HA Exam #2
Hepatitis A Overview
Acute Viral Liver Infection
Caused by Hepatitis A virus (HAV)
Transmission
Oral-fecal route via contaminated food and water
Prevention
Preventable with a vaccine
Demographic Impact
Affects adults more severely than children
Resolution
Typically resolves within a year.
Hepatitis A (Causes/Risk Factors)
Primary Risk Factors
Poor sanitation
Consumption of contaminated food or water
Close contact with infected individuals
Travel to endemic areas
Hepatitis A (Subjective Data)
Symptoms Reported by Patients
Fatigue
Malaise
Loss of appetite
Nausea
Right upper quadrant pain
Hepatitis A (Objective Data)
Signs Observable Upon Examination
Jaundice (yellowing of the skin and eyes)
Dark urine
Pale stools
Hepatomegaly (enlarged liver)
Elevated liver enzymes (specifically ALT, AST)
Hepatitis A (Complications)
Complication Overview
Usually self-limiting
Rarely leads to chronic conditions
Fulminant hepatitis is very rare
Hepatitis B Overview
Virus Type
DNA virus transmitted primarily via blood and body fluid exposure
Transmission Methods
Sexual contact
Perinatal (from mother to baby)
Perinatal infections are common in infants
Chronic Disease Potential
Can develop into chronic disease
Hepatitis B (Causes/Risk Factors)
High-Risk Behaviors and Conditions
IV drug use
Unprotected sexual intercourse
Healthcare exposure
Hemodialysis
Perinatal exposure
Additional Risk Factors: Advanced age, alcohol use, cigarette smoking, coinfection with Hepatitis C
Hepatitis B (Subjective Data)
Patient Symptoms
Fatigue
Anorexia
Nausea
Abdominal discomfort
Myalgia (muscle pain)
Arthralgia (joint pain)
Hepatitis B (Objective Data)
Visible Signs and Lab Findings
Jaundice
Dark urine
Clay-colored stools
Hepatomegaly
Positive HBsAg (Hepatitis B surface antigen)
Elevated liver enzymes (specifically AST and ALT)
Elevated bilirubin levels
Hepatitis B (Complications)
Potential Long-term Complications
Chronic hepatitis
Cirrhosis
Hepatic carcinoma (liver cancer)
Liver failure
Hepatitis B (Prevention)
Preventative Measures
Administration of the Hepatitis B vaccine
Avoiding needle sharing and unprotected sexual intercourse
Identifying and vaccinating at-risk individuals and infants
Hepatitis C Overview
Virus Type
RNA virus transmitted via blood and body fluids
Vaccine Status
No vaccination available for Hepatitis C
Chronic Development
Chronic Hepatitis C develops in over half of patients infected with acute Hepatitis C
Hepatitis C (Causes/Risk Factors)
High-Risk Behaviors and Conditions
IV drug use
Transfusions prior to 1992
Unsterile tattoos or piercings
Needlestick injuries
Alcohol use
Smoking
Coinfection with Hepatitis B or HIV
Hepatitis C (Subjective Data)
Symptoms Reported by Patients
Often asymptomatic until liver damage occurs
Fatigue
Malaise
Nausea
Hepatitis C (Objective Data)
Visible Signs and Lab Findings
Jaundice (occur in late stages)
Elevated liver enzymes
Hepatomegaly
Hepatitis C (Complications)
Potential Long-term Complications
Chronic hepatitis
Liver fibrosis
Cirrhosis
Liver cancer
Hepatocellular carcinoma
Sickle Cell Disease in African Americans Overview
Genetic Disorder
Glucose-6-phosphate dehydrogenase (G6PD) deficiency and lactose intolerance are more frequently diagnosed in African Americans
Genetic disorder leads to abnormal hemoglobin S, resulting in sickle-shaped red blood cells (RBCs) that can obstruct blood flow
Common among African Americans and those of Mediterranean descent
Common Symptoms in SCD
Splenomegaly (enlarged spleen)
Jaundice
Sickle Cell Disease (Causes/Risk Factors)
Genetic Inheritance
Autosomal recessive inheritance
Common Triggers
Dehydration
Infection
Cold exposure
Hypoxia
Sickle Cell Disease (Subjective Data)
Symptoms Reported by Patients
Severe pain (in joints, chest, abdomen)
Fatigue
Shortness of breath (SOB)
Weakness
Vomiting
Sickle Cell Disease (Objective Data)
Visible Signs and Lab Findings
Pallor (paleness)
Jaundice
Delayed growth
Tachycardia (rapid heart rate)
Leg ulcers
Fever
Swelling during crisis
Sickle Cell Disease (Complications)
Severe Complications
Vaso-occlusive crisis
Stroke
Organ ischemia
Acute chest syndrome
Increased risk of infection
Sickle Cell Disease (Nursing Interventions)
Primary Focus Areas for Care
Monitor for signs of crisis
Maintain hydration
Administer oxygen
Provide pain control
Educate patients on avoiding triggers
Visceral, Parietal, and Referred Pain
Visceral Pain Characteristics
Occurs when hollow organs are distended, stretched, or contract forcefully
Difficult to localize
Patients may describe it as gnawing, burning, cramping, or aching
If severe, may be associated with sweating, pallor, nausea, vomiting, or restlessness
Originates from internal organs; dull, deep, poorly localized pain caused by stretching, inflammation, or ischemia (e.g., appendicitis before peritoneal irritation)
Parietal Pain Characteristics
Results from inflammation of the peritoneum
Usually severe and localized over the involved structure
Patients describe it as steady, aching, or sharp, especially with movement or coughing (e.g., peritonitis)
Originates from the parietal peritoneum or body wall
Referred Pain Characteristics
Occurs in distant sites innervated at approximately the same spinal level as the disordered structure
Felt in a different location from its source due to shared nerve pathways (e.g., gallbladder pain in the right shoulder, cardiac pain in the left arm or jaw)
Self-Breast Exam (Purpose)
Objective
Early detection of breast abnormalities such as lumps or discharge
Self-Breast Exam (Timing)
Recommended Timing
Monthly, 3-5 days after menstruation
Postmenopausal women should select a consistent day for the exam
Self-Breast Exam (Steps)
Procedure
Inspect breasts in a mirror for symmetry, dimpling, or redness
Palpate breasts with three fingers in a circular pattern while standing or lying down
Check nipples for discharge or tenderness
Self-Breast Exam (Abnormal Findings)
Indicators of Concern
Presence of lumps
Thickening of breast tissue
Peau d'orange (orange peel appearance)
Asymmetry in breast
Spontaneous discharge from nipples
Self-Breast Exam (Nursing Education)
Patient Education Key Points
Teach patients proper technique for self-exams
Encourage regular monthly checks
Mammography (Purpose)
Objective
Radiographic screening for breast cancer; aims to detect lesions before they become palpable
Recommended for women between 30 – 40 years of age
Mammography (Recommendations)
Age-specific Guidelines
Ages 40-44: Optional annual mammograms
Ages 45-54: Yearly mammograms
Age 55 and above: Every 1-2 years
Mammography (Patient Education)
Preparation and Guidelines
Avoid using deodorants or lotions before the test
Schedule the test for one week post-menses
Brief discomfort during the test is expected
Mammography (Abnormal Findings)
Indicators of Concern
Microcalcifications
Presence of masses
Distortion of breast tissue which requires further testing
DVT Overview
Definition
Formation of a clot in a deep vein, most commonly in the leg
Part of the Venous Thromboembolism (VTE) spectrum
Risk Factors
Increased immobility, surgery, pregnancy, oral contraceptive pills (OCPs), smoking, obesity, cancer
DVT (Subjective Data)
Symptoms Reported by Patients
Pain
Tenderness
Warmth
Heaviness in the affected leg
DVT (Objective Data)
Visible Signs and Lab Findings
Swelling
Redness
Warmth
Positive Homan’s sign (note: not diagnostic)
DVT (Complications)
Severe Risks
Pulmonary embolism
Post-thrombotic syndrome
DVT (Nursing Focus)
Key Nursing Responsibilities
Assess swelling and pain
Encourage ambulation
Elevate legs when possible
Use compression stockings
Monitor for signs of pulmonary embolism (PE)
Homan’s Sign
Definition and Use
Used to test for DVT
The test involves dorsiflexing the foot; pain during this maneuver suggests a positive result indicating DVT
Note: This test lacks sensitivity and specificity; it is recommended that Homan’s sign be omitted from the assessment of patients with suspected DVT.
Venous Thromboembolism
Definition
Includes both Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE); caused by thrombus formation in the venous system
Risk Increase
Risk increases with advancing age
Exercise Recommendations
Regular walking programs are important for improving quality of life
Neglect Risks
Inactivity may be an overlooked symptom in patients with undiagnosed Peripheral Arterial Disease (PAD) and can exacerbate the disease's progression
Venous Thromboembolism (Pathophysiology)
Virchow's Triad
Risk factors for thrombus development include:
1) Venous stasis (immobility)
2) Endothelial injury (trauma/surgery)
3) Hypercoagulability (e.g., cancer, hormonal factors)
Venous Thromboembolism (Subjective Data)
Symptoms Reported by Patients
DVT: leg pain, heaviness
PE: sudden chest pain, shortness of breath (SOB), anxiety
Venous Thromboembolism (Objective Data)
Visible Signs and Lab Findings
DVT: swelling, redness, warmth, asymmetry
PE: tachycardia, tachypnea, decreased O₂ saturation, hypotension (noted in late stages)
Venous Thromboembolism (Nursing Interventions)
Primary Nursing Focus Areas
Encourage ambulation and perform leg exercises
Ensure adequate hydration
Use compression devices as applicable
Administer anticoagulants as prescribed
Monitor patients for signs of respiratory distress
Peripheral Artery Disease (Overview)
Description
Chronic arterial disorder caused by atherosclerosis that reduces blood flow to the limbs
Peripheral Artery Disease (Risk Factors)
Nonmodifiable Risk Factors
Age
Male sex
Family history
Modifiable Risk Factors
Smoking
Diabetes
Hypertension
Hyperlipidemia
Obesity
Sedentary lifestyle
Peripheral Artery Disease (Subjective Data)
Symptoms Reported by Patients
Intermittent claudication (pain or cramping in the legs during walking, relieved by rest)
Numbness
Coldness in the legs
Peripheral Artery Disease (Objective Data)
Visible Signs and Lab Findings
Weak or absent pulses in the lower extremities
Shiny, hairless skin
Pallor on elevation
Dependent rubor (redness when hanging down)
Ulcers present on toes
Delayed capillary refill time
Peripheral Artery Disease (Complications)
Severe Complications
Non-healing wounds
Gangrene
Possible amputation
Peripheral Artery Disease (Nursing Focus)
Key Nursing Responsibilities
Promote smoking cessation
Encourage exercise
Provide foot care information
Manage risk factors with medication or lifestyle changes
Assess pulses and temperature regularly
Keep the legs in a dependent position to promote blood flow
Cardiovascular Disease (Modifiable Risk Factors)
Key Modifiable Factors
Hypertension
Hyperlipidemia
Smoking
Diabetes
Obesity
Alcohol consumption
Stress
Poor diet
High cholesterol levels, high-fat diets, and physical inactivity contribute to cardiovascular disease
Behavioral Improvements
Healthy behaviors such as quitting smoking, reducing high blood pressure, and lowering high cholesterol are essential
Overall Goals
Improve cardiovascular health with better hypertension and cholesterol control, and increased educational efforts about signs and symptoms of disease, early detection, and treatment options (Reference: Office of Disease Prevention and Health Promotion [ODPHP], 2020)
Cardiovascular Disease (Nonmodifiable Risk Factors)
Key Nonmodifiable Factors
Age
Family history
Male gender
Ethnicity (higher prevalence observed in African American, Hispanic, and Native American populations)
Cardiovascular Disease (Nursing Focus)
Important Nursing Responsibilities
Monitor blood pressure, lipid levels, and glucose levels
Educate patients on lifestyle modifications and adherence to prescribed medications
Differential Diagnosis of Chest Pain
Cardiac Causes
Angina/myocardial infarction (MI): typically described as pressure or heaviness radiating to the jaw or arm
Pericarditis
Usually sharp pain, worse with inspiration
Pulmonary Causes
Sharp pleuritic pain
Gastrointestinal Causes
Burning pain relieved by antacids
Musculoskeletal Causes
Localized tenderness in response to palpation
Anxiety
May present as tightness and tingling sensations
Importance
Differential diagnosis of chest pain is critical as ischemic cardiac pain can result in loss of muscle cell function, which can lead to severe damage if untreated. An accurate description of the pain, along with alleviating factors and aggravating factors, can be highly indicative of the source.
Chest Pain (Nursing Focus)
Assessment Protocol
Assess onset, quality, radiation, and duration of the pain
Document associated symptoms
Obtain vital signs and an electrocardiogram (ECG) if cardiac distress is suspected
Grading of Pulses Scale
Pulse Grading
0: Nonpalpable or absent
1+: Weak and thready
2+: Normal and expected
3+: Full and increased
4+: Bounding
Nursing Note
Assess all major arteries; compare sides for symmetry and strength
Stridor (Definition)
Description
High-pitched inspiratory sound arising from upper airway obstruction (larynx or trachea) attributed to laryngeal spasm or constriction. In cases of severe laryngospasm, the larynx may be completely closed off.
Stridor (Causes)
Common Causes
Croup
Epiglottitis
Foreign body obstruction
Laryngeal edema
Anaphylaxis
Stridor (Assessment)
Observations
Audible without a stethoscope
Signs of respiratory distress
Possible cyanosis
Stridor (Nursing Priority)
Critical Nursing Responsibilities
Conduct airway assessments
Ensure oxygen is available
Prepare for advanced airway interventions as needed
Immediate medical intervention is crucial for this life-threatening emergency
Crackles, Wheezes, Rhonchi
Crackles
Discontinuous sounds resulting from fluid in airways or alveoli, or from reopened collapsed airways during deep breathing
Sound resembles hair rubbing together or Velcro being pulled apart
Most often heard during inspiration but can also be heard during expiration
Wheezes
Continuous, high-pitched musical sounds produced by air squeezing through narrowed airways
Typical in asthma cases, usually heard during expiration; can be noted during inspiration in severe cases
Important to document when wheezes occur (inspiration, expiration, or both)
Rhonchi
Continuous, low-pitched snoring sounds due to movement of secretions in airways
Louder during expiration but can be heard throughout the respiratory cycle; may clear with coughing
Commonly associated with chronic bronchitis
Lung Sounds (Nursing Focus)
Key Responsibilities
Document timing, location, and changes in lung sounds with coughing
Record presence, quality, and associated symptoms with lung sounds
CHF (Overview)
Definition
Heart fails to pump effectively, resulting in fluid accumulation in lungs and tissues
Congestion Types
Left-sided: pulmonary congestion
Right-sided: systemic congestion
CHF (Subjective Data)
Symptoms Reported by Patients
Fatigue
Dyspnea (shortness of breath) on exertion
Orthopnea (difficulty breathing while lying flat)
Paroxysmal nocturnal dyspnea (PND; sudden nighttime difficulty breathing)
Weight gain due to fluid retention
CHF (Objective Data)
Signs Observable Upon Examination
Left-sided CHF: Crackles and pink frothy sputum
Right-sided CHF: Jugular vein distention (JVD), edema, hepatomegaly, ascites
Additional signs: S3 gallop, tachycardia
CHF (Complications)
Severe Risks
Pulmonary edema
Renal impairment
Arrhythmias
CHF (Nursing Focus)
Key Nursing Responsibilities
Assess lung sounds diligently
Monitor daily weights
Measure intake and output (I&O)
Administer diuretics as prescribed
Position patients upright
Implement a low-sodium diet and fluid restriction
Tuberculosis (Overview)
Chronic Infection
Caused by Mycobacterium tuberculosis, primarily transmitted via airborne routes
Tuberculosis (Subjective Data)
Symptoms Reported by Patients
Fatigue
Weakness
Anorexia (loss of appetite)
Weight loss
Night sweats
Persistent cough
Hemoptysis (coughing up blood)
Tuberculosis (Objective Data)
Notable Exam Findings
Fever
Tachycardia
Decreased breath sounds
Dullness to percussion
Positive TB test results
Cavitary lesions visible on chest X-ray
Tuberculosis (Nursing Focus)
Key Nursing Responsibilities
Implement airborne isolation precautions (N95 mask, negative pressure rooms)
Ensure adherence to long-term antibiotic regimens
Monitor for hepatotoxicity associated with treatment
Asthma (Overview)
Chronic Condition
Inflammatory airway disease characterized by reversible bronchoconstriction and airway hyperresponsiveness
Asthma (Triggers)
Common Triggers
Allergens
Infections
Exercise
Cold air
Tobacco smoke
Stress
Asthma (Subjective Data)
Symptoms Reported by Patients
Dyspnea
Chest tightness
Anxiety
Wheezing
Coughing
Asthma (Objective Data)
Observable Signs
Wheezing
Prolonged expiration
Use of accessory muscles for breathing
Tachypnea (rapid breathing)
Tachycardia (increased heart rate)
Low oxygen saturation (O₂) levels
Asthma (Complications)
Severe Risks
Status asthmaticus (severe asthma attack)
Respiratory failure
Asthma (Nursing Focus)
Key Nursing Responsibilities
Assess airway and breathing status
Provide oxygen as necessary
Administer bronchodilators and steroids
Educate patients about trigger avoidance
Instruct on proper inhaler techniques and peak flow meter use
Risk Factors for Oral Diseases
Key Risk Factors
Tobacco use
Alcohol consumption
Poor oral hygiene practices
High-sugar diets
Diabetes
Dry mouth from medications
Ill-fitting dentures
Underlying systemic diseases
Potential Outcomes
Leading to caries (cavities), periodontitis, and oral cancer
Education on proper hygiene and regular dental care is crucial
Tinnitus (Definition)
Description
Perception of ringing, buzzing, or roaring sounds without an external source
Tinnitus (Causes)
Common Causative Factors
Noise-induced hearing loss
Ototoxic drugs
Ear infections
Earwax (cerumen) impaction
Ménière's disease
Hypertension
Tinnitus (Subjective Data)
Reported Experiences by Patients
Ringing or roaring sounds
May affect sleep or concentration
Tinnitus (Nursing Focus)
Assessment Areas
Evaluate medication use and noise exposure history
Educate on ear protection
Refer to audiology as necessary
PERRLA
Definition
Documented when pupils are equal, round, and reactive to light and accommodation
PERRLA (Assessment)
Assessing
Check size and shape of pupils
Observe constriction to light and accommodation when focusing on nearby objects
PERRLA (Abnormal Findings)
Indicators of Concern
Unequal pupils
Sluggish or fixed pupil response; may indicate neurological emergencies
Head and Neck (Subjective Data)
Common Patient Complaints
Headaches
Dizziness
Vertigo
Stiffness in the neck
Lumps in the neck
Difficulty swallowing
Hoarseness
Head and Neck (Objective Data)
Assessment Findings
Inspect for symmetry of the head
Palpate scalp, lymph nodes, and thyroid; assess for trachea midline positioning
Evaluate range of motion (ROM)
Head and Neck (Abnormal Findings)
Indicators of Concern
Fixed lymph nodes
Presence of a goiter
Torticollis (twisted neck)
Tenderness upon palpation
Head and Neck (Nursing Focus)
Key Responsibilities
Document lymph node characteristics and any unusual findings
Observe for facial symmetry
Report any discovered masses promptly
Skin, Hair, Nails (Subjective Data)
Patient Concerns
Changes in skin or moles
Lesions
Hair loss
Nail changes
Itching
Dryness
Exposures to irritants or allergens
Skin, Hair, Nails (Objective Data)
Assessment Findings
Inspect skin color and presence of lesions or bruises
Palpate skin for temperature, texture, and turgor
Hair should appear even, nails should be pink and smooth, capillary refill should be less than 2 seconds
Skin, Hair, Nails (Abnormal Findings)
Indicators of Concern
Pallor
Cyanosis
Jaundice
Clubbing of nails
Poor turgor
Alopecia
Hirsutism
Skin, Hair, Nails (Nursing Focus)
Key Responsibilities
Assess pressure areas for ulcers
Document findings related to skin lesions
Educate patients on sun safety and importance of the melanoma detection ABCDE criteria (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving)
Eye Assessment (Subjective Data)
Common Patient Concerns
Vision changes
Eye pain
Redness
Discharge
Halos around lights
Use of corrective lenses
Eye Assessment (Objective Data)
Assessment Findings
Inspect eyelids, conjunctiva, and sclera
Measure pupils (PERRLA)
Use Snellen chart for visual acuity assessment
Check extraocular movements (EOMs)
Eye Assessment (Abnormal Findings)
Indicators of Concern
Ptosis (drooping eyelids)
Redness, discharge
Unequal pupils
Nystagmus (involuntary eye movement)
Signs of cataracts or glaucoma
Eye Assessment (Nursing Focus)
Patient Education Focus Areas
Inquire about floaters/changes in eyesight
Encourage regular eye exams and lens safety
Ear Assessment (Subjective Data)
Common Patient Complaints
Hearing loss
Tinnitus
Vertigo
Ear pain
Ear drainage
History of noise exposure
Ear Assessment (Objective Data)
Assessment Findings
Inspect and palpate ears for tenderness
Conduct otoscopic examination to view the tympanic membrane (TM), which should be pearly gray and intact
Assess hearing using whisper, Weber, and Rinne tests
Ear Assessment (Abnormal Findings)
Indicators of Concern
Otitis externa or media
Cerumen impaction
Hearing loss
Ear Assessment (Nursing Focus)
Key Nursing Responsibilities
Review hearing aid use with patients
Teach on ear protection and proper cleaning techniques
Nose, Sinuses, Mouth, Throat (Subjective Data)
Common Patient Complaints
Nasal congestion
Nasal discharge
Sinus pain
Sore throat
Hoarseness
Dental hygiene habits
Nose, Sinuses, Mouth, Throat (Objective Data)
Assessment Findings
Inspect for midline nasal position and check mucosa for pink color
Palpate sinuses for tenderness
Ensure oral mucosa is intact, teeth are in good condition, and tonsils grade 1-2+ in size
Nose, Sinuses, Mouth, Throat (Abnormal Findings)
Indicators of Concern
Sinus tenderness
Nasal polyps
Oral lesions
Signs of tonsillitis or gingivitis
Nose, Sinuses, Mouth, Throat (Nursing Focus)
Key Responsibilities
Assess mucosal health
Encourage proper hygiene and hydration
Document any lesions or abnormalities
Abdominal Assessment (Subjective Data)
Common Patient Complaints
Changes in appetite
Nausea
Vomiting
Bowel habits fluctuations
Abdominal pain
Prior GI history
Abdominal Assessment (Objective Data)
Assessment Findings
Inspect contour of the abdomen
Auscultate bowel sounds
Percuss for tympany or dullness
Palpate for tenderness or masses
Abdominal Assessment (Abnormal Findings)
Indicators of Concern
Absent bowel sounds
Guarding or rigidity of the abdominal wall
Hepatosplenomegaly
Ascites (fluid build-up in the abdomen)
Abdominal Assessment (Nursing Focus)
Key Responsibilities
Assess bowel patterns routinely
Avoid palpation in the presence of suspected aneurysms
Monitor patient's nutritional status
Breast and Axillae Assessment (Subjective Data)
Common Patient Complaints
Presence of lumps
Tenderness
Nipple discharge
Family history of breast disease
Hormone therapy usage
Breast and Axillae Assessment (Objective Data)
Assessment Findings
Inspect breasts for size and symmetry
Palpate each quadrant of the breast and axillae systematically
Breast and Axillae Assessment (Abnormal Findings)
Indicators of Concern
Presence of lumps
Breast asymmetry
Peau d'orange texture
Retraction of the nipple
Node enlargement in axillae
Breast and Axillae Assessment (Nursing Focus)
Key Responsibilities
Teach self-breast examination (SBE) techniques
Encourage routine mammogram screenings
Report any new findings to healthcare provider promptly
Peripheral Vascular and Lymphatic (Subjective Data)
Common Patient Complaints
Leg pain
Swelling
Heaviness in legs
Tingling sensations
Presence of ulcers or varicose veins
Peripheral Vascular and Lymphatic (Objective Data)
Assessment Findings
Inspect color and condition of the legs
Evaluate for edema and varicosities
Palpate temperature, pulses, and lymph nodes
Peripheral Vascular and Lymphatic (Abnormal Findings)
Indicators of Concern
Presence of edema
Coolness of skin
Varicosities evident
Enlargement of lymph nodes
Peripheral Vascular and Lymphatic (Nursing Focus)
Key Responsibilities
Elevate legs for patients with venous issues
Keep legs dependent in arterial issues
Promote ambulation
Use compression stockings as indicated
Thorax and Lung (Subjective Data)
Common Patient Complaints
Cough
Sputum production
Dyspnea
Chest pain
Wheezing
History of smoking or relevant exposures
Thorax and Lung (Objective Data)
Assessment Findings
Inspect shape and symmetry of the chest
Palpate for chest expansion
Percuss for resonance
Auscultate for breath sounds
Thorax and Lung (Abnormal Findings)
Indicators of Concern
Asymmetrical expansion of the chest
Barrel chest appearance
Dull percussion notes
Diminished breath sounds
Presence of crackles, wheezes, or rhonchi
Thorax and Lung (Nursing Focus)
Key Responsibilities
Monitor respiratory rate diligently
Encourage deep breathing exercises
Document lung assessments and oxygen saturation status