Documentation of problem based assessment of the respiratory system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of respiratory system. Identify abnormal findings.
Apply assessment techniques for the neurological and respiratory systems.
Content: Use of three sections:
· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
· Standard American English (correct grammar, punctuation, etc.)
Chapter 5: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book].
Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30.
Some important things to remember:
1. Auscultation of the lungs should be performed in a systematic manner, listening side to side, either right to left then right to left or right to left then left to right.
2. Be sure to listen to the full inspiration and expiration before moving the stethoscope to the next area so you don’t miss anything. There are often end expiratory wheezes, and you might miss them otherwise.
3. Have the client breathe through their mouth as this will lead to increased air flow. Watch for dizziness though.
4. Remember where lung tissue is located, There is a small amount above the clavicles, listen downward to about T10 posteriorly, down to the 6th rib anteriorly, and laterally to the 8th rib.
5. Consider the things that can interfere with sounds – do not listen over clothing (even though you may see it done all the time but it is poor practice). If the chest is hairy, try wetting the hair to decrease the crackling sound. Watch for the tubing bumping together, patient shivering, and your own breathing on the tubing.
When inspecting the respiratory system, the first thing that should be noted is the respiration.
· Is it smooth, even, regular, how deep are the breaths, and what is the rate?
· Is the person using accessory muscles (those in the neck region) to draw in air?
· Do you see any retractions (skin being pulled in between the ribs)?
· What is the client’s posture?
· Are they sitting upright or in a tripod position?
The tripod position allows for more leverage so the muscles involved in respiration can aid in expiration
· What is the client’s skin color?
· Are they pinkish, red, or cyanotic?
· Are the finger and toe nails clubbed?
· What shape is the chest?