Sop Physical Examination of The Respiratory Sistem
Sop Physical Examination of The Respiratory Sistem
Sop Physical Examination of The Respiratory Sistem
Pre-interaction phase
Preparing tools:
1. Stethoscope
2. Handscoon
3. Penlight
4. Pencil/pen
5. Ruler
Working phase
Inspection:
1. Observe the color of the face and lips (the presence of cyanosis)
2. Observe the patient’s nails (color and shape)
3. Use lightening to observe the nose and nostrils (polyps or not) or the is sputum,the
color
4. Use the ovservation of tonsils,the patient is asked to open the mouth and slightly
remove the tongue
5. Observe the skin area in front of the trachea (bruises,lesions,swelling)
6. Thorax: shadow lines,skin color,texture,presence of lesions,fractures
7. Observe the chest shape (anteroposterior)
8. Observe the curvature of the spine
9. Breathing movements and chest irritation
Palpation:
Percusion:
5. Anterior thorax
- Start from the top of klavikula at supraklavikula space and continued to the low part of
diaphragm
- Compare one side of the lung with the other sicle
Posteriror thorax
- Ask clien to bow his head and fold hand forward the chest
- Do percussion at intercostal space with interval about 5 cm with systematic sequence
Diaphragm excursion
- Ask clien to take a deep breath and hold it second, while you do percussion along the
scapula line until faint sound appears at diaphragm height. Mark this point with the
pencil pr marker pen
- Repeat the procedure on the other side
- Ask the client to breath normally a few times and then take out the last overall breath
and hold it while you do an upward percussion from the marking the diaphragm
excursion during expiration in the chest on each side of the chest the chest
- Measure the distance between the two chests
Auscultation:
6. Anterior thorax
- Auscultation of the anterior chest using the sequence on percussion
Posterior thorax
-
Auscultation of the posterior chest using the percussion sequence
-
Ask the client to take a deep breath slowly through the mouth. Listen to the
breath sounds at each point during complete inspiration and expiration
- Compare the results at each point with the same point on the opposite side of
the chest
7. Explain the results of the examination to the client
Termination phase
8. Trimming tools
9. Nurses wash hands
10. Documentation right
The Dialogue of respiratory system examination
Orientation phase:
I'm (......),
Before i do this procedure do you have any question sir? (Yes or No)
Okay if you not have question we will start the procedure right now
Work phase
1. Your face and and lips looks good normal, no sianosis, no pale
2. May i see your nail? The colour is pink, and form normal
6. Your thorax is symmetrical, the colour is normal, the tekstur good, nothing lesi, and no
fracture
Then i will do percussion to know your lungs, heart, and liver position.
Okay sir...
Termination phase
Okay sir now im done with this procedure, before i go do you have any question sir?
(no, i don't)
Okay if you not have question i will back to my room and i will come again at 12 a.m. to
check your vital sign..
Good morning..