PERFORMANCE CHECKLIST - THORAX & LUNGSJarvis Text Ch18 pg 411 & Ch 4 pg 55; Lab Manual pg 147*ESSENTIAL BEHAVIORS MUST BE MUST DEMONSTRATED DURING FINAL CHECK-OFF WITH FACULTYY N*ITHELPSMEObtains age-relevant history -Pg 157 Lab Manual Determines presence of risk factors Inspect s Anterior and Posterior Chest Facial expressions (relaxed vs distress or pursed lip breathing) *LOC (alert vs disoriented to person, place or time) *Symmetry (symmetrical vs barrel chest vs pectus excavatum vs pectus carinatum) *Anterior to Transverse Diameter (1:2) *Rate of Respirations (#breaths/min,) *Rhythm (regular vs irregular) *Trachea (midline) Position for breathing (sitting, propping, tripod) *Skin color & condition (pink vs pale or cyanotic) Palpates Posterior Chest Symmetric expansion (using both hands) Tactile Fremitus (Palm of hands, pt says “99”, vibration decreases going down)Percusses Posterior Chest Anterior-6 locations, Posterior -8 locations Identifies prominent note over lung fields (dull over organs, flat over bone, resonance over lungs) Auscultates Lung Fields (Anterior-6 positions) (Posterior-8 positions) (Lateral-1 each R and L) Identifies variations in lung sounds (bronchial/bronchovesicular/vesicular) *Identifies clarity of breath sounds (clear vs adventitious sounds) *Identifies presence/absence of adventitious breath sounds (wheezing, etc)Describes procedure for assessing oxygen saturation using pulse oximeter*Uses stethoscope properly*Proceeds in head-to-toe fashion*Explains findings of exam or procedure to patient when completed*Adheres to School of Nursing professional dress codeDocuments findings Signs documentation with name and credentialsUpdated
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