Assessment of the Thorax and Lungs Checklist

Name: Romero, Richelle Grace M. Date: May 09, 2019 Score____________________

Criteria: 4 – Very satisfactory 2 – Fair

3 – Satisfactory 1 – Needs Improvement

I. Collecting Subjective Data: The Nursing Health History

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Preliminaries

1. Gather the necessary materials/equipment

needed.
2. Demonstrate courtesy.

3. Explain the procedure to the client.

History of Present Health Concern Findings

Difficulty Breathing

4. Do you ever experience difficulty The client denies experience

breathing or a loss of breath? If the client of difficulty in breathing or
answers yes, use COLDSPA to explore the loss of breath.
symptom.
a. Character: Describe the difficulty of
breathing.
b. Onset: When did it begin?
c. Location: Nonapplicable
d. Duration: How long did the dyspnea
last?
e. Severity: How did it affect you to carry
on your usual activities?
f. Palliative/aggravating factors: What
aggravates or relieves the dyspnea? Do
any specific activities cause the
difficulty in breathing?

Do you have difficulty breathing when

you are resting?

Do you have difficulty breathing when

you sleep? Do you use more than one
pillow or elevate the head of the bed
(HOB) when you sleep?

Do you snore when you sleep? Have

you been told that you stop breathing at
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 night when you snore?
g. Associated factors: Do you experience
any other symptoms when you have
difficulty breathing? Describe.
Chest Pain
5. Do you have chest pain? Is the pain
associated with a cold, fever, or deep
breathing?
Cough
6. Do you have a cough? When and how
often does it occur?
7. Do you produce any sputum when you
cough? If so, what color is the sputum?
How much sputum do you cough up? How
this amount increased or decreased
recently? Does the sputum have an odor?
8. Do you wheeze when you cough or when
you are active?
Gastrointestinal Symptoms
9. Do you have any gastrointestinal
symptoms such as heartburn, frequent
hiccups, or chronic cough?
Personal Health History
10. Have you had prior respiratory problems?
11. Have you ever had any thoracic surgery,
biopsy, or trauma?
12. Have you been tested for or diagnosed with The client denies being
allergies?
The client denies chest pain.
The client experience cough
since April 22 (Monday) and
it occurs during day and
night. According to the
client, it is due to the sudden
change of temperature.
The client produces a
sputum with a yellow green
in color. The client does not
know the amount of sputum
she produces. According to
her, the amount has
decreased recently. Client
denies odor to the sputum.
The client does not know if
she wheeze when coughing
or when she is active.
The client denies any
gastrointestinal symptoms
such as heartburn, frequent
hiccups or chronic cough.
The client has asthma when
she was younger.
The client denies any
thoracic surgery, biopsy or
trauma.
tested for or diagnosed with
allergies.
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13. Are you currently taking medications for
breathing problems or other medications
(prescription or over the counter (OTC)
that affect your breathing? Do you use any
other treatments at home for your
respiratory problems?
14. Have you ever had a chest x-ray,
tuberculosis (TB) skin test, or influenza
immunization? Have you had any other
pulmonary studies in the past?
15. Have you recently travelled outside of the
Philippines?
Family History
16. Is there a history of lung disease in your
family?
17. Did any family members in your home
smoke when you were growing up?
18. Is there a history of other pulmonary
illnesses/disorders in the family (e.g.,
asthma)?
Lifestyle and Health Practices
19. Describe your usual dietary intake.
20. Have you ever smoked cigarettes or other
tobacco products? Do you currently
smoke? At what age did you start? How
much do you smoke and how much have
you smoked in the past? What activities do
you usually associate with smoking? Have
you ever tried to quit? Have you been
assessed using the 5 As of smoking
cessation (Ask, Advise, Assess, Assist,
Arrange) by a health professional?
21. If the client reports a history of difficulty of
breathing or a history of smoking ask the
client to answer the DRIVE4COPD
questionnaire.
22. Are you exposed to any environmental
conditions that affect your breathing?
The client is taking neozep
four times a day in every 6
hours but according to her
she stopped taking the
medicine last April 24.
The client had a chest x-ray
on the 3rd week of April but
denies tuberculosis skin test
and influenza immunization.
Client denies pulmonary
studies in the past.
The client did not travelled
outside the Philippines yet.
The client denies a history of
lung disease in the family.
The client denies any family
members in their home
smoking when she was
growing up.
According to the client, her
father and other four siblings
also have asthma.
The client’s usual dietary
intake is mostly chicken
every meal.
The client denies smoking
cigarettes or other tobacco
products.
The client denies a history of
difficulty of breathing or
history of smoking.
The client is not exposed to
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 Where do you work/study? Are you around
smokers?
23. Do you have difficulty performing your
usual daily activities? Describe any
difficulties.
24. What kind of stress are you experiencing at
this time? How does it affect your
breathing?
25. Have you used any herbal medicines or
alternative therapies to manage colds or
other respiratory problems?
Perfect score
Checklist: 100 points
Findings: 88 points
any environmental
conditions that affect her
breathing. The client studies
at AMCC Iligan City. The
client is not around with
people who smoke.
The client denies difficulty
in performing her usual daily
activities.
The client is experiencing
stress due to her major
subjects at school but it does
not affect her breathing.
The client reports drinking
calamansi juice and vitamin
C to manage colds or other
respiratory problems.
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 II. Collecting Objective Data: Physical Examination

Preliminaries 4 3 2 1
1. Prepare equipment (examination gown and drape,
gloves, stethoscope, light source, mask, skin marker,
metric ruler)
2. Do hand hygiene.
3. Provide privacy and ask client to put on gown.
4. Keep your hands warm.
General Findings
Inspection
5. Inspect for nasal flaring and pursed lip breathing. Nasal flaring and pursed lip breathing
are not observed.
6. Observe color of face, lips, and chest. The client has evenly colored skin
tone without unusual or prominent
discoloration. The client’s chest color
is lighter than the face.
7. Inspect color and shape of nails. The client’s nails are pink in color and
has a 160-degree angle between the
nail base and the skin.
Posterior Thorax

Inspection
8. Inspect configuration. While the client sits with arms at There is a slightly deviation on the
the sides , stand behind the client and observe the client’s right thoracic area or the
position of scapulae and the shape and configuration of scapula.
the chest wall.
9. Observe use of accessory muscles. Watch as the client The client does not use of accessory
breathes and note use of muscles. muscles when breathing.
10. Inspect the client’s positioning. Note the client’s Client was relaxed and could support
posture and ability to support weight while breathing weight while breathing comfortably
comfortably. with arms at the lap.
Palpation
11. Palpate for tenderness and sensation. Palpation maybe Client reports no tenderness, pain or
performed with one or both hands, but the sequence of unusual sensations. Temperature are
palpation is established. (Refer to Fig. 19 – 11 in your bilaterally equal.
textbook). Use your fingers to palpate for tenderness,
warmth, pain, or other sensations. Start toward the
midline at the level of the left scapula (over the apex of
the left lung) and move your hand left to right, comparing
findings bilaterally. Move systematically downward and
out to cover the lateral portions of the lungs at the bases.
12. Palpate for crepitus. Crepitus, also called No crepitus palpated.
subcutaneous emphysema, is a crackling sensation (like
bones or hairs rubbing against each other) that occurs
when air passes through fluid or exudate. Use your
fingers and follow the sequence in Fig. 19 – 11 when
palpating.
13. Palpate surface characteristics. Put on gloves and use There are no lesions and unusual
your fingers to palpate any lesions that you noticed masses in the skin being palpated.
during inspection. Feel for any unusual masses.
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14. Palpate for fremitus. Following the sequence Fremitus are heard loudly in the upper
described previously, use the ball or ulnar edge of one regions of the lungs. It is symmetric
hand to assess for fremitus (vibrations of air in the and easily identified.
bronchial tubes transmitted to the chest wall). As you
move your hand to each area, ask the client to say “99”.
Assess all areas for symmetry and intensity of vibration.
15. Assess chest expansion. Place hands Thumbs moved outward around 5-
on the posterior chest wall with your 10cm apart symmetrically.
thumbs at the level of T9 or T10 (at the
spine at the 8th- 10th rib -like butterfly), pressing
together a small skin fold. and observe the movement of
your thumbs as the client takes a deep breath
(if absent, decreased, or unequal). (Fig. 19 – 12)
16. Percuss for tone, starting at the apices above Resonance was observed in the upper
the scapulae and across the tops of both shoulders. part of the posterior thorax at the 5th
intercostal space. Hyper resonance or
Percuss intercostal spaces across and down, comparing dullness was observed starting at the
sides using indirect/ mediate percussion. 6th intercostal space.
Percuss to the lateral aspects at the bases of the lungs and
compare sides (Note areas of resonance, hyperresonance,
or dullness).
(Fig. 19 – 13)
17. Percuss for Diaphragmatic Excursion: Excursion is equal bilaterally and
 Have a patient take a deep breath & fully exhale, measures 3.1cm. The diaphragm is
then percuss the level of the diaphragm & mark. higher on the right because of the
 Have a patient take a deep breath & hold it , then position of the liver.
percuss the level of the diaphragm & mark.
 Measure the distance between the 2 marks.
 Perform this assessment technique on both sides
of the posterior thorax.

Auscultation
18. Auscultate for breath sounds noting location
(anterior, posterior, & lateral):
To best assess lung sounds, you will need to hear the
sounds as directly as possible. Do not attempt to listen
through clothing or a drape, which may produce
additional sound or muffle lung sounds that exist.
To begin, place the diaphragm of the stethoscope firmly
and directly on the posterior chest wall at the apex of the
lung at C7 to the bases of the lungs at T10.
Ask the client to breathe deeply through the mouth for
each area of auscultation (each placement of the
stethoscope) in the auscultation sequence so that you can
best hear inspiratory and expiratory sounds.
Normal breath sounds were
auscultated anteriorly and posteriorly.
Bronchial was heard at the thorax with
short inspiration and long expiration.
Bronchovesicular was heard between
the scapula with the same inspiration
and expiration in duration of
breathing. Vesicular was heard at the
base of the lungs or in the peripheral
lung fields with a long inspiration and
short expiration.

Be alert to the client’s comfort and offer times for rest

and normal breathing if fatigue is becoming a problem.

Normal breath sounds:

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• bronchial- are loud high pitched , and hollow
with a short inspiratory and long expiratory phase.
Normally heard in the anterior neck and nape of neck
posteriorly
• bronchovesicular- moderate sounding and
medium pitched with equal inspiratory and expiratory
phases. Heard over 1st to 2nd intercostal spaces anteriorly
and between scapula posteriorly.
• vesicular- soft and low pitched with long
inspiratory and short expiratory phase. Heard over most
lung fields.
Listen to one full respiratory cycle at each site.
Note normal, abnormal, adventitious sounds.
If adventitious sounds heard, have patient cough
& listen to see if sound has cleared

Fig. 19 – 16; Fig. 19 – 17

19. Auscultate for adventitious sounds (crackles, fine or
coarse, pleural friction rub, wheeze, sibilant or sonorous).
Testing for Abnormal Voice Sounds
20. Auscultate for voice sounds over chest wall.
Bronchophony: Have patient say ninety-nine, clearer
transmission of spoken voice sound over affected area.
21. Auscultate for voice sounds over chest wall.
Egophony: Have patient say “ee”, will sound
like “aa” over affected area (abnormal).
22. Whispered pectoriloquy: Have patient whisper “ 1, 2,
3”; clearer transmission of whispered voice sound over
affected area.
Anterior Thorax
Inspection
23. Inspect for shape, and configuration. Have the client
sit with arms at the sides. Stand in front of the client and
assess shape and configuration. This is to determine the
ratio of anteroposterior diameter to transverse diameter
(normally 1:2), costal angle, spinal deformities and
condition of skin.
24. Inspect for position of sternum from anterior and
lateral viewpoints.
25. Watch for sternal retractions.
Inspect for the slope of the ribs from anterior and lateral
viewpoints.
26. Inspect for quality and pattern of respiration, noting
breathing characteristics, rate, rhythm and depth.
27. Inspect intercostals spaces while client breathes
normally.
28. Inspect for use of accessory muscles when client
breathes normally.
Palpation
29. Palpate for tenderness, sensation, and surface masses
or lesions using fingers. Fig. 19 - 18
No adventitious sounds, crackles and
wheezes are auscultated.
Voice transmission is soft and
muffled. The word “ninety-nine” is
clear and distinguishable.
Voice transmission is soft and muffled
but letter E is distinguishable
Transmission of sound is very faint
and muffled. Phrases are heard but not
distinguishable.
The client has a normal chest
configuration. But the client has a
mild scoliosis.
The sternum is positioned at the
midline and straight.
Retractions not observed. Ribs slope
downward with symmetric intercostal
spaces, costal angle is within 90
degrees.
Respirations are relaxed, effortless and
quiet.
No retractions or bulging of intercostal
spaces are noted.
Use of accessory muscles are not
observed.
No tenderness or pain is palpated over
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30. Palpate for crepitus as you would on the posterior
thorax (described previously).
31. Palpate for fremitus. Place the balls of your hands
with your fingers hyperextended or the ulnar surface of
your hand on the patient’s chest. Have the patient say
“99” as you palpate vibrations. Note the level of where
the fremitus is palpable, increased, diminished, or absent.
(same as posterior technique)
32. Palpate for chest expansion by placing hands on the
anterolateral wall with the thumbs along the costal
margins and pointing toward the xiphoid process (like a
butterfly) and observe for the equal movement of the
thumbs as the client takes a deep breath.
Percussion
33. Percuss apices for tone above the clavicles and
then the intercostal spaces across and down, comparing
sides using indirect or mediate percussion. Note areas of
resonance, hyperresonance or dullness. Fig. 19 - 20
Auscultation
34. Auscultate for breath sounds, adventitious sounds,
and voice sounds. Fig. 19 -21, Fig. 19 – 22, and Fig. 19 -
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Perfect score
the lung area with respirations.
No crepitus palpated.
Fremitus is symmetric and easily
identified in the upper regions of the
lungs.
Thumbs moved outward in a
symmetric fashion from the midline.
Resonance was observed on the
clavicles and the intercostal spaces
symmetrically. Dullness was observed
over breast tissue, heart and the liver.
Normal breath sounds were observed.
Bronchial was heard at the trachea
with a short inspiration and long
expiration. Bronchovesicular was
heard at the first and second
intercostal spaces with the same length
of inspiration and expiration.
Vesicular was heard at the base of the
lungs or the peripheral lung fields with
a long inspiration and short expiration.

Checklist: 136 points

Findings: 120 points

Evaluated by:

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Signature over Printed Name of CI