23
Comments
Excellent
Satisfactory
Needs practice
Name __________________________________________________________ Date ____________________________________
Course _________________________________________________________ Year ____________________________________
Instructor/examiner _ ____________________________________________ Position _ _______________________________
Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
skill 2-5
Assessing the thorax and lungs
Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery:
A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment
Goal:
The assessment is completed without causing the
patient to experience anxiety or discomfort, the findings are
documented and the appropriate referral is made to other
healthcare professionals, as needed, for further evaluation.
1. Identify the patient.
2. Check the medical order or clinical pathway/care plan.
3. Introduce yourself, explain the rationale for the
procedure to the patient and family, and obtain consent.
4. Gather the necessary equipment.
Equipment:
stethoscope.
5. Undertake a risk assessment, if indicated.
6. Perform hand hygiene.
7. Put on personal protective equipment (PPE), if indicated.
8. Ensure patient privacy is maintained and that
interruptions are minimal.
9. Undertake a health history, as per Skill 2-1.
10. Help the patient to undress, if needed, and provide a
patient gown. Assist the patient to a sitting position and
expose the posterior thorax. Use a blanket or sheet to
cover any exposed area other than the one being assessed.
11. Inspect the posterior thorax. Examine the skin, bones and
muscles of the spine, shoulder blades and back, as well
as symmetry of expansion and accessory muscles used
during respiration.
12. Assess the anteroposterior (AP) and lateral diameters of
the thorax.
13. Palpate over the spine and posterior thorax.
(a) Use the palmar surface of your hand to palpate
for temperature, moisture, tenderness, muscle
development and masses.
(b) Instruct the patient to take a deep breath. Assess
for tactile fremitus by using the ball of your hand to
palpate over the posterior thorax while the patient
says ‘ninety-nine’.
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