- Good morning po, I am ____, The nurse assigned to this patient today.
- For today, I will be conducting a respiratory system assessment for the patient.
Assessing both the anterior and posterior thorax and lungs of the patient. The
patient will have to do a different position for this assessment. The patient
should be informed of the different positions that had to be done to avoid the
patient from feeling any discomfort or anxiety.
- Before entering the room, I will perform hand hygiene through handwashing
technique and observe other appropriate infection control procedures like
wearing Personal Protective Equipment (PPE) if necessary and ensuring that the
patient’s bed is clean, and that the equipment needed like the stethoscope are
disinfected.
❖ Introduce:
➢ Good morning po ma’am, I am nurse ___ and ako po yung magiging
nurse niyo for today.
❖ Verifying the patient’s Identity
➢ Pwede ko po bang malaman kung ano po yung buong pangalan niyo? At
ang iyong kaarawan po?
➢ Dahil tapos na po kayo sa interview we will proceed na po sa physical
examination po ng inyong respiratory system.
❖ Explain the procedure to the patient
➢ Bago po tayo mag-simula ipapaliwanag ko lang po yung gagawin ko po.
Ieexamine ko po yung harap at likurang bahagi po ng iyong katawan para
po malaman natin kung ano po ang kalagayan ng inyong lungs or baga
po. Okay lang po ba?
➢ Bukod pa doon, Papakiusapan ko din po kayong tumayo at yumuko po.
Kinakailangan ko din pong ilagay yung kamay ko sa dibdib niyo at ang
stethoscope ko po. Okay lang po ba?
❖ Repeat History:
➢ Bago po tayo magpatuloy may mga konting katanungan lang po ako
about sa history niyo po. Okay lang po?
■ May allergies po ba kayo?
■ May iniinom po ba kayong gamot?
■ Naninigarilyo po ba?
■ Inuubo po ba?
■ Pag humihinga po kayo lalo na kapag exhale o paglabas ng hangin
may tunog po ba na parang may pito po?
■ Sumasakit po ba ang dibdib niyo?
❖ Patient privacy:
RR
, ➢ Okay po, isasara ko lang po yung kurtina para po may privacy po tayo
habang ginagawa ko po yung physical exam sainyo.
➢ Okay let’s proceed na po, Ma’am kailangan ko pong tanggalin ang gown
niyo, Okay lang po ba?
POSTERIOR THORAX EXAMINATION:
INSPECTION:
➢ Ma’am sa part po nang examination na’to kailangan po nakatayo kayo. Kaya niyo
po bang mag-isa or gusto niyo po tulungan ko kayo tumayo?
➢ Titignan ko lang po ang hugis at kung pantay po ba ang dibdib niyo dito po sa
harap, sa likod po, at dito sa tagiliran.
➢ Next naman po titignan ko po kung pantay po ang hugis po ng spine niyo,
Ngayon po pupunta ako sa may likuran niyo to check and inspect po.
➢ Next naman po , pwede po ba kayong yumuko para po makita ko yung likod niyo
at macompare ko po kung pantay.
Technique Normal Findings Abnormal Findings
1. Inspect the shape and - Normally it's wider - The AP Diameter
symmetry of the thorax than it’s deep. may increase in
➔ Observe AP and COPD.
transverse diameter - Unilateral
impairment or
lagging of respi
movement suggest
disease of the
underlying lung or
pleura
2. Instruct px to bend over - The anteroposterior - Spinal processes that
their waist and check for diameter to deviate laterally in the
symmetry. transverse diameter thoracic area may indicate
➔ Palpate the patients normal ratio is 1:2. scoliosis.
left and right upper - Chest should be - Spinal configurations may
back. symmetrical have respiratory
(pantay) implications.
- Normal spine seen - Ribs appearing horizontal
from the side: has at an angle greater than
an S-Shape curved. 45 degrees with the spinal
- Normal spine when column are frequently the
RR
- For today, I will be conducting a respiratory system assessment for the patient.
Assessing both the anterior and posterior thorax and lungs of the patient. The
patient will have to do a different position for this assessment. The patient
should be informed of the different positions that had to be done to avoid the
patient from feeling any discomfort or anxiety.
- Before entering the room, I will perform hand hygiene through handwashing
technique and observe other appropriate infection control procedures like
wearing Personal Protective Equipment (PPE) if necessary and ensuring that the
patient’s bed is clean, and that the equipment needed like the stethoscope are
disinfected.
❖ Introduce:
➢ Good morning po ma’am, I am nurse ___ and ako po yung magiging
nurse niyo for today.
❖ Verifying the patient’s Identity
➢ Pwede ko po bang malaman kung ano po yung buong pangalan niyo? At
ang iyong kaarawan po?
➢ Dahil tapos na po kayo sa interview we will proceed na po sa physical
examination po ng inyong respiratory system.
❖ Explain the procedure to the patient
➢ Bago po tayo mag-simula ipapaliwanag ko lang po yung gagawin ko po.
Ieexamine ko po yung harap at likurang bahagi po ng iyong katawan para
po malaman natin kung ano po ang kalagayan ng inyong lungs or baga
po. Okay lang po ba?
➢ Bukod pa doon, Papakiusapan ko din po kayong tumayo at yumuko po.
Kinakailangan ko din pong ilagay yung kamay ko sa dibdib niyo at ang
stethoscope ko po. Okay lang po ba?
❖ Repeat History:
➢ Bago po tayo magpatuloy may mga konting katanungan lang po ako
about sa history niyo po. Okay lang po?
■ May allergies po ba kayo?
■ May iniinom po ba kayong gamot?
■ Naninigarilyo po ba?
■ Inuubo po ba?
■ Pag humihinga po kayo lalo na kapag exhale o paglabas ng hangin
may tunog po ba na parang may pito po?
■ Sumasakit po ba ang dibdib niyo?
❖ Patient privacy:
RR
, ➢ Okay po, isasara ko lang po yung kurtina para po may privacy po tayo
habang ginagawa ko po yung physical exam sainyo.
➢ Okay let’s proceed na po, Ma’am kailangan ko pong tanggalin ang gown
niyo, Okay lang po ba?
POSTERIOR THORAX EXAMINATION:
INSPECTION:
➢ Ma’am sa part po nang examination na’to kailangan po nakatayo kayo. Kaya niyo
po bang mag-isa or gusto niyo po tulungan ko kayo tumayo?
➢ Titignan ko lang po ang hugis at kung pantay po ba ang dibdib niyo dito po sa
harap, sa likod po, at dito sa tagiliran.
➢ Next naman po titignan ko po kung pantay po ang hugis po ng spine niyo,
Ngayon po pupunta ako sa may likuran niyo to check and inspect po.
➢ Next naman po , pwede po ba kayong yumuko para po makita ko yung likod niyo
at macompare ko po kung pantay.
Technique Normal Findings Abnormal Findings
1. Inspect the shape and - Normally it's wider - The AP Diameter
symmetry of the thorax than it’s deep. may increase in
➔ Observe AP and COPD.
transverse diameter - Unilateral
impairment or
lagging of respi
movement suggest
disease of the
underlying lung or
pleura
2. Instruct px to bend over - The anteroposterior - Spinal processes that
their waist and check for diameter to deviate laterally in the
symmetry. transverse diameter thoracic area may indicate
➔ Palpate the patients normal ratio is 1:2. scoliosis.
left and right upper - Chest should be - Spinal configurations may
back. symmetrical have respiratory
(pantay) implications.
- Normal spine seen - Ribs appearing horizontal
from the side: has at an angle greater than
an S-Shape curved. 45 degrees with the spinal
- Normal spine when column are frequently the
RR
