ST.

MICHAEL’S COLLEGE
Iligan City

COLLEGE OF NURSING

Name: ______________________________________________ Date : ____________

Clinical Instructor: ____________________________________ Grade: ____________

Assessing the Thorax and the Breast

Concept:
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Objectives:
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PROCEDURE RATIONALE
ASSESSMENT:
Explain the procedure to the client.
Obtain the patient’s health history which includes: the
biographical data. the chief complaint, current & past
health status.
PLANNING:
Gather all the materials needed.
IMPLEMENTATION:
Instruct the patient to void if possible.
Do handwashing.
Measure and record the height, weight and vital signs.
Assist the patient onto the examination table, stretcher or
bed: position and drape the patient according to the body
area to be assessed.
POSTERIOR CHEST
Inspect, Palpate, Percuss, Auscultate

Inspect the posterior thorax. Observe the skin, bone and

muscles of the spine, shoulder blades and the back as
well as symmetry of expansion and accessory muscle
use.

Inspect for nasal flaring and pursed lip breathing.

Observe color of face, lips, and chest. Inspect color and
shape of nails.

Inspect the client’s positioning. Note the client’s posture

and ability to support weight while breathing comfortably.

Assess the anteroposterior and lateral diameters of the

thorax.
Note: Warm your hands prior to palpation.
Palpate over spine and posterior thorax
Palpate for tenderness and sensation. Palpate for
crepitus.
Assess for respiratory excursion and tactile fremitus.
Percuss over the posterior and lateral lung fields and for
diaphragmatic excursion on each side of the thorax.
Percuss for diaphragmatic excursion.
Auscultate the lungs through the posterior thorax as the
patient breathes slowly and deeply and listen for breath,
adventitious and voice sounds.
ANTERIOR CHEST
Inspect, Palpate, Percuss, Auscultate

Examine the anterior thorax. Observe the skin, bones and

muscle as well as symmetry of expansion and accessory
muscle use.
Inspect for shape and configuration, the quality and
pattern of respiration, noting breathing characteristics,
rate, rhythm and depth.
Inspect the anterior thorax for lifts, heaves or thrusts.
Palpate for tenderness and masses. Check for apical
pulse.
Palpate for respiratory excursion and tactile fremitus.
Percuss over the anterior thorax. Note areas of
resonance, hyperresonance or dullness.
Auscultate the lungs through the anterior thorax as the
patient breathes slowly and deeply and listen for breath
and adventitious sounds.
BREAST
Inspect, Palpate

Inspect the breast and axilla with patient’s hands resting

on both sides of the body, placed on the hips and raised
above the head.
● Assess size, shape, symmetry and color of the
breast. Note for visible masses, lesion, edema and
venous pattern.
Have patient press hands together or press hands on
hips to check dimpling or retraction. Note dominant side.
● Note color, shape symmetry, inversion / eversion,
discharge, masses, lesions, and direction of nipples. Note
color, masses, lesions and hair distribution of the axilla.
Palpate the breast while the patient is lying on a supine
position, by making small circles with light, medium and
deep pressure using the finger pads of the three middle
fingers.
Palpate the axilla using the same method and with the
patient’s arms resting on the side of the body.
Palpate the clavicle down to the sixth and seventh
intercostal space and from sternum to mid axillary line.
Use vertical strip, pie wedge or circular method. Note the
texture, consistency, tenderness or masses of these
areas. Note for the location, size, mobility, border and
temperature of any palpable nodes.
Do hand hygiene.
EVALUATION:
Document significant normal & abnormal findings in an
organized manner.

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