Pulmonary/Respiratory Assessment

FIRST things you will do as you walk into the patient's room.

1. Hand hygiene!! 2. Introduce yourself. 3. Explain what you will be doing. 4. Get the patient to identify their full name and DOB. 5. Ask the patient their pain level. 6. Note if the patient is on any kind of supplemental O2 device or pulse ox VERBALIZE IT: "Good morning Ms. Jones. My name is Brittany and I am going to be the nurse taking care of you today. I need to perform a quick pulmonary/respiratory exam where I will be assessing your lungs. It will take just about 7 minutes. Is this ok? Ok great, first can I get you to identify your name and DOB? That matches what I have here in my records. Now I am going to go ahead and note that you are not on any kind of supplemental O2 device or pulse oximetry. The last thing I will ask is are you in any kind of pain? All right well, then I will proceed with my assessment." 7. Proceed to the respiratory assessment.

You are completely done with the assessment. What will you do before leaving the patient's room?

1. Lower bed. 2. Put call light back within reach. 3. Ask if the patient needs anything else before you leave. VERBALIZE IT: "Well this concludes my assessment. Thank you for allowing me to do this. Is there anything I can do for you before I leave?"

FOURTH step of the POSTERIOR assessment.

ASSESS CHEST EXPANSION -------------------------- VERBALIZE PROCESS: "Now I am going to feel for where you rib cage ends and place my hands just slightly above. I want you to take a deep breath in and breathe out." STATE FINDING: "So I did see bilateral chest expansion which is what we want to see."

THIRD step of the POSTERIOR assessment.

ASSESS FOR FREMITUS -------------------------- VERBALZIE PROCESS: "I am going to place my hands on your back and I want you to say 99 each time you feel me move." STATE FINDING: "I was feeling for vibrations as you said 99 and I felt the strongest vibrations at the top and they diminished in intensity as I moved down. They were even on both sides."

FOURTH (and final) step for the ANTERIOR assessment.

AUSCULTATION -------------------------- IMPORTANT: - Start at the top and work down. - Make sure to start above the clavicle near the trachea and move down in the ladder technique. - Make sure to listen to about 6 points on the chest (or however many are need to cover the entire chest) on the front. The listen to at least 2 points on each side. VERBALIZE PROCESS: "So now I am going to listen to your lungs as your breathe. Each time you feel my stethoscope move to a different area on your chest I want you to take a deep breath in and out through your mouth." STATE FINDING: "What I heard was clear and normal breath sounds equal bilaterally. I heard bronchial sounds when listening near your trachea, I hear bronchovesicular breath sounds on both sides of your sternum, and I hear vesicular breath sounds on each side of your chest. I did not hear any adventitious sounds like wheezing or crackling."

FIFTH (and final) step of the POSTERIOR assessment.

AUSCULTATION -------------------------- VERBALIZE PROCESS: "I am now going to take a listen to your lungs once again. Each time you feel me move my stethoscope I want you to take a deep breath in and out through your mouth." STATE FINDING: "I heard clear breath sounds that were equal bilaterally. I heard bronchovesicular sounds between your scapula and vesicular sounds on each of your sides. I did not hear any adventitious sounds. No wheezing or crackling."

Once done with the anterior assessment, what is your next step?

Ask the patient to sit up so that you can access their posterior side. VERBALIZE IT: "Now I am going to get you to sit up so that I can assess your lungs from the posterior or back side."

FIRST step of the ANTERIOR assessment.

EXPOSE CHEST AREA!

Once done with the posterior assessment, what is the last assessment you will do?

INSPECT THE ANTERIOR-POSTERIOR DIAMETER. VERBALIZE PROCESS: "The last thing I am going to do is inspect your anterior-posterior diameter." STATE FINDING: "Your ratio is 1 to 2 which is an expected finding."

SECOND step for the ANTERIOR assessment.

INSPECTION -------------------------- STATE FINDING: "You are not showing any signs of labored breathing. I do not see any use of accessory muscles such as your shoulders or abdomen. Your pattern of breathing appears to be even and unlabored. Now I am going to look at your trachea and it is midline which is what we expect. I'm going to now assess something we call the costal angle. It is the angle at which your ribs meet your sternum and we want the angle to be within 90 degrees and yours appears to be."

FIRST step of the POSTERIOR assessment.

INSPECTION -------------------------- STATE FINDING: "So again I do not see any use of accessory muscles and your spine appears to be straight."

THIRD step for the ANTERIOR assessment.

PALPATION -------------------------- VERBALIZE PROCESS: "I am going to lightly press on your chest and I want you to let me know if you feel any kind of pain or tenderness. What I am feeling for are any masses or lumps. I am also feeling/listening for something known as crepitus which is a crackling sensation that occurs if air has leaked out of the lungs and into the tissues." STATE FINDING: "I did not hear any crepitus or feel any masses. Did you feel any kind of pain during that?"

SECOND step of the POSTERIOR assessment.

PALPATION -------------------------- VERBALIZE PROCESS: "I am now going to lightly press around on your back. I want you to let me know if you feel any pain or tenderness." STATE FINDING: "I was feeling for any masses, lumps or crepitus and I did not feel any of that. Did you experience any pain as I palpated?"

On what side of the body do you begin with for the respiratory/pulmonary assessment?

The ANTERIOR side.