13.18:
Assessment of Respiration
Begin the assessment by explaining the purpose of the assessment and obtaining informed consent.
The respiratory assessment involves assessing the anterior, posterior, and lateral thorax. First, observe for signs of respiratory distress or difficulty breathing.
Perform hand hygiene to avoid cross-infection. Provide a comfortable position to the patient.
Ask the patient about any history of respiratory problems, including asthma, chronic bronchitis, or emphysema.
Start the assessment by inspecting the patient's chest for symmetry in shape and movement with respiration.
Assess for cyanosis around the lips or nail beds, which may suggest low oxygen levels in the bloodstream.
Next, palpate the chest wall for tenderness or abnormal expansion.
Then, percuss the chest to detect areas of dullness or hyperresonance, which could indicate a consolidation or pleural effusion.
Lastly, auscultate lungs with a stethoscope for abnormal breath sounds such as rhonchi, wheezes, or crackles, which may suggest airway obstruction or infection.
Replace the equipment and perform hand hygiene.
Document findings in the medical record.
13.18:
Assessment of Respiration
The respiratory system's basic structures and primary functions lay the foundation for nurses' comprehensive respiratory assessments. This assessment includes subjective and objective data to gauge the patient's respiratory health.
Subjective Assessment: Nurses interview the patient to gather information directly during the subjective assessment. It includes questions about the individual's medical history, medications, and symptoms, focusing on past respiratory conditions like asthma or COPD, surgeries, and allergies. It is important to ask about the family history to identify genetic predispositions and shared environmental factors.
Nurses should inquire about respiratory symptoms, including the presence, frequency, severity of coughs, and factors that worsen or alleviate them. Information on sputum color, consistency, and amount provides insights into potential respiratory conditions.
Lifestyle and environmental factors impacting respiratory health are also part of the subjective data. It includes smoking history, exposure to secondhand smoke, occupational exposure to irritants or toxins, and living conditions like mold, dust, and pet dander.
Objective Assessment: The objective assessment involves checking vital signs and physically examining the patient through inspection, palpation, auscultation, and percussion.
Evaluate Vital Signs: The assessment begins with interpreting vital signs, specifically the respiratory rate and pulse oximetry readings. Adults typically have a respiratory rate of 12-20 breaths per minute at rest, with ideal blood oxygen saturation levels between 95–100% (SpO2).
Inspection: A thorough inspection is critical, focusing on the patient's consciousness level, breathing rate, pattern, effort, skin color, chest configuration, and symmetry of expansion. Observations include breathing patterns and signs of respiratory difficulty like pursed-lip breathing, nasal flaring, and intercostal retractions. The chest is inspected for symmetry and configuration, focusing on the anteroposterior-transverse ratio, ideally 1:2.
Palpation: Palpation helps investigate abnormalities related to injury or procedural complications. Symmetric chest expansion is confirmed by placing hands on the chest at the same level, noting any unequal expansion that may indicate conditions like pneumonia or pneumothorax.
Auscultation: Auscultation involves listening to air movement during inspiration and expiration, typically using a stethoscope. Expected breath sounds include bronchial sounds over the trachea, bronchovesicular sounds over major bronchi, and vesicular breath sounds over lung surfaces. Adventitious lung sounds like wheezing, crackles, rales, rhonchi, stridor, and pleural rub are also noted.
Percussion: Percussion involves striking the fingers over lung fields to differentiate sounds. Dull sounds indicate high-density areas like pneumonia or atelectasis, while clear, low-pitched, hollow sounds are typical of normal lung tissue.
In summary, a focused respiratory assessment, including a thorough examination, is vital for identifying potential issues, monitoring changes, and facilitating timely interventions.