Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 2-5

Assessing the Thorax and Lungs (Continued)

Comments

10. Auscultate the lungs across and down the posterior thorax
    to the bases of lungs as the patient breathes slowly and
    deeply through the mouth.


11. Examine the anterior thorax. With the patient sitting,
    rearrange the gown so the anterior chest is exposed. Inspect
    the skin, bones, and muscles, as well as symmetry of lung
    expansion and accessory muscle use.


12. Palpate the anterior thorax using the proper sequence.
    Palpate for tactile fremitus (as the patient repeats the
    word “ninety-nine”).


13. Percuss over the anterior thorax using the proper sequence.


14. Auscultate the lungs through the anterior thorax as the
    patient breathes slowly and deeply through the mouth.


15. Inspect the breasts and axillae with the patient’s hands
    resting on both sides of the body, placed on the hips, and
    then raised above the head.


16. Palpate the axillae with the patient’s arms resting against
    the side of the body. Assist the patient into a supine
    position. Place a small pillow or towel under the patient’s
    back. Palpate the breasts and nipples. Wear gloves if there
    is any discharge from the nipples or if a lesion is present.


17. Assist the patient in replacing the gown. Remove gloves
    and any additional PPE, if used. Perform hand hygiene.
    Continue with assessments of specific body systems, as
    appropriate or indicated. Initiate appropriate referral to
    other healthcare practitioners for further evaluation, as
    indicated.

ExcellentSatisfactoryNeeds Practice