| Auscultating Lung Sounds | 肺部聽診 |
| Assessment | 評估 |
| 1. Calculate smoking history in pack years. | 按包/年計算吸煙史?！?/td> |
| 2. Identify six signs or symptoms of respiratory difficulty. | 識別呼吸困難的六個癥狀或體征?！?/td> |
| 3. Check for a history of allergies to airborne irritants and foods. | 檢查是否有空中刺激物和食物過敏史?！?/td> |
| 4. Determine baseline rate, rhythm, and depth of breathing. | 測定基線呼吸速度、節(jié)律和深度?！?/td> |
| Implementation | 實施 |
| 1. Use Standard Protocol. | 采用標(biāo)準(zhǔn)護理操作規(guī)定 |
| 2. Position | 體位 |
| A. Sit upright or elevate head of bed 45 to 90 degrees for bedridden client if possible. | 可能時，臥床病人可取端坐位或?qū)⒋差^抬高到40-90度。 |
| B. If client cannot tolerate sitting, supine position is allowed for anterior chest and side-lying position is used for posterior chest. | 如病人無法坐起，可取仰臥位聽診前胸，側(cè)臥位聽診后背?！?/td> |
| 3. Remove or raise gown, avoiding unnecessary exposure and providing full visibility of thorax. | 脫去或提高外衣，避免不必要暴露，充分露出喉部。 |
| 4. Auscultate breath sounds over intercostal spaces, moving stethoscope systematically from apex of lung down to lower lobes. Ask client to take slow, deep breaths through the mouth each time stethoscope is placed on chest. | 聽診肋間隙呼吸音，聽診器由肺尖部向肺下葉移動。囑病人在聽診器置于胸部時用口深、慢呼吸， |
| 5. Listen to entire inspiration and expiration at each stethoscope position. | 每一聽診部位聽診均應(yīng)呼、吸完整。 |
| 6. Assess client's respiratory character, observing symmetry and degree of chest wall abdominal movement. | 評估病人呼吸特征，觀察胸壁腹部移動對稱性及程度?！?/td> |
| 7. If adventitious sounds are auscultated, have client cough. Listen again with stethoscope to determine sound has cleared with coughing. | 如有附加音，囑病人咳嗽。再次聽診以確定附加音是否隨咳嗽消失?！?/td> |
| 8. If client has a productive cough and mucus is purulent, note amount, color, and odor of mucus. Obtaining a specimen may be indicated. | 如病人有排痰性咳嗽，粘液帶膿，應(yīng)注意粘液數(shù)量、顏色及氣味。獲取標(biāo)本?！?/td> |
| 9. Use Completion Protocol. | 實施完成操作程序。 |
| Evaluation | 評價 |
| 1. Compare respirations and breath sounds with previous findings. | 將本次呼吸與呼吸音與前次檢查結(jié)果相對照。 |
| Identify Unexpected Outcomes and Nursing Interventions | 確認(rèn)意外結(jié)果和護理介入。 |
| Record and Report | 記錄并報告 |
| 1. Respiratory assessment adventitious sounds （type, location, presence on inspiration/expiration or both）. | 呼吸評估附加音（類型、部位、是否出現(xiàn)于吸氣/呼氣或兩者都有）?！?/td> |
| 2. Cough: if productive amount, color, odor, and consistency of sputum | 咳嗽：如為排痰性咳嗽，注意痰的顏色、氣味和粘稠度。 |
| 3. Dyspnea or acute respiratory distress | 呼吸困難或急性呼吸窘迫?！?/td> |
| 4. Client's response | 病人反應(yīng)。 |
掃一掃立即下載
