This document outlines the steps for assessing the thorax and lungs, including gathering equipment, explaining the procedure to the client, inspecting the chest wall, palpating for tenderness and masses, percussing the chest, and auscultating breath and adventitious sounds. The assessment includes inspection, palpation, percussion, and auscultation of both the posterior and anterior chest while comparing both sides. Findings are then analyzed to formulate nursing diagnoses and determine if any referrals are necessary.

1. THORAX AND LUNGS
ASSESSMENT
BY: ROMMEL LUIS C. ISRAEL III

2. •GATHER EQUIPMENT
•GOWN & DRAPE
•GLOVES
•MASK
•STETHOSCOPE
•SKIN MARKER
•METRIC RULER
BY: ROMMEL LUIS C. ISRAEL III
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3. EXPLAIN THE PROCEDURE
TO THE CLIENT.
ASK THE CLIENT TO PUT ON
GOWN.
BY: ROMMEL LUIS C. ISRAEL III
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4. POSTERIOR THORAX
INSPECT FOR SHAPE & CONFIGURATION OF THE CHEST WALL & POSITION
OF SCAPULAE.
BARREL CHEST
BY: ROMMEL LUIS C. ISRAEL III
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5. • INSPECT FOR USE OF
ACCESSORY MUSCLES.
• INSPECT THE CLIENT’S
POSITIONING NOTING
POSTURE & ABILITY
TO SUPPORT WEIGHT
WHILE BREATHING.
BY: ROMMEL LUIS C. ISRAEL III
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6. PALPATE FOR TENDERNESS & SENSATION
WITH GLOVED FINGERS.
PALPATE FOR SURFACE CHARACTERISTICS
SUCH AS LESIONS OR MASSES.
BY: ROMMEL LUIS C. ISRAEL III
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7. •PALPATE FOR FREMITUS, USING THE BALL OR
ULNAR EDGE OF ONE HAND WHILE THE CLIENT
SAYS “NINETY-NINE.”
•ASSESS FOR SYMMETRY & INTENSITY OF
VIBRATION
BY: ROMMEL LUIS C. ISRAEL III
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8. •PALPATE FOR CHEST EXPANSION.
•PLACE HANDS ON THE POSTERIOR CHEST WALL
WITH YOUR THUMBS AT THE LEVEL OF T9 OR T10,
& OBSERVE THE MOVEMENT OF YOUR THUMBS
AS THE CLIENT TAKES A DEEP BREATH.
BY: ROMMEL LUIS C. ISRAEL III
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9. •PERCUSS FOR
TONE, STARTING
AT THE APICES
ABOVE THE
SCAPULAE &
ACROSS THE TOPS
OF BOTH
SHOULDERS.
BY: ROMMEL LUIS C. ISRAEL III
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10. PERCUSS INTERCOSTAL SPACES
ACROSS & DOWN, COMPARING
SIDES.
PERCUSS TO THE LATERAL ASPECTS
AT THE BASES OF THE LUNGS &
COMPARE SIDES.
BY: ROMMEL LUIS C. ISRAEL III
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11. BY: ROMMEL LUIS C. ISRAEL III
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12. BY: ROMMEL LUIS C. ISRAEL III
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13. • AUSCULTATE FOR
BREATH SOUNDS
(NORMAL:
BRONCHIAL,
BRONCHOVESICULAR,
& VESICULAR),
NOTING LOCATION.
AUSCULTATE FOR
ADVENTITIOUS
SOUNDS
BY: ROMMEL LUIS C. ISRAEL III
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14. BY: ROMMEL LUIS C. ISRAEL III
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15. •AUSCULTATE FOR ADVENTITIOUS SOUNDS:
•- CRACKLES, FINE OR COURSE
•- PLEURAL FRICTION RUB
•- WHEEZE, SIBILANT OR SONOROUS.
BY: ROMMEL LUIS C. ISRAEL III
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16. ANTERIOR THORAX
INSPECT FOR SHAPE & CONFIGURATION TO DETERMINE THE RATIO
OF ANTEROPOSTERIOR DIAMETER TO TRANSVERSE DIAMETER
(NORMALLY 1:2)
Pectus Carinatum
(Pigeon Chest
Pectus Excavatum
(funnel Chest
BY: ROMMEL LUIS C. ISRAEL III
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17. INSPECT FOR POSITION OF THE STERNUM FROM ANTERIOR & LATERAL
VIEWPOINTS
INSPECT
INSPECT FOR QUALITY & PATTERN OF RESPIRATION, NOTING BREATHING
CHARACTERISTICS, RATE, RHYTHM, & DEPTH.
INSPECT
INSPECT FOR USE OF ACCESSORY MUSCLES
INSPECT
BY: ROMMEL LUIS C. ISRAEL III
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18. PALPATE FOR
TENDERNESS &
SENSATION,
USING FINGERS
PALPATE SURFACE
CHARACTERISTICS
SUCH AS LESIONS
OR MASSES
BY: ROMMEL LUIS C. ISRAEL III
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19. BY: ROMMEL LUIS C. ISRAEL III
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20. •PALPATE FOR
FREMITUS
WHILE THE
CLIENT SAYS
“NINETY-NINE”.
BY: ROMMEL LUIS C. ISRAEL III
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21. •PALPATE FOR CHEST
EXPANSION BY
PLACING HANDS ON
ANTEROLATERAL
WALL WITH THE
THUMBS ALONG THE
COSTAL MARGINS &
POINTING TOWARD
THE XIPHOID
PROCESS.
BY: ROMMEL LUIS C. ISRAEL III
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22. •PERCUSS FOR
TONE ABOVE THE
CLAVICLES & THEN
THE INTERCOSTAL
SPACES ACROSS &
DOWN,
COMPARING
SIDES.
BY: ROMMEL LUIS C. ISRAEL III
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23. •AUSCULTATE FOR BREATH SOUNDS,
ADVENTITIOUS SOUNDS & VOICE SOUNDS.
BY: ROMMEL LUIS C. ISRAEL III
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24. BY: ROMMEL LUIS C. ISRAEL III
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25. ANALYSIS OF DATA
• FORMULATE NURSING
DIAGNOSES (WELLNESS, RISK,
ACTUAL)
• FORMULATE COLLABORATIVE
PROBLEMS.
• MAKE NECESSARY REFERRALS.
BY: ROMMEL LUIS C. ISRAEL III
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