![]() To assess for clubbing the nurse can check the nails profile sign, the normal angle is 160 degrees, a greater angle is indicative of clubbing. The nurse will start by picking up the patients hands and examine their colour, texture, temperature, turgor, and for the presence of any lesions, edema, or clubbing. The nurse will first inspect and palpate the arms comparing their findings in one arm to the other. Upon auscultation, the nurse is assessing whether the breath sounds are heard in the appropriate areas and if any abnormal breath sounds are audible. Bronchial sounds are high pitched and heard mainly over the area of the trachea. Broncho-vesicular sounds are medium pitched and heard over the main bronchi. Vesicular sounds are low pitched and heard over the area of the lungs. The three breath sounds which can be auscultated include vesicular sounds, broncho-vesicular sounds, and bronchial sounds. The lower lobes of the lungs are best heard on the posterior aspect, the upper lobes are best heard on the anterior aspect and the middle lobe is best heard on the lateral aspect. The nurse should auscultate the anterior, posterior and lateral aspects of the chest wall. Vibrations should be felt when the client speaks ,Īuscultation involves listening to a client's breath sounds using a stethoscope. The nurse then can measure the tactile fremitus of the chest wall by placing a hand on an area of the chest and asking the client to say "99". When palpating the nurse is also assessing for any pain or tenderness. Upon palpation of the chest wall, a nurse is feeling for any lumps or abnormalities. The chest wall should be percussed anteriorly and posteriorly, starting from above the clavicle to just below the rib cage. A resonant sound is low pitched and indicates normal lung tissue. A flat sound is high pitched and is an indication of solid tissue. A dull sound is medium pitched and indicates firm tissue. A tympanic sound presents as very hollow and indicates an air bubble beneath the area of percussion. This elicits a sound which can be tympanic, dull, flat, or resonant. ![]() It involves gently tapping the middle finger of one hand on the opposite hand which is positioned on the area of interest. In a respiratory assessment it can indicate the presence of fluid or air in the thorax, which can identify problems that are not identifiable by inspection or palpation. ![]() Percussion is used in a nursing assessment to assess the density of tissue in the area.
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