Health Medical Homework Help

Documentation of Respiratory Assessment

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Reason for Visit:

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Health History

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• 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?

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Physical Assessment

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• Inspection
  • 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.
• Palpation
  • Confirm symtetric chest expansion.
  • Palpate for tactile fremitus.
  • Palpate skin temp and moisture.
  • Palpate for any lumps masses or tenderness in the thorax area.
• Percussion
  • Percuss over lung fields and note any differences.
• Auscultation
  • Anterior lung sounds (at least 8 places)
  • Posterior lung sounds (at least 8 places)
  • Axillary (two on each side)
  • Bronchophony/egophony
  • Note any adventitious lung sounds.

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Regional Write-up

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• Subjective
• Objective
• Assessment of risks and plan (at least two risks)