Head to toe assessment checklist copd full#

Do they smoke? If so, what and how much?.

Is sputum present? If so what is the amount, colour, and consistency? Is this normal?.

Does the person experience trouble with breathing or shortness of breath? People with chronic respiratory disease often use one or more inhaled medications.

Ask about use of respiratory medications.

Presence of these may provide insight into explaining other respiratory assessment findings.

If you don’t already know, ask about respiratory diseases (COPD, asthma, cystic fibrosis).

If sputum is present, observe or inquire about amount, colour, and consistency. Observe and ask if the cough is a concern for the patient. Reasons for coughing might include bacterial or viral infection, aspiration, or presence of sputum. The nurse might observe coughing and expectorated sputum.

The nurse should always consider what interventions they can implement independently and what interventions have been ordered by the authorized prescriber to relieve impaired oxygenation. Wheezing may indicate bronchoconstriction related to asthma, bronchitis, or emphysema.įriction rub (creaking) may indicate inflammation related to pleurisy. If such things are affecting the patient negatively, intervention is needed.Ĭrackles may indicated mucous related to asthma or chronic obstructive pulmonary disease (COPD), or fluid related to pulmonary edema. The presence of crackles or wheezing must be further assessed, documented, and reported. Assess bilaterally comparing one side with the other in a systematic fashion.ĭiminished air entry may indicate atelectasis, pneumonia, hemothorax, pneumothorax, or collapsed lung. Use a stethoscope to auscultate breath sounds anterior and posterior for quality of air entry and any adventitious sounds. The more Hgb that is saturated with oxygen, the higher the SpO 2, which should normally measure above 95% oxygen saturation (SpO 2) (Perry et al., 2018). Pulse Oximetry: Consists of a probe with a light-emitting diode (LED) attached to the patient’s finger, forehead, or ear. Beams of red and infrared light are emitted from the LED, and the light wavelengths are absorbed differently by the oxygenated and the deoxygenated hemoglobin (Hgb) molecules. The receiving sensor measures the amount of light absorbed by the oxygenated and deoxygenated Hgb in the arterial (pulsatile) blood. If a patient’s respiratory status is stable, it may be appropriate to count respirations for 30 seconds and multiply by two to determine respiratory rate. Normal respiratory rate (interpreted as respirations per minute): Likewise, placing your hand on the patient’s chest and counting the rise / fall cycles Assessing respiratory rate.

Head to toe assessment checklist copd full#

One way to do this is to palpate radial pulse for a full minute but use some of that time to count respirations. If not, consider if this is a new or pre-existing condition.Ĭhest expansion may be asymmetrical with conditions such as atelectasis, pneumonia, fractured ribs, pneumothorax, or hemothorax.Īssess respiratory rate by inconspicuously observing breathing. The chest wall should expand and contract symmetrically. Some agencies use the following for objectively assessing respiratory distress and work of breathing (see page 22):.Unusual findings should be followed up with a focused respiratory assessment. Increased work of breathing may indicate respiratory compromise and impaired oxygenation caused by things like acute airway obstruction, pulmonary edema, atelectasis, and others. Likewise they may not appear distressed, depending on the severity and other comorbidities. The patient may appear distressed and/or feel anxious. Increased work of breathing is often associated with an increased respiratory rate. Increased work of breathing may be observed through a spectrum of responses including a small amount of nasal flaring through to use of all accessory muscles. Figure 2.10 Observe for work of breathing Observe the work of breathing including use of accessory muscles. Objective Data The data that we can observe with our senses. Document according to agency guidelines.Use appropriate listening and questioning skills.Be organized and systematic in your assessment.Confirm patient ID using two patient identifiers (e.g., name and date of birth).Checklist 17: Chest / Respiratory Assessment Figure 2.9 Respiratory System Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill. 2.7 Head-to-Toe Assessment: Chest / Respiratory AssessmentĬhecklist 17 provides a guide for subjective and objective data collection in a respiratory assessment.