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Pulmonary Focused
Pulmonary Focused Assessment
| Question | Answer |
|---|---|
| Introduce yourself, explain to the patient what you will be doing. Provide Privacy, wash hands, raise the bed to a comfortable working level. | |
| Start by inspecting the thorax configuration, paying attention to any barrell shape or curvature. | |
| Inspect the breathing pattern and inspect respiratory rate, rhythm & effort (nostrils flaring, pursed lip, use of accessory muscles) | |
| Observe the skin and nails (for clubbing & capillary refill) | |
| Palpate by testing for symmetry of chest expansion. | |
| Place hands on back, starting at the top and placing hands in two other places, each time having the patient say "99" to check for fremitus. | |
| Evaluate the excursion | |
| Auscultate bronchial breath sounds (over trachea) | |
| Ausculate vesiclar breath sounds (in 6 spaces, working in a zig-zag motion, posteriorly & anteriorly) | |
| Note any abnormal breath sounds (crackles, fine wheezing, coarse wheezi (rhonchi), pleural friction rub | |
| Make sure the patient is comfortable, lower the bed, raise the rails, and put the call bell in reach & wash hands. | |
| Document the procedure. |
Created by:
jessicaspring
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