Simpson Heidi
Kingston University, St George's Hospital Medical School, London.
Br J Nurs. 2006;15(9):484-8. doi: 10.12968/bjon.2006.15.9.484.
The ability to carry out and document a full respiratory assessment is an essential skill for all nurses. The elements included are: an initial assessment, history taking, inspection, palpation, percussion, auscultation and further investigations. A prompt initial assessment allows immediate evaluation of severity of illness and appropriate treatment measures may warrant instigation at this point. Following this, a comprehensive patient history will be elicited. Clinical examination of the patient follows and involves inspection, palpation, percussion and auscultation. At this point, consideration must be given to preparation of a light, warm, quiet, private environment for examination and suitable patient positioning. Inspection is a comprehensive visual assessment, while palpation involves using touch to gather information. The next stages are percussion and auscultation. While percussion is striking the chest to determine the state of underlying tissues, auscultation entails listening to and interpreting sound transmission through the chest wall via a stethoscope. Finally, further investigations may be necessary to confirm or negate suspected diagnoses.
进行全面的呼吸评估并记录是所有护士必备的技能。其内容包括：初步评估、病史采集、视诊、触诊、叩诊、听诊以及进一步检查。及时的初步评估能立即对病情严重程度进行评估，此时可能需要采取适当的治疗措施。在此之后，要全面了解患者病史。接着对患者进行临床检查，包括视诊、触诊、叩诊和听诊。此时，必须考虑为检查准备一个光线充足、温暖、安静、私密的环境以及合适的患者体位。视诊是全面的视觉评估，而触诊则是通过触摸来收集信息。接下来是叩诊和听诊。叩诊是敲击胸部以确定深层组织的状态，听诊则是通过听诊器听取并解读通过胸壁传播的声音。最后，可能需要进一步检查以证实或排除疑似诊断。
