Use the checklist below to review the steps for completion of a “Respiratory Assessment.”
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: stethoscope and pulse oximeter.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs.
- Obtain subjective data related to history of respiratory diseases, current symptoms, medications, and history of smoking using the suggested interview questions in Table 10.3a.
- Obtain and analyze vital signs, including the pulse oximetry reading. Act appropriately on unexpected findings outside the normal range.
- Assist the patient to a seated position if tolerated. Provide privacy while exposing only those areas of assessment.
- Assess level of consciousness for signs of hypoxia/hypercapnia
- Count respiratory rate for one minute
- Observe respirations for rhythm pattern, depth, symmetry, and work of breathing
- Observe configuration and symmetry of the chest. Compare anterior-posterior diameter to the transverse diameter
- Inspect skin color lips, face, hands, and feet
Note that early signs of hypoxia may include anxiety, confusion, restlessness, change in mental status, and/or level of consciousness (LOC).
- Inspect anterior/posterior chest wall for areas of tenderness, crepitus, lumps, or masses
- Compare for bilaterally equal chest expansion
- Auscultate: Use correct stethoscope placement directly on the skin over designated auscultation areas. Identify any adventitious sounds.
- Assist the patient back to a comfortable position, ask if they have any questions, and thank them for their time.
- Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Perform hand hygiene.
- Document the assessment findings. Report any concerns according to agency policy.