Health Assessment

Student Laboratory Guide Chapter 12: Lungs and Respiratory System

With your lab partner assuming the role of a client, conduct a focused history and examination. Your “student client” may role-play a client with a particular respiratory symptom.

History Name: M F

Gender: Age: Race: LMP:

Occupation:

Source of Data:

Immunizations:

Allergies/Reactions:

Presenting Problem (check all that apply):

Cough

Shortness of breath

Chest pain with breathing

Other:________

Symptom Analysis of Presenting Problem (location, quality, quantity, chronology, setting, associated manifestations, aggravating and alleviating factors, treatment) Present Health Status (include medications, dose, and frequency, or use of oxygen or breathing equipment at home) Past Medical and Surgical History (include description and dates) Family History Social Habits

Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 12 Lungs and Respiratory System Page 2

Examination

Examination Technique Findings (document findings below)

INSPECT the client for general appearance, posture, and breathing effort.

OBSERVE respirations for rate and quality, breathing pattern, and chest expansion.

INSPECT the client’s nail, skin, and lips for color.

Posterior Thorax

INSPECT the posterior thorax for shape and symmetry, and muscle development.

AUSCULTATE the posterior and lateral thorax for breath sounds.

Anterior Thorax

INSPECT the anterior thorax for shape and symmetry, muscle development, anteroposterior diameter to lateral diameter, and costal angle.

AUSCULTATE the anterior thorax for breath sounds.

Advanced Practice and Special Circumstances

Posterior Thorax Lateral

PALPATE posterior thoracic muscles for tenderness, bulges, and symmetry.

PALPATE the posterior chest wall for thoracic expansion.

PALPATE the posterior thorax wall for vocal (tactile) fremitus (advanced practice).

PERCUSS the posterior and lateral thorax for tone (advanced practice).

PERCUSS the thorax for diaphragmatic (respiratory) excursion (advanced practice).

AUSCULTATE the thorax for vocal sounds (vocal resonance)

(advanced practice).

Breathing Effort/Quality

Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 12 Lungs and Respiratory System Page 3

Anterior Thorax

PALPATE the trachea for position. PALPATE the anterior thoracic muscles

for tenderness, bulges, and symmetry.

PALPATE the anterior chest wall for thoracic expansion.

PALPATE the anterior thorax wall for vocal (tactile) fremitus (advanced practice).

PERCUSS the anterior thorax for tone (advanced practice).

Nursing Diagnoses and Collaborative Problems

Based on the subjective and objective data collected above, identify applicable nursing diagnoses and collaborative problems

Nursing Diagnoses Collaborative Problems

Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

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