Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide § Rhonchi: Rhonchi are low-pitched, snoring sounds heard primarilyon exhalation. § Rales or crackles: Rales or crackles are popping sounds heardduring inhalation and exhalation. § Pleural rub: A pleural rub is a low-pitched, grating sound heard on inhalation and exhalation. § Stridor: Stridor is a high-pitched sound heard on inspiration when the trachea is obstructed. • Assess the anterior thorax: The assessment of the anterior thorax is best done withthe patient in a seated position. o Normal: Respiratory effort rhythmic and effortless; 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 but is diminished over muscle and bone; vesicular and bronchovesicular sounds auscultated and symmetrical bilaterally using the diaphragm of the stethoscope o Deviations from normal: Abnormal breathing patterns; temperature 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, rhonchi, rales or crackles, pleural rub, or stridor Evaluation It is important to compare all findings with previous findings to determine if there are changes to any abnormal chest, thorax, or respiratory findings. Record and report any significant deviations from the normal. 2.10 Breasts and Lymph Nodes Breasts on both males and females should be assessed. Equipment needed for the breast exam includes a 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.

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