Respiratory Assessment Flashcards
Area of Assessment to focus on (respiratory)
- How are they seated?
- How fast are they breathing?
- Are they speaking in complete sentences?
- What is their mental status?
- What is their ETCO2?
- What is their SPO2?
- What are their lung sounds?
- How loud are their lung sounds?
How is auscultation performed?
In a ladder fashion
1. Apices
2. Superior lobes
3. Inferior lobes
4. Lung bases
Treatment considerations for Respiratory Patients
- O2
- Bronchodilators via MDI
- Bronchodilators via nebulizer
- Bronchodilators via MDI with BVM
- Advanced airway placement
- ALS support
Priorities for reassessment in Respiratory Patients
- Positioning
- Should speak in complete sentences
- LOC should normalize
- Lung sounds should be easier to hear
- Wheezes should start to go away
- ETCO2 should trend back to normal
- SpO2 should trend back towards 100%
Stages of Respiratory Distress
Stage 1: Respiratory Distress
Stage 2: Increased Respiratory Distress
Stage 3: Worsening Respiratory Distress
Stage 4: Worsening Respiratory Distress
Physical findings for stage 1 of respiratory distress
- Tracking your entry
- Relaxed in a neutral position with little anxiety noted
- Lungs sounds are loud
- Slight increased WOB
- Speaking near complete sentences
Physical findings for stage 2 of respiratory distress
- Tracking your entry
- Maintaining muscle tone in whatever position found but not relaxed
- lung sounds are still loud
- A little breathless when speaking
Physical findings for stage 3 of respiratory distress
- Aware of your presence but focusing on breathing
- Mental status appears drowsy, tired, lethargic
- Difficulties following instructions without help
- Lung sounds harder to hear
- Increased WOB
- If speaking, 2-3 word sentences
Physical findings for stage 4 of respiratory distress
- Head bobbing
- Not paying attention to you
- Head is rolling around without purpose
- Unaware of what’s happening to them
- Lung sounds are silent!
- Increased WOB
- Cannot speak (DO NOT MAKE THEM)
What do wheezes mean?
- Swelling is present in the bronchial tree
- Mucous present in the alveoli
Differential diagnosis regarding Wheezes
- Asthma
- Exacerbation of COPD
- Anaphylaxis
- Pneumonia
- Lower airway burn
Risk Factors of Asthma
- Allergies
- Exercise induced
- Smoking
- Common cold
- Emotions
Assessment finding for Asthma
- Chest tightness, worse with deep breath
- Auscultation: Wheezes
- Increased WOB seen
- Difficulties speaking
- tripod position or arms lifted away from body
Risk Factors for Exacerbated COPD
- Adults
- Occupational exposure
- Asbestos exposure
- Air pollutants
- Asthma
- Genetics
Assessment finding for Exacerbated COPD
- Chest tightness, worse with deep breathe
- Auscultation: Wheezes
- Increased WOB seen
- Difficulties speaking
- Barrel Chested and performing self PEEP
- Tripod position or arms lifted away from body
