respiratory Assessment Flashcards
What are the four main components
Inspection, Palpation, Percussion, Auscultation
What do I need to look for in the end of bed assessment?
Positioning, Cyanosis, Audible wheeze, level of consciousness, environmental factors such as temperature, medication, overdose, home oxygen
Starting at the hands what are we looking for?
The colour - are they cyanosed, Is there any clubbing, Is there any tar staining, Do they have a Asterixis (flapping termour), Is there any Pallor of the palmer creases (indates aneamia), Do they have a fine tremor, Are there any skin changes, Any joint swelling or deformities.
At the Head and neck what dio we check for?
Conjuctive Pallor (indates aneamia which can cause SOB) - central cyanosis associated with hypoxaemia - Oral candidiasis (whir patches on the inner cheeks, tongue, roof of mouth, redness) - Check that the trachea is central - Check the lymph nodes for enlargement - Check the JVP.
What are we doing on inspection?
Look at the chest for symmetrical breathing, any bulging, scars, rashes, is it the right shape, do they use the accessory muscle?
Where do you palpate?
Palpate the anterior, posterior and axilla chest walls
How do you check the chest expansion?
Both hands should expand equally. Place hands on the chest wall and ask the patient to take a deep breath and the thumbs should move symmetrically
What areas of the chest should I percuss?
Suptaclavicular region (lung apices), Infraclavicular region, Chest wall (over 3-4 locations bilaterally), axilla.
What sounds are we looking for in auscultation?
Wheeze, Pleural rub (Creaking sound), Crackles, high pitched breath sound with hollow or blowing quality.
What is the last step after auscultation?
Check the rest of the body
What are we checking the rest of the body for?
Any odema, calf pain/swelling (indicates DVT) and the perfusion status (colour and warmth).
