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Thorax Exam

Nursing 315

StepVariablesDocumentation
Step 1: Inspect Posterior Symmetry in shape and muscle development, abnormalities. AP diameter vs transverse diameter. Posterior thorax is symmetrical in shape and muscle development. No anomalies noted. AP<Transverse diameter.
Step 2: Assess Respirations Rhythm, type, depth, effort. Symmetry of chest expansion, retractions. Respirations are regular, costal, normal depth, and unlabored. Chest expansion is symmetrical and without retractions.
Step 3: Palpate Posterior Tenderness of spine and costovertebral angle. Symmetry of expansion. No tenderness palpable over spine and costovertebral angle. Symmetrical thoracic expansion.
Step 4: Palpate Posterior for Tactile Fremitus Symmetry of vibrations. Vibrations equal bilaterally.
Step 5: Percuss Posterior Resonance over lung fields. Tenderness of costovertebral angle bilaterally. Resonance noted over posterior lung fields bilaterally. No costovertebral tenderness bilaterally.
Step 6: Auscultate Posterior Rate of respirations. Clarity of sounds bilaterally. Adventiitous sounds. Rate of respirations = 18 per minute. Breaths sounds clear bilaterally. No adventitious sounds.
Step 7: Inspect Anterior Symmetry in shape and muscle development, abnormalities. Anterior thorax is symmetric in shape and muscle development. No anomalies noted.
Step 8: Auscultate Anterior Clarity of sounds bilaterally. Adventitious sounds. Breath sounds clear and equal bilaterally. No adventitious sounds. Vesicular sounds heard in majority of lung fields.
Steps 1-8: 1:Inspect Posterior, 2:Assess Respirations, 3:Palpate Posterior, 4:Palpate Posterior for Tactile Fremitus, 5:Percuss Posterior, 6:Auscultate Posterior, 7:Inspect Anterior, 8:Auscultate Anterior.
Created by: bethanne89
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