| Auscultating Lung Sounds |
肺部听诊 |
| Assessment |
评估 |
| 1. Calculate smoking history in pack years. |
按包/年计算吸烟史。 |
| 2. Identify six signs or symptoms of respiratory difficulty. |
识别呼吸困难的六个症状或体征。 |
| 3. Check for a history of allergies to airborne irritants and foods. |
检查是否有空中刺激物和食物过敏史。 |
| 4. Determine baseline rate, rhythm, and depth of breathing. |
测定基线呼吸速度、节律和深度。 |
| Implementation |
实施 |
| 1. Use Standard Protocol. |
采用标准护理操作规定 |
| 2. Position |
体位 |
| A. Sit upright or elevate head of bed 45 to 90 degrees for bedridden client if possible. |
可能时，卧床病人可取端坐位或将床头抬高到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. |
如病人无法坐起，可取仰卧位听诊前胸，侧卧位听诊后背。 |
| 3. Remove or raise gown, avoiding unnecessary exposure and providing full visibility of thorax. |
脱去或提高外衣，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. |
听诊肋间隙呼吸音，听诊器由肺尖部向肺下叶移动。嘱病人在听诊器置于胸部时用口深、慢呼吸， |
| 5. Listen to entire inspiration and expiration at each stethoscope position. |
每一听诊部位听诊均应呼、吸完整。 |
| 6. Assess client's respiratory character, observing symmetry and degree of chest wall abdominal movement. |
评估病人呼吸特征，观察胸壁腹部移动对称性及程度。 |
| 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，嘱病人咳嗽。再次听诊以确定附加音是否随咳嗽消失。 |
| 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，粘液带脓，应注意粘液数量、颜色及气味。获取标本。 |
| 9. Use Completion Protocol. |
实施完成操作程序。 |
| Evaluation |
评价 |
| 1. Compare respirations and breath sounds with previous findings. |
将本次呼吸与呼吸音与前次检查结果相对照。 |
| Identify Unexpected Outcomes and Nursing Interventions |
确认意外结果和护理介入。 |
| Record and Report |
记录并报告 |
| 1. Respiratory assessment adventitious sounds （type, location, presence on inspiration/expiration or both）. |
呼吸评估附加音（类型、部位、是否出现于吸气/呼气或两者都有）。 |
| 2. Cough: if productive amount, color, odor, and consistency of sputum |
咳嗽：如为排痰性咳嗽，注意痰的颜色、气味和粘稠度。 |
| 3. Dyspnea or acute respiratory distress |
呼吸困难或急性呼吸窘迫。 |
| 4. Client's response |
病人反应。 |
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