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14 Cards in this Set
- Front
- Back
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INTRODUCE
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self and explain procedure
Ask if there are any questions |
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ASSESS
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overall appearance of the client in a "once over" evaluation
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DETERMINE
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if there is any immediate need of client (ie: need of bathroom)
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WASH
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hands. Assure privacy, drape patient to protect modesty
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OBTAIN
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baseline measurements
(ht, wt, temp, hr, rhythm, vol., Respiratory rate/rhythm, & BP bilaterally |
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INSPECT
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skin color, nail bed angles
capillary refill, turgor, edema, temp and moisture; no nasal flaring; check for clubbing |
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INSPECT
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the chest area over lung to assess for symmetry, deformity and
AP to Lateral Ratio, Costal Angle |
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PALPATE
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The trachea for midline, the chest anteriorly and posteriorly for structure and support;
Use fingers to assess for crepitus |
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DETERMINE
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symmetry of chest expansion
(thumbs posteriorly) uneven: |
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AUSCULTATE using diaphragm
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Anterior neck (Bronchial 1:2)
Bronchovesicular 1:1 2nd IS-RSB & LSB and everywhere else (vesicular 3:1) Listen for full insp and exp cycle. Move 2 - 3 inch down. |
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AUSCULTATE
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under left arm 3 places starting close to axillary;
under right arm 4 places starting close to axillary |
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AUSCULTATE
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Posteriorly 8 - 10 spots depending on size of lung field; flare out toward the bottom; Have client take 4 deep breaths to evaluate adventitious sounds over the mid and lower lung fields.
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IDENTIFY or explain
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Crackles: (ie: Pneumonia)
Wheezing: melodious (ie: asthma) rhonchi: snoring (bronchitis) Adventitious bronchial and pleural rub: superficial, low-pitched rubbing (pleurisy) |
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DOCUMENTATION
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RR 16 unlabored: No spinal or sternal deformities, scars, lesions, tatoos noted. No use of accessory muscles. No tenderness or crepitus on palpation; costal angle < 90 AP/Lateral diameter 1:2; Resp. expansion equal bilaterally. No clubbing noted; Trachea midline; Lungs clear to auscultation through bilaterally. No adventitious breath sounds appreciated; patient tolerated well....DM, ADNSN
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