Respiratory System Assessment for Nurses Cheat Sheet
Your Ultimate Guide to the Nursing Respiratory Assessment + a FREE Cheat Sheet!
Respiratory System:
Respiratory illness in children is common and many other conditions may also cause respiratory distress. Assessment of severity of respiratory conditions
Respiratory assessment includes:
History
- Onset + duration of symptoms cough / shortness of Breath
- Triggers ( dust / aerosol / pollen)
Inspection/Observation
- Observe the overall appearance of the child: alert, orientated, active/hyperactive/drowsy, irritable.
- Colour(centrally and peripherally): pink, flushed, pale, mottled, cyanosed , clubbing
- Respiratory rate, rhythm and depth (shallow, normal or deep)
- Respiratory effort (Work of Breathing -WOB): mild, moderate, severe, inspiratory: expiratory ratio, shortness of breath
- Use of accessory muscles (UOAM): intercostal/subcostal/suprasternal/supraclavicular/substernal retractions, head bob, nasal flaring, tracheal tug.
- Symmetry and shape of chest
- Tracheal position
- Audible sounds: vocalisation, wheeze, stridor, grunt, cough – productive/paroxysmal
- Monitor for oxygen saturation
Auscultation
- Listen for absence /equality of breath sounds
- Auscultate lung fields for bilateral adventitious noises e.g.: wheeze, crackles, stridor etc.
Palpation
- Bilateral symmetry of chest expansion
- Skin condition – temperature, turgor and moisture
- capillary refill (central/peripheral)
- Fremitus (tactile)
- Subcutaneous emphysema
- air to the lungs (bronchitis)
