Checklists for Clinical Nursing Skills

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Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

skill 2-5 Assessing the thorax and lungs

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed without causing the patient to experience anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation. 1. Identify the patient. 2. Check the medical order or clinical pathway/care plan. 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. Equipment: stethoscope. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), if indicated. 8. Ensure patient privacy is maintained and that interruptions are minimal. 9. Undertake a health history, as per Skill 2-1. 10. Help the patient to undress, if needed, and provide a patient gown. Assist the patient to a sitting position and expose the posterior thorax. Use a blanket or sheet to cover any exposed area other than the one being assessed. 11. Inspect the posterior thorax. Examine the skin, bones and muscles of the spine, shoulder blades and back, as well as symmetry of expansion and accessory muscles used during respiration. 12. Assess the anteroposterior (AP) and lateral diameters of the thorax. 13. Palpate over the spine and posterior thorax. (a) Use the palmar surface of your hand to palpate for temperature, moisture, tenderness, muscle development and masses. (b) Instruct the patient to take a deep breath. Assess for tactile fremitus by using the ball of your hand to palpate over the posterior thorax while the patient says ‘ninety-nine’.

Comments

Excellent

Satisfactory

Needs practice

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