respiratory assessment

respiratory assessment,

an evaluation of the condition and function of a person's respiratory system.

method The nurse or other health care provider asks if the person coughs; wheezes; is short of breath; tires easily; or experiences chest or abdominal pain, chills, fever, excessive sweating, dizziness, or swelling of feet and hands. Signs of confusion; anxiety; restlessness; flaring nostrils; cyanotic lips, gums, earlobes, or nails; clubbing of extremities; fever; anorexia; and a tendency to sit upright are noted if present. The person's breathing is closely observed for evidence of slow, rapid, irregular, shallow, or Cheyne-Stokes respiration; hyperventilation; and a long expiratory phase or periods of apnea, as well as for retractions in the suprasternal, supraclavicular, substernal, or intercostal areas during breathing. The presence of tachycardia, bradycardia, or sinus arrhythmia or evidence of congestive heart failure such as crackles, rhonchi, edema, hepatosplenomegaly, abdominal distension, or pain is recorded. The thorax is examined for scoliosis, kyphosis, funnel or barrel chest, or unequal shoulder height and is palpated for indications of thoracic expansion, tracheal deviation, crepitations, or fremitus. Percussion is performed to evaluate resonance, hyperresonance, tympany, and dull or flat sounds. Crackles, rhonchi, wheezing, friction rubs, the transmission of spoken words through the chest wall, and decreased or absent breath sounds are detected by auscultation. Background information pertinent to the evaluation includes allergies, recent exposure to infection, immunizations, exposure to environmental irritants, previous respiratory disorders and operations, preexisting chronic conditions, medication currently taken, the person's smoking habits, and the family history. Valuable diagnostic aids include a chest x-ray examination; complete blood count; electrocardiogram, pulmonary function tests, and bronchoscopy; determination of blood gases and electrolytes; studies of sputum, throat, or nasopharyngeal cultures; gastric washings; lung scans; and biopsies.

interventions The nurse or other health care provider collects the background information and the results of diagnostic tests and may perform the examination. In a respiratory care unit, a registered nurse, staff nurse, nurse clinician, or practitioner may interpret data from electrocardiographic tracings, set up and adjust a respirator, titrate medications, and obtain specimens for blood gas determination.

outcome criteria An accurate and thorough assessment of respiratory function is an essential component of the physical examination and is vital to the diagnosis or ongoing care of a respiratory illness.