STATE: Washed hands, provided privacy, identified patient. Hi, my name is Beverly, and I’m your nurse today.

I’m going to do an assessment on your lungs. Please tell me where you are, what day it is.

CHEST:
INSPECT:

SUBJ Q: Do you have any chest pain when breathing? Position /Respiratory pattern\ /Labored, Effortless \ / Difficulty, Distressed\ Color LOC Facial expression Orientation Accessory muscle use

REPORT:

Patient is sitting. Respiration is effortless Color is pink/no pallor or cyanosis Expression is relaxed. Patient is A&O X 3 No use of accessory muscles.

POSTERIOR/LATERAL CHEST:
PALPATION: Shape: Anteroposterior to Transverse (Use both hands; measure AP; Turn pt to measure Transverse) Deformities: Check sideway view for lordosis, kyphosis. Run finger tips down spine to check for scoliosis. Symmetry: Hold at #10 ICS, have pt take deep breath in/out without raising shoulders. Masses: Feel with hand in a rubbing motion from shoulders to bottom of thorax Crepitus: to check for masses/crepitus Tenderness: and tenderness Percuss pt starting at apex of lungs, going side-to-side down to 10th ICS, over to 8th ICS and up to 6th ICS. Anteroposterior to Transverse is 1:2. No scoliosis, lordosis or kyphosis. Pt. has symmetrical expansion bilaterally at 10th thoracic space. No masses, crepitus or tenderness. Pt. has resonance throughout entire lung fields, posteriorly and laterally. Listen to pts lung sounds starting at apex and going down to 10th ICS, over to 8th ICS, and up to 6th ICS listening for normal and adventitious lung sounds.

PERCUSS:

REPORT:

AUSCULATE:

REPORT:

Pts. lungs are clear to auscultation posteriorly and laterally. No adventitious lung sounds.

ANTERIOR CHEST:
INSPECTION: Look at pts chest looking for carinatum and excavatum.

REPORT:

No carinatum or excavatum. Begin at apex of lungs, go to 2nd ICS and 4th ICS and stop. Verbalize rest in report. Pts breasts were displaced and percussed to the 6th ICS. Resonance heard bilaterally. Begin at apex of lung, go to 2nd ICS and 4th ICS and stop. Verbalize rest in report. Pts breast were displaced and auscultated to the 6th ICS. Lung sound were clear to auscultation bilaterally with no adventitious lung sounds.

PERCUSS:

REPORT:

AUSCULTATE:

REPORT:

BREASTS
SUBJ Q: INSPECT: Do you have any Hx of breast issues: pain, discharge, cancer? Ask pt to open gown, inspect for symmetry and skin characteristics. -Ask pt to put hands above head and push together. -Ask pt to put hands in front of abdomen and push. -Ask pt to put hands on hips and push. -Ask pt to lean forward.

D – Dimpling/discoloration O – Orange peel R - Redness/Retractions V - Venous pattern L - Lesions S - Symmetry

REPORT:

Pts breasts have no dimpling or discoloration. No orange peel. No redness or retractions. No abnormal venous pattern. No lesions. Breasts are symmetric bilaterally.

LYMPH NODES
INSPECT: Inspect axillary area for: B - Bulging E - Edema D - Discoloration REPORT: PALPATION: Pt has no bulging, edema or discoloration in axillary. Tell pt let you know if there is any tenderness. Feel axillary with fingertips in circular motion: -Central/midline – push fingertips up in axilla and feel. -Pectoral/anterior – circular motion down to waist. -Subscapular/posterior – circular motion down to waist. -Interior aspect of arm/lateral – circular motion to interior elbow. No lymphadenopathy in middle, anterior, posterior and upper inner arm lymph nodes.

REPORT:

BREASTS
PALPATION: Have pt lay on bed with hand over their head. Tell pt to let you know if there is any tenderness during exam. Position fake breast in proper position on pt. Place fake breasts on table for exam. Squeeze nipple looking for any discharge. Starting over nipple, use 3 fingertips moving in a circular motion over entire breast going in a circular motion including Tail of Spence noting any tenderness or lumps. No nipple discharge. Lump noted at (using clock face pattern) 3:00, 6:00, 9:00, 12:00 -orIn the Tail of Spence located off the LOQ of breast tissue in the upper, middle or lower 1/3. Size: Lump is 2cm X 2cm X 1cm Shape: Round/oval/lobulated Feel: Soft/firm/hard Movability: Fixed/movable Amount: There is 1 or many Boarders: The border is regular/irregular Nipple placement: displaced/points up/down/laterally Skin over lesion: none or red/swollen/tender/warm.

REPORT: