Thorax and lungs: Subjective & Objective data Name________________
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
| Questions | Findings |
| Current Symptoms | |
| 1. Difficulty breathing (at rest, with specific activities, while sleeping, other symptoms when having trouble breathing)? | |
| 2. Chest pain associated with a cold, fever, or deep breathing? | |
| 3. Cough, with or without sputum? | |
| Past History | |
| 1. Prior respiratory problems? | |
| 2. Previous thoracic surgery, biopsy, or trauma? | |
| 3. Allergies, symptoms/treatments? | |
| 4. Pulmonary studies/tests: chest x-ray, TB skin test, or influenza immunization? | |
| Family History | |
| 1. Family history of lung disease? | |
| Lifestyle and Health Practices | |
| 1. Use of tobacco products, cigarettes or e-cigarettes (number of years, number per day)? | |
| 2. Exposure to environmental conditions that affect breathing at work or at home, including secondhand smoke? | |
| 3. Difficulty performing usual daily activities? | |
| 4. Medications for breathing (prescribed or OTC), other breathing treatments? | |
Thorax and lungs: Objective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
| Questions | Findings |
| Current Symptoms | |
| Posterior Thorax | |
| 1. Inspect for shape and configuration of the chest wall and position of scapulae. | |
| 2. Inspect for use of accessory muscles. | |
| 3. Inspect the client’s positioning noting posture and ability to support weight while breathing. | |
| 4. Palpate for tenderness and sensation. | |
| 5. Palpate for surface characteristics such as lesions or masses. | |
| 6. Palpate for fremitus, using the ball or ulnar edge of one hand while the client says “ninety-nine.” Assess for symmetry and intensity of vibration. | |
| 7. Palpate for chest expansion. Place hands on the posterior chest wall with your thumbs at the level of T9 or T10, and observe the movement of your thumbs as the client takes a deep breath. | |
| 8. Percuss for tone, starting at the apices above the scapulae and across the tops of both shoulders. | |
| 9. Percuss for diaphragmatic excursion, using the procedure in the textbook. | |
| 10. AAuscultate for breath sounds (normal: bronchial, broncho-vesicular, and vesicular), noting location. | |
| 11. AAuscultate for adventitious sounds (crackles, fine or coarse, pleural friction rub, wheeze, sibilant, or sonorous). (For this exercise, don’t use the term, “rhonchi”). | |
| 12. AAuscultate for voice sounds over the chest wall: Bronchophony—ask the client to repeat the phrase “ninety-nine”; egophony—ask the client to repeat the letter “E”; whispered pectoriloquy—ask the client to whisper the phrase “one-two-three.” | (In my experience, this particular technique has been of very limited value, but …this is a health assessment class, and is the place to learn of these rather interesting methods. You may encounter it at some point in your career.) |
| Anterior Thorax | |
| 1. Inspect for shape and configuration to determine the ratio of anteroposterior diameter to transverse diameter (normally 1:2). | |
| 2. Inspect for position of sternum from anterior and lateral viewpoints. | |
| 3. Inspect for slope of the ribs from anterior and lateral viewpoints. | |
| 4. Inspect for quality and pattern of respiration, noting breathing characteristics, rate, rhythm, and depth. | |
| 5. Inspect intercostal spaces while client breathes normally. | |
| 6. Inspect for use of accessory muscles. | |
| 7. Palpate for tenderness and sensation, using fingers. | |
| 8. Palpate surface characteristics such as lesions or masses, using fingers of gloved hand. | |
| 9. Palpate for fremitus while the client says “ninety-nine.” | |
| 10. Palpate for chest expansion by placing hands on anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process. Observe the movement of the thumbs as the client takes a deep breath. | |
| 11. Percuss for tone above the clavicles and then the intercostal spaces across and down, comparing sides. | |
| 12. Auscultate for breath sounds, adventitious sounds, and voice sounds. | |
| 13. Respiratory rate |
SBAR
Read the instructions and rubric on the assignment form before completing this. As you have assessed your patient, which finding from Module 3 assessments would require attention from the clinician (if it is sufficiently serious to warrant medical attention) or from you as a nurse if it regards a health promotional/lifestyle problem? Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing. If your assessment partner has chronic health problems or pain, address one of those problems below.
| SBAR | |
| Situation
(What is the most important problem you have identified? When did it start, and how severe is it?)
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| Background
(The evidence—Health history relating to this problem, what is being done, and what assessment findings are most important now.) |
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| Assessment
(What do you think the problem is—which direction does it seem to be going?) |
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| Recommendation
(What needs to happen next |
