Module 1,2,3
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? | |
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Thorax and lungs: Objective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions | Findings |
Current Symptoms | |
Posterior Thorax | |
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| (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 | |
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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. | |
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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?) | |
Background (The evidence—Health history relating to this problem, what is being done, and what assessment findings are most important now.) | |
Assessment (What do you think the problem is—which direction does it seem to be going?) | |
Recommendation (What needs to happen next?) |