Thorax and Lung Assessment
Summary
TLDRNurse Nancy introduces herself to Mr. Hoffman and explains that she will be assessing his respiratory system. She begins with a health history inquiry, noting he has no smoking history or lung problems. Nancy proceeds with a physical examination, observing normal respiratory rate and rhythm, symmetric chest shape, and absence of retractions. She palpates the chest for tenderness or abnormalities and checks for skin color changes. Nancy then auscultates lung sounds, moving from the trachea to the chest's anterior, lateral, and posterior areas, listening for normal vesicular breath sounds. The assessment concludes with normal findings.
Takeaways
- 😷 The nurse, Nancy, is conducting a respiratory system assessment for Mr. Hoffman.
- 🚬 Mr. Hoffman has no current or past history of smoking cigarettes or any other form of tobacco.
- 🏥 The patient denies any history of lung problems such as asthma, emphysema, or bronchitis.
- 🔍 The nurse begins with an inspection, noting Mr. Hoffman's respiratory rate and rhythm are within normal limits.
- 👀 The nurse observes no retractions or bulging of the interspaces, and the patient's posture is upright.
- 🔢 The anterior-posterior to transverse ratio of the chest is noted to be within the normal range of 2:1.
- 👐 During palpation, the nurse checks for tenderness, pain, and any abnormal bumps, bruises, or masses.
- 🌡 The nurse also inspects the skin for any signs of pallor, pick Hale, or cyanosis while palpating.
- 💪 The patient is asked to stand and perform a deep breath to assess chest expansion symmetry.
- 👂 Auscultation is performed to listen to lung sounds, starting at the trachea and moving across different lung areas.
- 🗣️ The patient is instructed to breathe deeply and through the mouth to facilitate clear lung sound auscultation.
- 🔊 Breath sounds heard over the trachea, sternum, and back are described as vesicular, indicating normal lung function.
Q & A
What is the purpose of the assessment being conducted by Nancy?
-The purpose of the assessment is to evaluate Mr. Hoffman's respiratory system.
What are the two initial questions Nancy asks Mr. Hoffman?
-Nancy asks if Mr. Hoffman currently smokes cigarettes and if he has ever smoked in the past.
What respiratory conditions is Nancy inquiring about in Mr. Hoffman's medical history?
-Nancy inquires about any history of lung problems such as asthma, emphysema, and bronchitis.
What observations does Nancy make during the inspection phase of the assessment?
-Nancy notes that Mr. Hoffman's respiratory rate is within normal limits, the rhythm is regular, respirations are deep, there are no retractions or bulging of the interspaces, and the chest is symmetric with a normal anterior-posterior to transverse ratio.
What does Nancy look for when she palpates Mr. Hoffman's chest?
-Nancy palpates the chest to check for tenderness, pain, abnormal bumps, bruises, masses, and to observe the skin for any abnormalities such as pallor, pick Hale, or cyanosis.
How does Nancy assess the expansion of Mr. Hoffman's chest?
-Nancy assesses chest expansion by placing her thumbs on the chest and asking Mr. Hoffman to take a deep breath in and out, observing the symmetrical movement of her hands.
What is the significance of auscultation in the respiratory assessment?
-Auscultation is significant as it allows Nancy to listen to the lung sounds and identify any abnormal breath sounds that may indicate a respiratory issue.
What areas does Nancy auscultate during the assessment?
-Nancy auscultates the trachea, the area near the sternum, the periphery of the chest, and the posterior area, comparing side to side as she goes down the chest.
What type of breath sounds does Nancy expect to hear over the trachea and the periphery of the lungs?
-Nancy expects to hear bronchovesicular breath sounds over the trachea and vesicular breath sounds in the periphery of the lungs.
What does the absence of abnormal breath sounds during auscultation suggest about Mr. Hoffman's respiratory health?
-The absence of abnormal breath sounds suggests that Mr. Hoffman's respiratory system is functioning normally, with no apparent respiratory issues detected during the assessment.
How does Nancy ensure that the auscultation process is thorough and accurate?
-Nancy ensures thoroughness and accuracy by listening to a full breath in each spot, comparing side to side, and following a systematic pattern across the anterior, lateral, and posterior areas of the chest.
Outlines
👩⚕️ Nurse's Initial Assessment
The paragraph introduces a nurse, Nancy, who begins an assessment of Mr. Hoffman's respiratory system. She starts with a brief interview, asking about smoking habits and any history of lung conditions. Nancy proceeds with an inspection, noting Mr. Hoffman's respiratory rate and rhythm, the absence of retractions or bulging, and the symmetry of his chest. She also observes the anterior-posterior to transverse ratio of his chest, which is normal. Nancy then palpates Mr. Hoffman's chest, checking for tenderness, pain, or any abnormal bumps, and inspects his skin for pallor, pick Hale, or cyanosis. She asks Mr. Hoffman to stand and checks for symmetrical chest expansion. The assessment continues with auscultation, where Nancy listens to lung sounds at various points on the chest, comparing sides and using specific techniques for different areas.
👂 Auscultation Results and Conclusion
In this paragraph, Nancy concludes the auscultation part of the respiratory assessment. She listens for breath sounds over the trachea, the center near the sternum, and the upper back area, identifying vesicular breath sounds in these regions. She also auscultates the peripheral areas and the posterior, confirming vesicular breath sounds there as well. The paragraph ends with Nancy summarizing the findings of the respiratory assessment, indicating that the examination of the lungs is complete.
Mindmap
Keywords
💡Respiratory System
💡Assessment
💡Smoking
💡Lung Problems
💡Respiratory Rate
💡Rhythm
💡Retractions
💡Chest Expansion
💡Palpation
💡Auscultation
💡Vesicular Breath Sounds
Highlights
Introduction of the nurse and the purpose of the visit.
Consent obtained from Mr. Hoffman for the respiratory system assessment.
Inquiry about smoking habits to assess respiratory health.
Questioning about past lung problems to understand medical history.
Observation of respiratory rate and rhythm as part of the inspection.
Assessment of respiratory depth and absence of retractions or bulging.
Evaluation of the patient's posture and chest symmetry.
Measurement of the anterior posterior to transverse chest ratio.
Palpation of the chest to check for tenderness, pain, or abnormalities.
Inspection of the skin for pallor, pick Hale, or cyanosis.
Demonstration of chest expansion during deep breathing.
Auscultation of lung sounds starting at the trachea.
Use of a systematic pattern for listening to lung sounds.
Comparison of breath sounds side to side during auscultation.
Listening for vesicular breath sounds in the periphery and posterior.
Conclusion of the respiratory system assessment.
Transcripts
alright I'm entering the room and
washing my hands
hi mr. Hoffman my name is Nancy I'm
going to be your nurse this afternoon
and we're going to be doing a assessment
of your respiratory system is that okay
that's fine all right I want to start
out with two questions do you smoke
cigarettes no and have you ever smoked
snow do you have any history of lung
problems like asthma emphysema
bronchitis
okay all right good so I'm going to
proceed with the assessment first thing
that I'm going to do is I'm just going
to be observing and looking at the tests
and this is the inspection so I'm first
noting his respiratory rate is within
normal limits that's how fast he's
breathing and the rhythm is regular
meaning it's a nice normal regular
pattern I see respirations are deep I do
not see any retractions or bulging of
the interspaces I see you're sitting up
straight as opposed to leaning over
trying to catch your breath and I see
that the chest is symmetric I also
notice that the anterior posterior ratio
to the transverse ratio is two to one
which is
then I'm going to continue my inspection
also looking for terior Li at the
posterior chest same thing looking for
any abnormalities for the shape of the
chest which is within normal limits the
chest should be shaped like a cone all
right then I'm going to continue the
assessment by palpating the chest I'm
going to touch you and I'm going to
touch the chest all over things that you
know if you have any tenderness or pain
in any areas and lift up here and I'm
checking for anything abnormal bumps
bruises masses pain tenderness I'm
looking at the skin for anything
abnormal I'm looking at the color of the
skin while I'm doing this particularly
looking for pallor pick Hale or cyanosis
which would be blue and then can you
stand up for me so just turn around and
I'm going to check the expansion of the
chest by putting my thumb's right here
and then having can you take a big
breath in and out okay and you see my
hands move in and out do that one more
time in and out good
until the chest expands symmetrically
hempseed again
and then I'm going to continue with my
assessment by oskol teen lung sounds so
they start auscultation at the trachea
and then I want you to open your mouth
and breathe a little bit deeper than
normal in and out
not too deep this little bit deeper
but I'm going to continue
listening
I listen to a full breath in each spot
and I compare side to side as I go down
the chest
good are you okay filling my tent or
anything I feel fine
okay so just be normal for a second even
on a female patient you're going to
listen in this pattern okay round here
and then you can lift up to listen down
low so you can listen above the bra here
and below the bra across here and then
I'm going to listen on each side so left
lateral you lift your arm up listen in
two places big breath and again
all right you can you stand up for me
and then right laterally or not listen
in three spots
so on the right there's three lobes so
you listen in three places one two three
like a triangle and then posterior we're
going to listen starting at the very top
the AP sees of the lungs come way up
here a big breath open your mouth and
breathe in and out through your mouth
I compare side to side
and I'm going around the scapula
one more
okay good have a seat so over the
trachea I burn my fuel breath sounds
over this area the center near the
sternum and also in the back in the
upper area
I heard breckel vesicular breath sounds
and all the periphery out here and
posterior and all the periphery I hear
vesicular breath sounds alright so that
concludes our assessment of the farts
and lungs
5.0 / 5 (0 votes)