Documentation of Respiratory Assessment

ocumentation of Respiratory Assessment

Examiner:

Date:

Patient:

Reason for Visit:

Health History

1.      Do you have any cough?

2.      Do you have any shortness of breath?

3.      Do you experience any chest pain with breathing?

4.      Do you have any history of lung diseases?

5.      Do you or have you ever smoked cigarettes?

a.       When did you start?

b.      How many per day?

c.       Have you tried to quit?

6.      Do you have any living or work conditions that affect your breathing?

7.      When was your last TB skin test and flu vaccine?

Physical Assessment

1.      Inspection

a.       Inspect thoracic cage for symmetry and deformities

b.      Inspect respiratory rate and pattern

c.       Inspect skin and nails (any clubbing?)

d.      Inspect position and facial expression.

e.       Assess level of consciousness.

2.      Palpation

a.       Confirm symtetric chest expansion.

b.      Palpate for tactile fremitus.

c.       Palpate skin temp and moisture.

d.      Palpate for any lumps masses or tenderness in the thorax area.

3.      Percussion

a.       Percuss over lung fields and note any differences.

4.      Auscultation

a.       Anterior lung sounds (at least 8 places)

b.      Posterior lung sounds (at least 8 places)

c.       Axillary (two on each side)

d.      Bronchophony/egophony

e.       Note any adventitious lung sounds.

Regional Write-up

1.      Subjective

2.      Objective

3.      Assessment of risks and plan (at least two risks)