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Documentation of Respiratory Assessment Reason for Visit & Health History
You will perform a history of a respiratory problem that either your instructor has provided you or one that you have experienced and perform a respiratory assessment. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.
Documentation of Respiratory Assessment
Reason for Visit:
- Do you have any cough?
- Do you have any shortness of breath?
- Do you experience any chest pain with breathing?
- Do you have any history of lung diseases?
- Do you or have you ever smoked cigarettes?
- When did you start?
- How many per day?
- Have you tried to quit?
- Do you have any living or work conditions that affect your breathing?
- When was your last TB skin test and flu vaccine?
- Inspect thoracic cage for symmetry and deformities
- Inspect respiratory rate and pattern
- Inspect skin and nails (any clubbing?)
- Inspect position and facial expression.
- Assess level of consciousness.
- Confirm symtetric chest expansion.
- Palpate for tactile fremitus.
- Palpate skin temp and moisture.
- Palpate for any lumps masses or tenderness in the thorax area.
- Percuss over lung fields and note any differences.
- Anterior lung sounds (at least 8 places)
- Posterior lung sounds (at least 8 places)
- Axillary (two on each side)
- Note any adventitious lung sounds.
- Assessment of risks and plan (at least two risks)
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