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Assess of Respiratory System

Skill
Document: assessment, interventions, outcomes
Inspect
Respirations for rate, depth, effort, pattern, and presence of cough (productive or nonproductive), noting signs of distress such as nasal flaring or sternal retractions. Inspect size and shape of chest, symmetry of chest wall movement, and use of accessory
muscles. Inspect extremities for cyanosis and fingers for clubbing indicating chronic hypoxia. Inspect trachea for scars, stomas, or deviation from midline.
Palpate
Anterior and posterior thorax for subcutaneous emphysema, crepitus, and tenderness. Assess tactile fremitus by palpating the chest as the Pt says “99.”
Percuss
Anterior and posterior thorax for tympany (hollow organs), resonance (air-filled organs), dullness (solid organs), or flatness (muscle or bone).
Auscultate
Use a stethoscope and auscultate all anterior and posterior lung fields, noting normal, abnormal, or absence of lung sounds.

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