Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide 2.9 Chest/Thorax To examine the chest, the nurse should have access to the patient's bare thorax. Typically, the patient should be examined in a sitting position to allow full lung expansion. Most clinicians will begin with an examination of the posterior chest followed by the anterior and lateral. Equipment needed for the chest and thorax exam includes a stethoscope and ruler. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.). • Wash hands before starting the exam, any time the hands or gloves become soiled, and upon completion of the exam. • Provide a quiet, well-lit, and private place for theexam. • Ensure that the examination room is warm, since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about presence or history of: o History or family history of chest diseases (Tuberculosis, cancer,etc.) o Smoking o Environmental exposure to fumes, smoke, chemicals, etc. o Current signs or symptoms of illness (cough, pain, wheezing, etc.) • Assess the posterior thorax: The assessment of the posterior thorax is best donewith the patient in a seated position, except for the spinal assessment, which is done with the patient in a standing position. o Normal: Symmetric with anteroposterior to transverse diameter 1:2; spine aligned vertically with shoulders at the same height and hips at the same height; uniform temperature of back; no lesions or masses; chest wall intact; no tenderness; full and symmetric chest expansion when the patient takes a deep breath; bilateral vocal fremitus felt most strongly at apex of lungs when the patient speaks; percussion over lung areas elicits resonate notes; vesicular and bronchovesicular sounds auscultated and symmetrical bilaterally using the diaphragm of the stethoscope o Deviations from normal: Asymmetric with anteroposterior to transverse diameter greater than 1:2 (barrel chest); spine misaligned when patient bends forward at the waist (scoliosis); spinal curvatures exaggerated (kyphosis or lordosis); temperature of the back not uniform, with areas of increased temperature; lesions, lumps, depressions, or masses; chest wall tenderness; asymmetric or diminished chest expansion when the patient takes a deep breath; decreased, increased, or absent vocal fremitus felt when the patient speaks; asymmetry of percussion; percussion over lung areas elicits dullness or flatness; absence of breath sounds or adventitious sounds auscultated using the diaphragm of the stethoscope; adventitious sounds include: § Wheeze: This is a high-pitched, whistling sound heard at inhalation and exhalation.

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