Suggested Respiratorursing Assessmenty NSkills to Be Demonstrated: • Inspection: Client positioning – tripod, position of comfort; (face) nasal flaring, pursed lips, color of face, lips;
(posterior)level of scapula – rise evenly, use of accessory muscles anterior/posterior, sternal/intercostal
retractions. Quality and pattern of respirations.
• Palpation: (posterior) down the back sequentially checking for tenderness/pain, warmth, crepitus & fremitus (best with ball of hand), chest wall expansion(symmetry) – thumbs over spine and fingers spread like butterfly
wings-pneumonia, pneumothorax. Assess for masses, bulges, muscle tone
• Percussion: Across and down back for resonance vs hyperresonance (pneumothorax), dullness (pneumonia). Avoid percussing over bone.
• Auscultation: Posterior – down the back sequentially from C7 (lung apex) to T10; anterior – above clavicles to sixth rib (xiphoid); flanks from axillae to 8th rib. Ladder type sequence moving right to left for comparison.
Listen for full inspirations and expiration.
• Palpation, percussion and auscultation follow same pattern and avoids scapula and spine (posterior) and mammary tissue (anteriorly) – assess as close to chest wall as possible. Compare left to right for aeration =
Make Learning Active! • Role play or go through the interview/body assessment process – student to student or as a group.
• Review the case study as an application exercise in small groups or together as a class.
• Depending on your program some of this content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Instead use it to promote learning by having students
identify what they do not yet know and provide guidance to where they can find the information in the
textbook or on the internet to address knowledge gaps. This is educational best practice and another way
to scaffold knowledge!
© 2019 Keith Rischer/www.KeithRN.com
Present Problem: John Franklin is a 35-year-old African American male who has a history of hypertension and asthma who smokes ½ ppd since the age of eighteen. He began to feel more short of breath after supper today and began to have a persistent non-
productive cough. He ran out of his albuterol inhaler two months ago and has audible expiratory wheezing when he
comes to the triage window of the emergency department (ED).
John is promptly brought to a room in the ED and you are the nurse responsible for his care.
What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse? (