ThereIore cyanosis is not a reliable sign oI hypoxia. In the presence
oI a pulmonary condition central cyanosis is assessed by observing the color oI
tongue and lips. This indicates a decrease in oxygen tension in the blood.
Peripheral cyanosis result Irom decreased oxygen supply to certain parts oI
body as in vasoconstriction oI nail beds or earlobes Irom exposure oI cold and
does not necessarily indicate a central systemic problem.

Adequate respiratory examination requires a warm, well-lighted, quiet room. In
addition to adequate room lighting, a mechanism Ior supplementary lighting is
essential to aid in close inspection oI speciIic areas .Privacy is important
because oI the need to examine the entire chest area. Female clients may wish to
have a gown or towel to cover their breasts while the posterior thorax is being
examined. Tell them that you will be asking them to move their breasts to the
side so that you will be better able to palpate, percuss, and auscultate
the anterior thorax. BeIore starting the examination, teach the patient how to sit
and how to breathe during the auscultation oI the posterior thorax. For
examination oI the posterior thorax, instruct the client to hunch Iorward slightly
and cross the arms over the chest so that the greatest amount oI lung surIace is
available Ior examination. Also, instruct the patient to breathe deeply and
quietly, slowly inhaling and exhaling through the open mouth. The client can be
seated throughout the examination and stripped to the waist. Female clients can
use a towel or grown to cover their breasts when the posterior and lateral
portions oI the chest are being examined. The examination oI the respiratory
system generally is done in the traditional sequence-inspection, palpation,
percussion, and auscultation. Examination technique and normal Iindings
Inspection is perIormed to
(1) measure and assess the pattern oI
(2) assess the skin and the overall conIiguration, symmetry, and
integrity oI the thorax.
(3) evidence Ior the loss oI subcutaneous tissue.
The approach to the physical examination is regional and integrated.
The examination oI systems is combined in body regions when appropriate.
Because the client is uncovered to the waist during the examination, a large
portion oI skin and tissue is accessible to inspection. The observation oI skin
and underlying tissue provides inIormation about the client's general
nutritional state. Common thoracic Iindings are the spider nevi associated with
Thoracic configuration.

The Iirst point oI observation is the general shape oI the thorax and its
symmetry. Although no individual is absolutely symmetrical in both
body hemispheres, most individuals are reasonably similar Irom side to side.
Using the client as his or her own control whenever paired parts are examined is
an excellent habit and oIten yields important Iindings. The anteroposterior
diameter oI the thorax in the normal adult is less than the transverse diameter at
an approximate ratio oI 12 .
Barrel chest
In the normal inIant, in some adults with pulmonary disease, and in
elderly adults, the thorax is generally round. This condition is called barrel
chest. The barrel chest is characterized by horizontal ribs, slight kyphosis oI the
thoracic spline, and prominent sternal angle. The chest appears as though it is in
continuous inspiratory position. There is an increase in the anterio posterior
diameter oI the thorax .In a patient with emphysema the ribs are more widely
spaced and the intercostals spaces tend to bulge on expiration.
Other observed abnormalities oI thoracic shape include the Iollowing
#etraction of thorax.

The retraction is unilateral, involving only one side.

!igeon or chicken chest.
Sternal protrusion anteriorly. The anteroposterior diameter oI the chest
is increased, and the resultant conIiguration resembles the thorax oI a Iowl. It
also occurs due to the displacement oI the sternum. This may occur with rickets
or MarIan`s syndrome or severe kyphoscoliosis.
A kyphoscoliosis is characterised by elevation oI scapula and a
corresponding S shaped spine. This deIormity limits lung expansion within
thorax. It may occur with osterioporosis and other skeletal disorders that aIIect
the thorax.
!attern of respiration.
Normally, men and children breathe diaphragmatically, and women
breathe thoracically or costally. A change in this pattern might be signiIicant. II
the client appears to have labored respiration, it is important to observe Ior the
use oI the accessory muscles oI respiration in the neck (sternocleidomastoid,
scalenus, and trapezius muscles) and Ior supraclavicular retraction. Impedance
to air inIlow is oIten accompanied by retraction oI the intercostals spaces during
inspiration. An excessively long expiratory phase oI respiration is characteristic
oI outIlow impedance and may be accompanied by the use oI abdominal
muscles to aid in expiration. In the normal adult, the resting respiratory rate is
12 to 20 breaths/min and is regular and unlabored. The ratio oI respiratory rate
to pulse rate normally is 14.
It is an adult respiratory rate oI more than 24 breaths/min . It is
commonly seen in patients with pneumonia, pulmonary edema, metabolic
acidosis , septicaemia, severe pain, rib Iracture. Shallow or irregular breathing is
called hypoventilation..
It is an adult respiratory rate oI less than 10 breaths/min .It is associated
with increased intracranial pressure, brain injury, and drug overdoze.
It is a subjective phenomenon oI inadequate or distressIul respiration.
Many more abnormal patterns oI respiration exist, such as
Cheyne-Stokes respiration,
It is charecterised by alternating episodes oI Apnea ( cessation oI
breathing) and periods oI deep breathing. Deep inspirations become
increasingly shallow , Iollowed by apnea that may last approximately 20
seconds.The cycle repeats aIter each apneic period. The duration oI period oI
apnea may vary and may progressively lengthen , thereIore it is timed and
reported. Cheyne stokes respiration is usually associated withheart Iailure and
damage to respiratory centre.( drug induced , tumour, trauma)
Biot's breathing
It is also called cluster breathing .These are cycles oI breath that vary
indepth and have varying periods oI apnea.It is seen with some central venous
system disorders .


Palpation is perIormed to
(1) Iurther assess abnormalities suggested by
the health history or by observation, such as tenderness, pulsations, masses, or
skin lesions;
(2) assess the skin and subcutaneous structures;
(3) assess thoracic expansion;
(4) assess tactile fremitus; and
(5) assess tracheal position.
In examination oI the thorax, three parts oI the thorax need consideration
posterior chest, anterior chest, right and leIt lateral chest. During the
examination, move Irom the area oI one hemisphere to the corresponding area
on the other side (right to leIt, leIt to right) until all Iour major parts have been
surveyed. During palpation Ior assessment oI Iremitus and all subsequent
procedures Ior examination oI the respiratory system, examine all areas
meticulous ly and systematically. A very helpIul landmark Ior location oI points
on the thorax, especially the counting oI ribs and interspaces, is the angle of
Louis, the junction oI the manubrium and the body oI the sternum. It is also
important to remember that the second rib connects with this palpable bony
prominence and that the second interspace lies immediately below it.

Assessment of thoracic expansion.
The degree oI thoracic expansion can be
Assessed Irom the anterior or the posterior chest. Anteriorly, place your hands
over the client's anterolateral chest with the thumbs extended along the costal
margin, pointing to the xiphoid process. Posteriorly, place the thumbs at the
level oI the tenth rib and place the palms on the posterolateral chest. In either
position, the thumbs will be approximately 3 to 5 cm apart beIore inspiration,
depending on the client's size. The amount and symmetry oI the thoracic
expansion can be Ielt during quiet and deep respiration. First, Ieel thoracic
expansion during normal, quiet respiration. Next, ask the client to take a deep
breath in slowly and then exhale. The symmetry oI respiration should be Ielt
between the leIt and the right hemi thoraces as the thumbs are separated an
additional 3 to 5 cm during the deep inspiration.

Assessment of tactile fremitus.
Fremitus is vibration that is perceptible on palpations. Sound generated
by the larynx travels distally along the bronchial tree to set the chest wall in
resonant motion This is especially true oI consonant sounds. The detection oI
the resulting vibration on the chest wall by touch is called tactile Iremitus.
Normal Iremitus is widely varied. It is inIluenced by the thickness oI the chest
wall especially iI that thickness is muscular .However the increase in
subcutaneous tissue with increase in obesity may also aIIect Iremitus. Lower
pitched sounds travel better through the normal lungs and produce greater
vibration oI the chest wall . ThereIore Iremitus is more pronounced in men than
in women because oI the deeper male voice. Tactile (sometimes also called
"vocal") Iremitus is palpable vibration oI the thoracic wall produced by
phonation. Ask the client to repeat "one, two, three" or "ninetynine" while you
systematically palpate the thorax. Use the palmar bases oI the Iingers, the ulnar
aspect oI the hand, or the ulnar aspect oI the closed Iist. You can use two hands
to assess both sides oI the chest simultaneously or one hand moving alternately
to compare one side oI the chest to the other. II one hand is used, move it Irom
one side oI the chest to the corresponding area on the other side. II two hands
are used, place them simultaneously on the corresponding areas oI each thoracic
side. Fremitus is decreased or absent when the distance between the palpating
hand is increased or when there is interIerence with sound transmission.
Distance is increased and sound transmission is decreased in the Iollowing
conditions pneumothorax with lung collapse, Iluid in the pleural space (pleural
eIIusion), pleural thickening, tumors or masses in the pleural space,
emphysema, bronchial obstruction, and a thick, muscular chest wall. Fremitus is
increased in conditions that decrease the distance between the lungs and the
palpating Iingers and that Iavor the sound transmission in the chest, Ior
example, in pneumonia with consolidation,
atelectasis (with open bronchus), lung tumors, pulmonary inIarction, and
pulmonary Iibrosis.

Assessment of tracheal deviation.
The trachea is assessed by palpation Ior lateral deviation. Place the index Iinger
oI your dominant hand on the trachea in the suprasternal notch, then move the
Iinger laterally leIt and right in the spaces
bordered by the upper edge oI the clavicle, the inner aspect oI the
sternocleidomastoid muscle, and the trachea. These spaces should be equal on
both sides. In diseases such as atelectasis and pulmonary Iibrosis, the trachea
may be deviated toward the abnormal side. The trachea may be deviated toward
the normal side in conditions such as neck tumors, thyroid enlargement,
enlarged lymph nodes, pleural eIIusion, unilateral emphysema, and tension

Percussion is the tapping oI an object to set underlying structures in
motion and thus produce a sound called a percussion note and a palpable
vibration. Percussion penetrates to a depth oI approximately 5 to 7 cm into the
chest. This technique is used in the thoracic examination to determine the
relative amounts oI air, liquid, or solid material in the underlying lung and to
determine the positions and boundaries oI organs. With experience and study,
one learns to diIIerentiate among the Iive percussion tones commonly elicited
Irom the human body. The procedure Ior thoracic percussion is as Iollows

Position the client with the head bent and the arms Iolded over the
chest. With this maneuver, the scapulae move laterally and more
lung area is accessible to examination. On the posterior chest,
percuss systematically at about 5 cm intervals Irom the upper to
lower chest, moving leIt to right, right to leIt, and avoiding
scapular and other bony areas.
Percuss the lateral chest with the client's arm positioned over the
. On the anterior chest, percuss systematically, with the patient in
upright position with shoulders arched backward and arms at the
side. The nurse begins in the supraclavicular area and proceeds
downward, Irom one intercostals space to the next. Dullness
noted to the leIt oI sternum between the third and IiIth intercostals
spaces is a normal Iinding because that is the location oI the heart.
II the client's breathing is shallow or painIul, the measurement oI
diaphragmatic excursion is indicated. Various pulmonary and
abdominal lesions, ascites, or trauma may limit the movement oI
the diaphragm. The Iollowing is the procedure Ior assessing
diaphragmatic excursion
1. Instruct the client to inhale deeply and hold the breath in.
2. Percuss dwn the scapular line on one side, starting at T7 or at the end oI the
scapula, until the lower edge oI the lung is identiIied. Sound will change Irom
resonance to dullness.
3. Mark the point oI change at the scapular line. This point is the edge oI the
diaphragm at Iull inhalation.
4. Instruct the client to take a Iew normal respirations.
5. Instruct the client to take a deep breath, exhale completely, and hold the
breath at the end oI the expiration.
6. Proceed to percuss upward Irom the marked point at the scapular line. Mark
the point where dullness oI the diaphragm changes to the resonance oI the lung.
This point is the level oI the diaphragm at Iull expiration. An alternate method
oI determining the level oI the diaphragm at Iull exhalation is to percuss down
along the scapular line and note where the resonance oI the lung changes to the
dullness oI the diaphragm.
7. Repeat the procedure on the opposite side.
8. Measure and record the diaphragmatic excursion, the distance between the
upper and lower marks in centimeters Ior each side oI the thorax.
The diaphragm is usually slightly higher on the right side because oI the
location oI the liver on that side. Diaphragmatic excursion which is normally 3
to 5 cm bilaterally, is usually measured only on the posterior chest

Through auscultation, inIormation can be obtained about the Iunctioning oI the
respiratory system and about the presence oI any obstruction in the passages.
For auscultation oI the lungs, a stethoscope is used. The diaphragm oI the
stethoscope is commonly used Ior the thoracic examination because it covers a
larger surIace than does the bell. Also, the diaphragm is designed to transmit the
usually higher pitch oI abnormal breath sounds. Place the stethoscope Iirmly,
but not tightly, on the skin. Avoid client or stethoscope movement because
movements oI muscle under the skin or movements oI the stethoscope over hair
produce conIusing extrinsic sounds.
The auscultatory assessment includes
(1) analysis oI breath sounds,
(2) detection oI any abnormal sounds, and
(3) examination oI the sounds produced by the spoken voice.
As with percussion, use a zigzag approach, comparing the Iinding at each point
with the corresponding point on the opposite hemithorax. BeIore beginning
auscultation, instruct the client to breathe through the mouth and more deeply
and more slowly than in usual respiration. Then, systematically auscultate the
posterior, lateral, and anterior chest. At each application oI the stethoscope,
listen to at least one complete respiration. Observe the client Ior signs oI
hyperventilation and alter the procedure iI the client becomes lightheaded or
Breath sounds. Breath sounds are produced by the movement oI air through the
tracheobronchoalveolar system. These sounds are analyzed according to pitch,
intensity, quality, and relative duration oI inspiratory and expiratory phases.
The sounds heard over normal lung parenchyma are called ;esicular breath
sounds. The inspiratory phase oI the vesicular breath sounds is heard better than
the expiratory phase and is about 2.5 times longer. These sounds have a low
pitch and soIt intensity. Broncho;esicular breath sounds are normally heard in
the areas oI the major bronchi, especially in the apex oI the right lung and at the
sternal borders anteriorly and posteriorly between the scapula. Bronchovesicular
breath sounds are characterized by inspiratory and expiratory phases oI equal
duration, moderate pitch, and moderate intensity. When bronchovesicular breath
sounds are heard over the peripheral lung oI an adult, an underlying
pathological condition is likely to be present. Bronchial breath sounds are
normally heard over the trachea and indicate a pathological condition iI heard
over lung tissue. They are high-pitched, loud sounds associated with shortened
inspiratory and lengthened expiratory phases. A gap oI silence audibly
separates the inspiratory and expiratory phases. Absent or decreased breath
sounds can occur in (1) any condition that causes the deposition oI Ioreign
matter in the pleural space, (2) bronchial obstruction, (3) emphysema, or (4)
shallow breathing. Increased breath sounds, as Irom vesicular to
bronchovesicular or bronchial, can occur in any condition that causes a
consolidation oI lung tissue.

Abnormal or adventitious sounds.
Adventitious sounds are not alterations in breath sounds but abnormal sounds
superimposed on breath sounds.
A crackle (or rale, a term used in older texts) is a short, discrete, interrupted,
crackling or bubbling sound that is most commonly heard during inspiration.
The sound oI crackles is similar to that produced by hairs being rolled between
the Iingers while close to die ear. The exact mechanism by which crackles are
produced is not Iully understood. Crackles are thought to be produced by air
passing through
Iluid in the bronchi, bronchioles, and alveoli or by air rushing through passages
and alveoli that were closed during expiration and abruptly opened during
inspiration. The pitch and location in the inspiratory phase oI the crackles are
thought to indicate their site oI production. Low-pitched, coarse crackles
occurring early in inspiration are thought to originate in the bronchi, as in
Medium-pitched crackles in midinspiration occur in diseases oI the small
bronchi, as in bronchiectasis. High-pitched, Iine crackles are Iound in diseases
aIIecting the bronchioles and alveoli and occur late in inspiration.

heezes (rhonchi) are continuous sounds produced by the movement oI air
through narrowed passages in the trachcobronchial tree. Sonorous wheezes
predominate in expiration because bronchi are shortened and narrowed during
this respiratory phase. However, they can occur in both the inspiratory and the
expiratory phase oI respiration, suggesting that lumina have been narrowed
during both respiratory phases. As with crackles, the pitch and location oI
sonorous wheezes in the expiratory phase are thought to indicate their origins.
Low-pitched sonorous wheezes are usually heard in early expiration and
probably originate in the larger bronchi. High-pitched, sibilant wheezes
originate in small bronchioles and oIten occur in late expiration.
A pleural friction rub is a loud, dry, creaking or grating sound indicative oI
pleural irritation. It is produced by the rubbing together oI inIlamed and
roughened pleural surIaces during respiration (e.g., in pleurisy). ThereIore it is
heard best during the latter part oI inspiration and the beginning oI expiration.
Because thoracic expansion is greatest in the lower anterolateral thorax, pleural
Iriction rubs are most oIten heard there.