NUR 341 Thorax and Lungs
Jeremiah
Terms in this set (9)
Collect equipment
clean stethoscope
wash hands
Step 1 introduce seld
obtain two forms of ID
State "I will provide proper draping and privacy"
provide drap and perform assessment directly on skin
Inspect shape and configuration of chest wall
Step 2
A-P-Transverse diameter ratio (should be 1:2)
Step 3 Inspect skin color for cyanosis
State "I will assess the respiratory rate and pattern"
Step 4 labored or unlabored
symmetrical
Palpate for symmetric chest expansion posterior/anterior
Step 5
(pinch up the skin at the coastal angle and T10
Palpate for tactile fremitus (posterior/lateral)
Step 6
(hands on marks, say "99" and feel vibration)
Percuss and identify expected tone over the anterior/posterior lung fields
Step 7
(resonance, dull, flat) - should be resonant
Auscultate anterior, posterior, lateral chest
Step 8
identify normal breath sounds (bronchial, brochovesicular, vesicular) with location
Verbalize adventitious sounds
Step 9
(crackles - fluid buildup/wheezes - constriction)
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