NURS 258 Lecture Notes - Lecture 7: Pulse Oximetry, Sports Bra, Nursing Diagnosis
Respiratory Assessment
Learning Outcomes:
• Discuss changes in respiratory function & problems occurring throughout the
lifespan.
• Describe common manifestations of altered respiratory function.
• Discuss diagnostic tests used to assess respiratory function.
• List appropriate nursing interventions for altered respiratory function.
• Identify health promotion topics related to the respiratory system.
• Perform a complete nursing assessment of the respiratory system.
• Demonstrate correct techniques for inspection, palpation, and auscultation of the
respiratory system.
• Demonstrate proper use of a pulse oximeter.
• Record history and physical examination findings accurately, develop a nursing
diagnosis and specific client outcomes related to the assessment findings.
QSEN Competency Categories: Teamwork & Collaboration, Patient Centered Care,
Safety
Learner Level: Beginner
Preparation:
Reading:
• Jarvis: pp. 419 (start at developmental competence) – 425, 429-432, 435-439, Table
18-3, Table 18-8
• Potter:
• Oxygen Delivery Devices
o pp. 902-903 and Box 41-9
• Pulse Oximeter
o p. 502, Skill 30-3, Skill 30-4
• Incentive Spirometer
o p. 896, Skill 50-1
Bring to Lab:
• Laptop computer
• Watch with a second hand
• Stethoscope
• Appropriate clothing for assessment: Female- sports bra and shorts; Male- shorts
• Paper copy of case study found in D2L
• Notebook
Outline for Lecture Bring your stethoscope to lecture.
Respiratory Assessment
Subjective Data “what the pt. tells you”
1. Health Hx questions
• Shortness of breath – when did it start, how long has it lasted, activity or at rest, what
treatment has the pt. done
• Cough – coughing spells, how long does it last, productive, color of sputum, any blood,
and treatment
• Smoking Hx – how many years, how many packs per day/week, try to quit, what did they
try, did it work, educate the pt.
• PMH – past medical history, if they came in for respiratory if it happened in the past
Objective Data – measurable
1. Physical Exam
• Inspections
o Level of consciousness – awake, alert
o Facial expression – angry, sad
o Skin color & condition – pink, white, ashy (purple) dusky, cyanotic (blue),
cool/warm, clammy
o Rate – fast, accessory muscles used (not normally used in breathing)
o Rhythm – regular/irregular
o Quality - labored/unlabored
▪ Retractions – difficult time breathing (normally seen in kids)
▪ Subcostal – retracts below the ribs
▪ Intercostal – retracts in between the ribs
▪ May also occur near the collar bone
▪ Nasal Flaring – can see nostrils flare, child is having respiratory issues
o Thorax – chest expansion, shape,
▪ Anterior Posterior (AP) should be smaller than transverse or elliptical
o Trachea – midline, off center (on the side with less pressure)
• Auscultation
o Important points
▪ Sitting up
▪ Do not listen over clothing
▪ Deep breaths in/out mouth
▪ Listen each area for 1 full breath
▪ Compare right to left
