Procedure 25-4nAuscultating Breath Sounds 1
Procedure Checklists for Craven and Hirnle’s Fundamentals of Nursing:
Human Health and Function, 6th edition
Name ______Date ______
Unit ______Position ______
Instructor/Evaluator: ______Position ______
Procedure 25-4AUSCULTATING BREATH SOUNDS
Excellent
/Satisfactory
/Needs Practice
/ Goal: To listen for variations in breath sounds that may indicate the presence of airway obstruction or disease process; to assess the effectiveness of medications or therapies in opening or clearing airways; to detect fluid volume excess or pulmonary edema. / Comments___
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/ 1. Wash hands.___
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/ 2. Assist the client to an upright sitting position. Remove client’s gown to expose chest.___
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/ 3. Warm the diaphragm of the stethoscope by holding it between your hands for a short time.___
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/ 4. Ask client to breathe deeply through the mouth. Client should breathe slowly.___
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/ Auscultate Anterior Chest___
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/ 5. Place diaphragm of stethoscope about1 inch below the middle of the right clavicle, making sure it lies between the ribs. Listen to one full inspiration and exhalation. Repeat the process at the corresponding site on the left side.
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/ 6. Note normal and adventitious breath sounds at each point on the chest as you proceed.___
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/ 7. Move stethoscope downward about 1.5 to2 inches along midclavicular line. Note sounds; move stethoscope laterally to opposite side.
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/ 8. Move stethoscope downward another inch or two along midclavicular line to fifth intercostal space. (This space lies just below the nipple line on men, approximately across from the head of the xiphoid process of the sternum.) Note sounds, then move to same spot on opposite side.___
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/ Auscultate Posterior Chest___
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/ 9. Instruct client to lean forward and cross arms in front.___
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/ 10. Begin by auscultating the area about2 inches below the shoulders and 2 inches to the right of the spine. Note sounds, then move to corresponding point on left.
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/ 11. Move stethoscope directly downward 2 or 2.5 inches; note sounds, then move stethoscope laterally and listen on the right.___
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/ 12. Repeat process, moving downward 2 to2.5 inches; listen to corresponding opposite side.
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/ 13. Move stethoscope downward to area just below scapula. Listen on right and left. Listen also to areas laterally along lower rib cage.___
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/ 14. Replace client’s clothes and assist the client to a comfortable position.___
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/ 15. Discuss your findings with the client.___
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/ 16. Record assessment findings. Be specific as to description and location of adventitious sounds.Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins. Procedure Checklists for Craven and Hirnle’s Fundamentals of Nursing: Human Health
and Function, 6th edition, by Ruth F. Craven and Constance J. Hirnle.