Checklists for Clinical Nursing Skills

24

skill 2-5 Assessing the thorax and lungs (continued)

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14. Assess thoracic expansion by standing behind the patient, placing both thumbs on either side of the patient’s spine at the level of T9 or T10 and asking the patient to take a deep breath. Note the movement of your hands. 15. Percuss over the posterior and lateral lung fields for tone using a zigzag pattern, starting above the scapulae to the bases of the lungs. Note the intensity, pitch, duration and quality of sounds produced. Percuss for diaphragmatic excursion on each side of the posterior thorax. 16. Auscultate the lungs across and down the posterior thorax to the bases of lungs as the patient breathes slowly and deeply through the mouth. 17. Examine 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. 18. Palpate the anterior thorax systematically. Palpate for tactile fremitus (as the patient repeats the words ‘ninety-nine’). 19. Percuss over the anterior thorax using the proper sequence. 20. Auscultate the lungs through the anterior thorax as the patient breathes slowly and deeply through the mouth. Listen for the duration, pitch and intensity of sounds. 21. Inspect the breasts and axillae with the patient’s hands resting on both sides of the body, placed on the hips and then raised above the head. 22. Palpate the axillae with the patient’s arms resting against the sides of the body. Assist the patient into a supine position. Place a small pillow or towel under the patient’s back. Palpate the breasts and nipples. Wear gloves if there is any discharge from the nipples or if a lesion is present. 23. Cover the patient’s chest and back and assist them into a position of comfort. 24. Remove used PPE/equipment and dispose of them in the appropriate receptacle. 25. Perform hand hygiene. 26. Document assessment findings on the patient’s chart and make any necessary referrals. Report any abnormal results to a senior nurse, medical officer or endorsed nurse practitioner immediately.

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Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.