Saturday, March 6, 2010

Selected Areas of Care - Respiratory Assessment

Respiratory Assessment RN CEU Link 
Respiratory Assessment

  1. Complies with established guidelines
  2. Positions the patient to faciliatate assessment
  3. Assesses the patient's respiratory status by
    • Instructing the patient specifically to breathe in and out as deeply as possible
    • Auscultating breath sounds over upper and lower lobes by systematically moving the stethoscope from side to side
    • Observing breathing patterns
    • Meassuring oxygen saturation, when assigned
  4. Records data related to
    • Comparison of breathing sounds bilaterally
    • Abnormal breathing patterns
    • Oxygen saturation, when assigned
Mnemonics -

PAIR of lungs (respiratory assessment)
Position patient
Assess the rate rhythm, accessory muscle use, and pattern
Instruct to deep breath

HAIR, or pair of hairy lungs (respiratory managgement) you must do the respiratory assessment first
How did the patient tolerate deep breathing?
Always perform deep breathing and cough
Incentive Spirometry (if assigned)
Re-assess after deep breathing/cough/IS

If you are assigned oxygen management -

SOAPI (soapy tire with air bubbles coming out the top)
Skin assessment - check the skin around the canula, face mask, ears, it red? intact?
Oxygen status - O2 saturation or capillary refill
Activity level - assess patient's response to activity, tired? short of breath?
Postion patient to help facilitate breathing
Ignition sources

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