Central Mindanao University

University Town, Musuan, Maramag Bukidnon

College of Nursing

PERFORMANCE CHECKLIST

THORAX (LUNGS) AND CHEST (HEART)

NAME: ___________________________________________ RATING: _____________

SEC/GRP: ________________ DATE: ______________

Directions: Every student will be rated according to the rating scale below. Keeping the guidelines in
mind, please complete the Assessment Tool.
Scale Description Interpretation Assistance Needed
5 Outstanding Demonstrates exceptional performance and mastery of the procedure. Proficient, Without Direction
coordinated and confident
Very Able to state and demonstrate the step-by-step procedure but failed to mention the With occasional physical or
4
Satisfactory rationale. Efficient, coordinated, confident. Expedient use of time. verbal direction
Meets the standards or basic requirements of the procedure. Misses some steps
With frequent verbal and/or
3 Satisfactory and rationale with partial demonstration of skills, inefficient, uncoordinated. Delayed
direction
time Expenditure
Barely meets the requirements of the Performance of the procedure. Unskilled and With continuous verbal and/or
2 Fair
inefficient. Considerable and prolonged time expenditure. physical direction
Needs Fails to meet the requirements of the performance of the procedure. Misses most of With continuous verbal and
1
Improvement the steps, without rationale. Lacks confidence, coordination and efficiency. physical direction

STEPS 5 4 3 2 1
Preparatory Phase
1 Reassess client's previous medical records if available.
2 Determine the scope of assessment needed. Prepare necessary equipment.
3 Perform hand washing and donned gloves (if deemed necessary).
4 Assemble equipment & supplies needed
5 Introduce self and verify the client's identity.
6 Explain the procedure to the client.
7 Position patient comfortably and provides privacy.
Assessment Phase
THORAX (LUNGS)
8 Inspect respiratory rate, rhythm, depth, and symmetry of chest movements anteriorly, posteriorly
and laterally.
9 Inspect antero-posterior (AP) to lateral ratio, costal angle, spinal deformities, and condition of skin
10 Lightly palpate antero-posterior chest for tenderness and crepitus.
ASSESS FOR CHEST EXCURSION
Anteriorly, place hands vertically on the chest with fingers spread on the costal margin and thumbs
11 together at the costal angle (like a butterfly).
Posteriorly, place hands vertically on the chest with fingers spread and the thumbs together at the
12 spine at the eighth to tenth rib (like a butterfly)
13 Feel for equal expansion of the chest; if absent, decreased, or unequal, move up the chest.
ASSESS FOR TACTILE FREMITUS
Place the balls of your hands with your fingers
14 hyperextended or the ulnar surface of your hand
on the patient’s chest
15 Have patient say “99” as you palpate vibrations
Note level where fremitus is palpable, increased,
16 diminished, or absent
PERCUSS FOR ANTERO-POSTERIOR and LATERAL THORAX
Perform mediate percussion in a systematic pattern:
17 a. Ask the client to bend the head and fold the arms forward across the chest.
18 b. Percuss in the intercostal spaces at about 2 in. intervals in a systematic sequence
c. Compare one side of the thorax with the other and note for areas of resonance,
19 hyperresonance, or dullness.
d. Percuss the lateral thorax every few inches, starting at the axilla and working down to the eighth
20 rib.
ASSESS FOR DIAPHRAGMATIC EXCURSION
21 Have patient take a deep breath and fully exhale, then percuss the level of the diaphragm and mark
22 Have the patient take a deep breath and hold it, then percuss the level of the diaphragm
 STEPS 5 4 3 2 1
23 Measure the distance between the two marks
TEST FOR NORMAL BREATH SOUNDS AND ABNORMAL VOICE SOUNDS
Auscultate the chest over auscultatory sites anterior, posterior, and lateral using the flat-disc
24 diaphragm of the stethoscope in a systematic manner l
25 Listen to one full respiratory cycle at each site.
Ask the client to take slow, deep breaths through the mouth. Listen at each point to the breath
26 sounds during a complete inspiration and expiration.
27 Note normal, abnormal, and adventitious sounds
28 Have patient cough then listen to see if sound has cleared if adventitious sound heard.
29 Have patient say “ee”; will sound like “aa” over affected area
30 Have patient say “1, 2, 3”; clearer transmission of spoken voice sound over affected area
31 Have patient whisper “1, 2, 3”; clearer transmission of whispered voice sound over affected area.
HEART AND CENTRAL VESSELS
MEASURE FOR JUGULAR VENOUS PRESSURE
32 Position patient with the head of bed at 30 to 45-degree angle
33 Place a ruler vertically, perpendicular to the chest at the angle of Louis (sternal angle).
Identify the highest level of the jugular vein pulsation; if unable to see pulsations, use the highest
34 level of jugular vein distension
35 Place another ruler horizontally at the point of the highest level of the venous pulsation
36 Measure the distance of the jugular vein up from the chest wall
Lightly palpate each carotid separately with caution and note for rate, rhythm, amplitude, contour,
37 symmetry, elasticity, thrills.
38 Have patient hold breath and auscultate the carotid with the bell portion of the stethoscope for bruits
39 Auscultate the jugulars with the bell portion of the stethoscope for venous hums
ASSESS FOR THE PRECORDIUM
Inspect for pulsations on the precordium, paying particular attention to the apex area. Position
40 patient in supine position with the head of the bed elevated between 30-45 degrees, stand on the
patient’s right side and look for the apical impulse.
Palpate the apical impulse. Remain on the client’s right side and ask the client to remain supine.
41 Use one or two finger pads to palpate the apical impulse in the mitral area. (Fourth or fifth intercostal
space at the mid-clavicular line).
42 Percuss the area to determine the cardiac borders
Auscultate heart rate and rhythm. Place the diaphragm of the stethoscope at the apex and listen
43 closely to the rate and rhythm of the apical impulse.
Auscultate at each site (apex, LLSB, Erb’s point, base left and base right. Note S1, S2, extra sounds,
44 or murmurs
Auscultate with the patient assuming other positions:
45 a. Ask the client to assume a left lateral position. Use the bell of the stethoscope and listen at the
apex of the heart.
46 b. Ask the client to sit up, lean forward, and exhale. Use the diaphragm of the stethoscope and
listen over the apex and along the left sternal border.
Termination Phase
Review the information obtained during the assessment phase and discussed findings to the client.
47 Present to the client possible plans to resolve health concern, if present.
Measure client's understanding of the plan and the need for further teaching. Provide the client the
48 opportunity to clarify, ask or raise any concern
49 End the interview politely.
50 Do after care. Fix the equipment used and arrange it properly.
51 Perform hand washing.
52 Document the findings in the client’s record.
TOTAL
References:
Dillon, P. (2006). Nursing Health Assessment: A Critical Thinking, Case Studies Approach, 2nd Ed. Philadelphia: F A Davis.
Potter AP, Perry GA. 2007. Basic nursing essentials for practice. 6th edition. India: Mosby Elsevier
Weber, Janet R. (2018). Health Assessment in Nursing. Philadelphia: Lippincott Williams & Wilkins.