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Discussion

Charting lung sounds

I've been out of nurses for a while, actually unemployed. I can't remember how to chart lung sounds. So confused. If its the right upper lung is it the patients right side? If the nurse is facing the client and she is listening on her right side is it charged as right or left(because its actually the clients left lung)??

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    You refer to the patient when charting. Patient's right lung, not the one on your right, which would be the patient's left lung. I mentally turn myself around and "become" the patient when I am figuring out which is which. For some reason this works better for me.

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    • Experts

    Well if you know anything about anatomy it should be a dead give away as to how to document assessment findings based on what your options are in the chart. Left lung only has two lobes an upper and lower. Right lung has 3 lobes, upper, middle, and lower. The chart will reflect this and it will always be from the patient's point of reference not your own.

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    I will give you a few examples of how I chart:

    1. Crackles auscultated in lower lobes bilaterally R>L.

    2. Coorifice lung sounds ascultated in all lung fields bilaterally.

    3. Rhonchi heard upon inspiration in R lung, wheezes auscultated on expiration bilaterally.

    Occationally I will chart : Loud rhonchi heard near primary bronchus bilaterally (only if it is clearly located near the primary bronchus and other fields are clear.

    I have never specified lung sounds being heard on the R middle lobe, I dont know if it is my lack of experience but I dont believe I have heard where the sounds were isolated near the right middle lobe, I typically hear it near the bases or in all three lobes on the right)

    And always base your assessment data on the patient, I usually have to think about it for a second, and like caliotter 3 I will mentally turn myself to be sure.

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    It's the patient's body to which you are referring, so it would always be charted with this in mind, no matter the area/organ of assessment.

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    If possible, listen on the person's back...you will get a better sound and it makes right vs. left easier...and, yes, it is always the pt's right/left for all references of lateralization.

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