HEAD TO TOE ASSESSMENT CHECKLIST 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.
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