Respiratory Assessment

Question 1

Give therapeutic interaction.

Answer 1

Hi (insert the patients name here), I’m (insert your name here) and I’m a student nurse that will be looking after you today. Would it be ok for me to do a respiratory assessment on you today? Great it will involve me touching and listening to both your front and back chest area and asking you some questions as well as checking your vital signs: B.P, spO2, T.P.R. This will require you to wear a gown so I can access your chest area (and if you are a female, removing your bra). I will just go gather my equipment and perform my hand hygiene while you get changed. Be back soon.

Question 2

What equipment would you need?

Answer 2

Stethoscope, thermometer, pulse oximeter,

Question 3

What subjective data would you be asking?

Answer 3

Surgical Hx
Medical Hx:
Cough- colour, smell, sound, duration, anything make it better or worse
Shortness of breath
Chest pain with breathing
History of respiratory infections
Social Hx: smoking Hx, drug Hx
Work environment: dust/occupational/asthma/silica/asbestos
Home environment: air pollution/smoke/allergens
Hobbies/leisure: bird breeding/ woodwork/scuba

Question 4

List the 3 breathing sounds you would here.

Answer 4

Bronchial breath sounds - loudest sound
Bronchialvesicular breath sounds - medium sound
Vesicular breath sounds - quieter sound

Question 5

List the adventitious sounds.

Answer 5

There are 3 adventitious sounds which are:
Crackles
Wheeze
Atelectatic crackles = (alveoli collapsed)

Question 6

In your objective data (physical exam) INSPECTION of the anterior, lateral and posterior chest what would you be doing?

Answer 6

You would be inspecting:
The thoracic cage - for shape and configuration of the chest wall.
The position of the person -  upright, tripod position
Skin colour and condition
Facial expression
Level of consciousness
Rib interspaces
Use of accessory muscles
Respiration rate and oximetry

Question 7

List the objective data (physical exam) when you PALPATE the anterior, lateral and posterior chest.

Answer 7

You would palpate:
The symmetrical expansion
The entire chest wall

Question 8

When conducting your objective data (physical exam) what are you doing when you AUSCULTATE the anterior, lateral and posterior chest?

Answer 8

Listening to different points on the lateral, anterior and posterior chest through one full respiration on each point.

Question 9

List the indications for conducting a Respiratory assessment.

Answer 9

To establish a baseline for subsequent comparison.

Those who may be under the influence of drugs or alcohol

Question 10

Identify the indications for performing a Respiratory assessment.

Answer 10

To establish a baseline.

Question 11

What would you say for your therapeutic interaction?

Answer 11

Hi (insert patients name), I’m (insert your name) and I will be your nurse for today.Would you mind if I conduct a Respiratory assessment on you today? This will involve me getting some respiratory history from you, listening to your the front and back of your chest and doing some observations on you like SPO2, pulse, Respirations. I will need you to dress in a gown (if female it will require you removing your bra) so that I can access your chest area. Great, I will just go gather my equipment and wash my hands while you change.