Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [55], C).
2. 2.Show
   Gain the patient's verbal consent.
   Consent must be gained before any procedure takes place (NMC [55], C).
3. 3.Show
   Make sure the patient is warm and comfortable and sitting on the edge of the bed or on a chair.
   To ensure that both the anterior (front) and posterior (back) thorax and lungs can be examined (Bickley and Szilagyi [9], E).
4. 4.Show
   Expose the patient from head to waist while maintaining privacy and dignity.
   To allow a thorough examination (Talley and O'Connor [82], E).

Procedure

1. 5.Show
   Wash and dry hands.
   To prevent the spread of infection (NHS England and NHSI [54], C).

General inspection

1. 6.Show
   Take a global view of the patient.
   See ‘Inspection’ above.
2. 7.Show
   Look at the patient's skin and nails. Feel the texture, temperature and turgor of the skin.
   Abnormalities of the skin and nails can be an indication of a variety of different conditions, for example heart disease, lung disease, cyanosis and/or anaemia (Bickley and Szilagyi [9], Rushforth [74]). Look for tobacco staining (Innes and Tiernan [40]). E
3. 8.Show
   Press either side of the patient's finger (first digit) firmly between your finger and thumb for 5 seconds and then let go. Count how many seconds it takes for the colour to return.
   To assess capillary refill; this can give an indication of the status of circulation (Paterson and Dover [23]). Normal return is 2 seconds. E
4. 9.Show
   Ask the patient to hold out their arms with their wrists flexed and their palms facing forwards for 1 minute.
   To assess for flapping tremor; a fine tremor can be a side‐effect of high‐dose beta‐agonist bronchodilators. A coarse flapping tremor of the outstretched hands is seen in patients with carbon dioxide retention (Innes and Tiernan [40], E).
5. 10.Show
   Look at the patient's eyes.
   To assess for any abnormalities, particularly looking for any signs of hypercholesterolaemia (corneal arcus or xanthelasma) or anaemia (conjunctival pallor). Look for any signs of unilateral ptosis or pupillary constriction, which may constitute Horner's syndrome (Innes and Tiernan [40], E).
6. 11.Show
   Look at and in the patient's mouth.
   The mouth can give a snapshot of the patient's general state of health. Look for signs of malnutrition, infection, central cyanosis and any sores (Bickley and Szilagyi [9]). Look for signs of mouth breathing and upper respiratory tract infection (Innes et al. [39]). E
7. 12.Show
   Look at and in the patient's nose.
   To assess for nasal flare, deviated septum and nasal polyps (Talley and O'Connor [82], E).
8. 13.Show
   Listen to the patient's breathing.
   To assess for any audible wheeze or stridor (Bickley and Szilagyi [9], E).
9. 14.Show
   Look at the patient's neck.
   To assess whether accessory muscles are being used and whether the trachea is at the midline ( Bickley and Szilagyi [9], E).
10. 15.Show
    Check the patient's jugular venous pressure (JVP). To do this, ensure the patient is positioned at 30–45° and ask them to turn their head away from you. Measure the JVP (number of centimetres vertically from the sternal angle to the upper border of pulsation). (For more information, see the section ‘Steps for measuring the JVP’ below.)
    To check for a raised JVP, which can indicate pulmonary hypertension, tension pneumothorax or large pulmonary embolism (Innes and Tiernan [40], E).
11. 16.Show
    Palpate the trachea gently with your index finger and thumb.
    To ensure it is at the midline with no deviation (Innes and Tiernan [40], E).
12. 17.Show
    Palpate the head and neck nodes (see Figure 2.8).
    To assess for enlarged nodes; this can be a sign of malignancy or infection (Dover et al. [23], E).

Posterior chest

1. 18.Show
   Inspect the patient's chest.
   To assess for any scars, masses, deformities and asymmetry (Bickley and Szilagyi [9], E).

Palpation

1. 19.Show
   Lightly palpate the chest.
   To assess for any signs of tenderness, pain or masses (Bickley and Szilagyi [9], Rushforth [74], E).
2. 20.Show
   Place your thumbs at the level of the 10th rib either side of the spine with your fingers fanned out towards the lateral (side) chest. Ask the patient to take a deep breath in (see Figure 2.9).
   To assess chest expansion (Bickley and Szilagyi [9], Rushforth [74], Talley and O'Connor [82], E).
3. 21.Show
   Place the edge of your palm and little finger on the patient's chest at the points seen in Figures 2.10 and 2.11 and ask the patient to say ‘99’. Assess both sides of the chest together using both hands.
   To assess for tactile fremitus (Bickley and Szilagyi [9], Rushforth [74], Talley and O'Connor [82], E).

Percussion

1. 22.Show
   Percuss the chest (see Figure 2.12).
   To assess for normal resonance in the lungs and identify any abnormalities (Bickley and Szilagyi [9], E).

Auscultation

1. 23.Show
   Auscultate the lungs using the diaphragm of the stethoscope (see Figure 2.12).
   To assess for vesicular breath sounds and any adventitious sounds (Bickley and Szilagyi [9], E).

Anterior chest

1. 24.Show
   Inspect the patient's chest.
   To assess for any scars, masses, deformities and asymmetry (Bickley and Szilagyi [9], E).

Palpation

1. 25.Show
   Lightly palpate the chest
   To assess for any signs of tenderness, pain or masses (Bickley and Szilagyi [9], Rushforth [74], E).
2. 26.Show
   Place your thumbs along each costal margin at about the fifth or sixth rib with your fingers fanned out towards the lateral chest. Ask the patient to take a deep breath in.
   To assess chest expansion (Bickley and Szilagyi [9], Rushforth [74], Talley and O'Connor [82], E).
3. 27.Show
   Place the edge of your palm and little finger on the patient's chest at the points seen in Figure 2.9 and ask the patient to say ‘99’. Assess both sides of the chest together using both hands.
   To assess for tactile fremitus (Bickley and Szilagyi [9], Rushforth [74], Talley and O'Connor [82], E).

Percussion

1. 28.Show
   Percuss the chest (see Figure 2.12).
   To assess for normal resonance in the lungs and identify any abnormalities (Bickley and Szilagyi [9], E).

Auscultation

1. 29.Show
   Auscultate the lung using the bell of the stethoscope for the apex of the lung (above the clavicle) and the diaphragm of the stethoscope for the rest of the chest (see Figure 2.12).
   To assess for vesicular breath sounds and any adventitious sounds (Bickley and Szilagyi [9], E).

Post‐procedure

1. 30.Show
   Document fully.
   Accurate records should be kept of all discussions and/or assessments made (NMC [55], C).
2. 31.Show
   Report any abnormal findings to a senior nurse or to medical staff.
   Patients should be cared for as part of a multidisciplinary team and, where appropriate, patient care should be referred to another more experienced practitioner (NMC [55], C).
3. 32.Show
   Clean the equipment used and wash hands.
   To prevent the spread of infection (NHS England and NHSI [54], C).
4. 33.Show
   Explain findings to the patient.
   The patient should be told, in a way they can understand, the information they want or need to know about their health (NMC [55], C).
5. 34.Show
   Discuss plan of care with the patient.
   Where possible, patients should be involved in planning their care (NMC [55], C).
6. 35.Show
   Additional bedside investigations: assess vital signs, and inspect sputum and send for microbiology, culture and sensitivity.
   This additional information can be used to assess the adequacy of gas exchange (Fisher and Potter [28], E).
7. 36.Show
   Order further investigations as needed to include blood, chest X‐ray and lung function tests.
   This additional information can further refine the differential diagnoses (Fisher and Potter [28], E).