PAMANTASAN NG CABUYAO

College of Health and Allied Sciences

Bachelor of Science in Nursing

PHYSICAL ASSESSMENT CHECKLIST EVALUATION

THORAX AND LUNGS ASSESSMENT

Name: _____________________________________________ Rate: _________________________________

Clinical Instructor: ___________________________________ Yr./Section/Grp: ________________________

Objective:
● Demonstrate ability to use correct techniques in performing physical assessment of the thorax and
lungs
● Interview clients for an accurate nursing history of the thorax and lungs
● Differentiate abnormal and normal findings of the thorax and lungs

Rating Scale:
5 – The student demonstrates the procedure with thorough in independent manner
4 – Demonstrate the procedure with minimal guidance and supervision
3 – Demonstrate the procedure with frequent guidance and supervision
2 – Demonstrate the procedure with errors even with frequent guidance and supervision
1 – Does not demonstrate the procedure even under close supervision and guidance

Performance
Preparation Remarks
5 4 3 2 1
1. Assemble equipment and supplies:
Stethoscope
Skin marker/pencil
Centimeter ruler

Procedure
1. Explain to the client what you are
going to do, why it is necessary, and how he or
she can cooperate.
2. Wash hands and observe other appropriate
infection control procedures.
3. Provide for client privacy.
4. Determine client’s history of the following:
● Family history of illness, including cancer
● Allergies
● Tuberculosis
● Smoking and occupational hazards
● Any medications being taken
● Current problems such as swellings, coughs,
wheezing, pain
Assessment
Posterior Thorax
5. Inspect the shape and symmetry of the thorax
from posterior and lateral views.
6. Inspect the spinal alignment for deformities.
● Have the client stand. From a lateral position,
observe the three normal curvatures: cervical,
thoracic, and lumbar.
● To assess for lateral deviation of spine
 (scoliosis), observe the standing client from
the rear. Have the client bend forward at the
waist and observe from behind.
7. Palpate the posterior thorax.
● For clients who have no respiratory
complaints, rapidly assess the temperature
and integrity of all chest skin.
● For clients who do have respiratory
complaints, palpate all chest areas for bulges,
tenderness, or abnormal movements. Avoid
deep palpation for painful areas, especially if
a fractured rib is suspected.
8. Palpate the posterior chest for respiratory
excursion.
● Place the palms of both your hands over the
lower thorax, with your thumbs adjacent to
the spine and your fingers stretched laterally.
Ask the client to take a deep breath while
you observe the movement of your hands and
any lag in movement.
9. Palpate the chest for vocal (tactile) fremitus.
● Place the palmar surfaces of your fingertips
or the ulnar aspect of your hand or closed fist
on the posterior chest, starting near the apex
of the lungs.
● Ask the client to repeat such words as “blue
moon” or “one, two, three.”
● Repeat the two steps, moving your hands
sequentially to the base of the lungs.
● Compare the fremitus on both lungs and
between the apex and the base of each lung,
either 1) using one hand and moving it from
one side of the client to the corresponding
area on the other side or 2) using two hands
that are placed simultaneously on the
corresponding areas of each side of the chest
10 Percuss the thorax.
11 Percuss for diaphragmatic excursion.
12 Auscultate the chest using the flat-disc
diaphragm of the stethoscope.
● Use the systematic zigzag procedure used in
percussion.
● Ask the client to take slow, deep breaths
through the mouth. Listen at each point to the
breath sounds during a complete inspiration
and expiration
● Compare findings at each point with the
corresponding point on the opposite side of
the chest.
Anterior Thorax
13 Inspect breathing patterns.
14 Inspect the costal angle and the angle at which
the ribs enter the spine.
15 Palpate the anterior chest.
16 Palpate the anterior chest for respiratory
excursion.
● Place the palms of both your hands on the
lower thorax, with your fingers laterally
along the lower rib cage and your thumbs
along the costal margins
 ● Ask the client to take a deep breath while
you observe the movement of your hands.
17 Palpate tactile fremitus in the same manner as for
the posterior chest.
● If the breasts are large and cannot be
retracted adequately for palpation, this part
of the examination is usually omitted.
18 Percuss the anterior chest systematically.
● Begin above the clavicles in the
supraclavicular space and proceed downward
to the diaphragm.
● Compare one side of the lung to the other.
● Displace female breasts for proper
examination.
19 Auscultate the trachea.
20 Auscultate the anterior chest.
● Use the sequence used in percussion,
beginning over the bronchi between the
sternum and the clavicles.
21 Document findings in the client record.
Total
To compute for the Total Score: Add each item’s rating. Score

To compute for the Average: Divide the total SCORE by Ave.

total number of items, multiply by 100
-------/110

Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

______________________________________ ___________________________________
Student’s Signature over Printed Name CI’s Signature over Printed Name
 PAMANTASAN NG CABUYAO
College of Health and Allied Sciences
Bachelor of Science in Nursing

PHYSICAL ASSESSMENT CHECKLIST EVALUATION

BREASTS AND AXILLAE ASSESSMENT

Name: _____________________________________________ Rate: _________________________________

Clinical Instructor: ___________________________________ Yr./Section/Grp: ________________________

Objective:
● Demonstrate ability to use correct techniques in performing physical assessment of the Breasts and
Axillae
● Interview clients for an accurate nursing history of the Breasts and Axillae
● Differentiate abnormal and normal findings of the Breasts and Axillae

Rating Scale:
5 – The student demonstrates the procedure with thorough in independent manner
4 – Demonstrate the procedure with minimal guidance and supervision
3 – Demonstrate the procedure with frequent guidance and supervision
2 – Demonstrate the procedure with errors even with frequent guidance and supervision
1 – Does not demonstrate the procedure even under close supervision and guidance

Performance
Preparation
5 4 3 2 1 Remarks
1. Assemble equipment and supplies:
Centimeter ruler
Procedure
1. Explain to the client what you are
going to do, why it is necessary, and how she can
cooperate.
2. Wash hands and observe other appropriate infection
control procedures.
3. Provide for client privacy.
4 Determine client’s history of the following:
● Breast self-examination: technique used and when
performed in relation to the menstrual cycle
● Breast masses, and what was done about them
● Any pain or tenderness in the breasts and relation to
the woman’s menstrual cycle
● Any discharge from the nipple
● Medication history
● Estrogen replacement therapy
● Alcohol consumption
● High-fat diet
● Obesity
● Use of oral contraceptive
● Menarche before age 12
● Menopause after age 55
● Pregnancy after age 30
Assessment
5. Inspect the breasts for size, symmetry, and contour or
shape while the client is in a sitting position.
6. Inspect the skin of the breast for localized discolorations
or hyperpigmentation, retraction or dimpling, localized
hyper vascular areas, swelling, or edema.
7. Emphasize any retraction by having the client:
● Raise the arms above the head
 ● Push the hands together, with elbows flexed
● Press the hands down on the hips
8. Inspect the areola area for size, shape, symmetry, color,
surface characteristics, and any masses or lesions.
9. Inspect the nipples for size, shape, position, color,
discharge, and lesions.
10 Palpate the axillary, sub clavicular, and supraclavicular
lymph nodes.
● The client is seated with the arms abducted and
supported on the nurse’s forearm
● Use the flat surfaces of all fingertips to palpate the
four areas of the axilla:
● The edge of the greater pectoral muscle along the
anterior axillary line
● The thoracic wall in the midaxillary area
● The upper part of the humerus
● The anterior edge of the latissimus dorsi muscle along
the posterior axillary line
11 Palpate the breast for masses, tenderness, and any
discharge from the nipples.
12 Palpate the areola and the nipples for masses.
● Compress each nipple to determine the presence of
any discharge. If discharge is present, milk the breast
along its radius to identify the discharge-producing
lobe.
● Assess any discharge for amount, color, consistency,
and odor.
● Note any tenderness on palpation
13 Teach the client the technique of breast self-examination.
14 Document findings in the client record.
Total
To compute for the Total Score: Add each item’s rating. Score

To compute for the Average: Divide the total SCORE by total Ave.
number of items, multiply by 100
----------/75

Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

______________________________________ ___________________________________
Student’s Signature over Printed Name CI’s Signature over Printed Name