The purpose of the lungs is most importantly the exchange of gases in the body. The right lung is divided into three separate and distinct lobes by deep fissures. The lungs are the cone-shaped organs located in the pleural spaces in the right and left sides of the bony thorax.

Dyspnea – ask circumstances surrounding trouble breathing.

Cough – type of cough, type and character of sputum, blood in sputum.

Pain – pulmonary pain, pleural pain, muscular pain, cardiac pain, describe in detail.

Specific Medical History (specific to this hospitalization).

Major medical problems heart, GI, GU, respiratory surgery, etc.

Consider the part of the country they are from some diseases are endogenous.

Exposure to exotic animals, birds pigeons, parrots, parakeets.

Type of work patient is engaged in are they exposed to air or chemical pollutants.

Family history (TB, allergy, asthma, smoking).

Reason for Hospitalization (medical diagnosis from chart).

The nursing history may repeat some of the same items that the medical history has obtained but the nurse will have different objectives in mind when asking questions and gathering data, The following guide can be used to obtain information from the patient and nursing-related information. The history is very important to obtain before you begin your examination. PATIENT HISTORYįollowing is a guide to the history-taking process. In this text, we will describe the characteristics of normal and common abnormal breath sounds. Percussing - is usually helpful only in a limited capacity to the examiner, as we will discuss later.Īusculation - is the process of listening to the breath sounds with the use of a stethoscope. Some systemic problems can be detected during this part of the exam as well as just mechanical breathing problems. Many breathing difficulties can be seen during this step. Palpation - is the first step of the assessment, where we will touch the patient. This is a very important part of the exam, since many abnormalities can be detected by merely inspecting the thorax as the patient is breathing. Visual Inspection - is the first step of the examination.

You first start with a very general inspection and history of the patient then your exam becomes more detailed as you begin to examine the interaction of all body systems. These steps are designed to take the nurse through the assessment in a logical and organized sequence. These same steps are very popular today in assessment of all systems of the body.

Lung sounds diminished documentation