Nursing Respiratory Assessment Documentation Example

Nursing Respiratory Assessment Documentation: A Comprehensive Guide

Respiratory assessment is a cornerstone of nursing practice. Accurately documenting these assessments is crucial for effective patient care, clear communication among healthcare professionals, and legal protection. This comprehensive guide provides a detailed example of respiratory assessment documentation, along with explanations to ensure you understand the significance of each element. We'll cover key assessment components, best practices for documentation, and frequently asked questions to help you master this essential nursing skill.

I. Introduction: The Importance of Accurate Respiratory Assessment Documentation

Accurate and complete documentation of respiratory assessments is vital for several reasons:

• Continuity of Care: It provides a clear record of the patient's respiratory status over time, allowing healthcare providers to track progress, identify trends, and make informed decisions about treatment.
• Legal Protection: Thorough documentation protects nurses from potential legal ramifications by demonstrating that they provided appropriate care and met established standards.
• Communication: It facilitates effective communication among healthcare professionals involved in the patient's care, ensuring everyone is on the same page regarding the patient's respiratory condition.
• Quality Improvement: Data from respiratory assessments contribute to the ongoing evaluation and improvement of patient care within healthcare facilities.

II. Example of Nursing Respiratory Assessment Documentation

Let's consider a hypothetical patient, Mrs. Jane Doe, a 72-year-old female admitted with pneumonia. Below is an example of a thorough respiratory assessment documentation:

Patient: Jane Doe, 72-year-old female Date: October 26, 2023 Time: 0800

Subjective Data:

• Chief Complaint: "I've been coughing a lot and having trouble catching my breath for the past three days."
• History of Present Illness (HPI): Reports increasing shortness of breath (SOB) over the past three days, accompanied by a productive cough with greenish-yellow sputum. Denies chest pain. Reports feeling fatigued and weak. States she has a history of COPD.
• Past Medical History (PMH): Chronic Obstructive Pulmonary Disease (COPD), Hypertension, Type 2 Diabetes Mellitus.
• Medications: Albuterol inhaler (2 puffs q4h prn), Ipratropium bromide inhaler (2 puffs q6h prn), Prednisone 20mg daily, Metformin 1000mg BID, Lisinopril 20mg daily.
• Allergies: Penicillin (rash)
• Social History: Lives alone, smokes 1 pack of cigarettes per day (40-year history).

Objective Data:

• General Appearance: Appears slightly anxious and dyspneic. Sitting upright in bed. Skin is pale and cool to the touch.
• Vital Signs:
  • Temperature: 38.2°C (100.8°F) (oral)
  • Heart Rate: 110 bpm (tachycardia)
  • Respiratory Rate: 28 breaths/min (tachypnea)
  • Blood Pressure: 140/90 mmHg (hypertension)
  • SpO2: 88% on room air (hypoxemia)
• Respiratory Assessment:
  • Inspection: Use of accessory muscles (sternocleidomastoids and intercostals) noted during breathing. Slight nasal flaring observed. Patient appears to be working hard to breathe. No chest wall deformities noted.
  • Palpation: Tactile fremitus decreased bilaterally in the lower lung fields. Chest expansion slightly decreased on the right side. No palpable masses or tenderness.
  • Percussion: Dullness to percussion over the right lower lobe. Resonance over the remaining lung fields.
  • Auscultation: Crackles heard in the right lower lobe. Breath sounds diminished in the right lower lobe. Wheezing noted in the bilateral upper lobes.
• Other Pertinent Findings: Lung sounds are coarse and congested. Patient's cough is productive with thick, greenish-yellow sputum.

Assessment:

• Nursing Diagnosis: Ineffective airway clearance related to excessive secretions and inflammation secondary to pneumonia, as evidenced by productive cough with greenish-yellow sputum, crackles on auscultation, and increased respiratory rate and work of breathing. Impaired gas exchange related to alveolar-capillary membrane changes secondary to pneumonia, as evidenced by decreased SpO2 and use of accessory muscles. Activity intolerance related to oxygen deficit secondary to pneumonia, as evidenced by fatigue and shortness of breath.

Plan:

• Interventions: Administer oxygen therapy via nasal cannula at 2L/min. Encourage deep breathing and coughing exercises. Suction airway prn. Administer prescribed medications. Monitor vital signs and SpO2 frequently. Encourage increased fluid intake. Assess pain levels and provide comfort measures. Monitor for changes in respiratory status. Educate patient and family on respiratory care techniques and the importance of medication adherence.
• Expected Outcomes: Improved oxygen saturation (SpO2 > 92%), decreased respiratory rate (12-20 breaths/min), reduced use of accessory muscles, decreased shortness of breath, and improved cough production.

III. Key Components of a Thorough Respiratory Assessment

A complete respiratory assessment encompasses several key elements:

• Subjective Data: This involves gathering information directly from the patient, including their chief complaint, history of present illness, past medical history, medications, allergies, and social history. Pay close attention to the patient's description of their symptoms, including the onset, duration, character, and severity of their respiratory issues.

• Objective Data: This involves performing a physical examination of the respiratory system. This includes:

  • Inspection: Observe the patient's respiratory effort, including rate, rhythm, depth, and use of accessory muscles. Note any abnormalities in chest shape or movement. Look for signs of cyanosis or clubbing.
  • Palpation: Assess tactile fremitus (vibrations felt on the chest wall during speech), chest expansion, and tenderness.
  • Percussion: Tap the chest wall to assess the underlying lung tissue density. Note any areas of dullness or hyperresonance.
  • Auscultation: Listen to lung sounds using a stethoscope, noting the presence of normal breath sounds, adventitious sounds (e.g., crackles, wheezes, rhonchi, pleural rubs), and any abnormalities in breath sounds.

• Vital Signs: Monitor vital signs, including respiratory rate, heart rate, blood pressure, temperature, and oxygen saturation (SpO2). Changes in these vital signs can indicate a worsening respiratory condition.

• Assessment: This section involves analyzing the subjective and objective data to identify nursing diagnoses related to the patient's respiratory status. Use the Nursing Diagnoses (NANDA-I) taxonomy for accurate and consistent diagnoses.

• Plan: Develop a plan of care that includes specific interventions to address the identified nursing diagnoses. The plan should outline the goals of care and expected outcomes.

IV. Best Practices for Respiratory Assessment Documentation

• Use clear and concise language: Avoid medical jargon and use terms that are easily understood by all members of the healthcare team.
• Be specific and detailed: Provide specific details about the patient's symptoms, findings on physical examination, and interventions provided.
• Use standard abbreviations and terminology: Follow the guidelines of your healthcare facility for abbreviations and terminology.
• Document all assessments promptly: Document your assessments immediately after completing them to ensure accuracy and completeness.
• Chart chronologically: Document your findings in chronological order to provide a clear picture of the patient's respiratory status over time.
• Maintain confidentiality: Ensure that all documentation is confidential and protected from unauthorized access.
• Sign and date all entries: Sign and date all entries to establish accountability.
• Correct errors appropriately: If you make an error, correct it appropriately using the facility's established method. Never erase or obliterate original entries.

V. Frequently Asked Questions (FAQs)

• What are the normal ranges for respiratory rate, heart rate, and oxygen saturation? Normal respiratory rate for adults is 12-20 breaths/minute. Normal heart rate for adults is 60-100 bpm. Normal oxygen saturation (SpO2) is typically above 95%. However, these values can vary depending on the individual and their medical history.

• What are some common adventitious lung sounds and what do they indicate? Crackles (rales) indicate fluid in the airways, wheezes indicate narrowed airways, rhonchi indicate mucus in the larger airways, and pleural rubs indicate inflammation of the pleural space.

• How can I improve my skills in performing and documenting respiratory assessments? Practice regularly, seek feedback from experienced nurses, review relevant resources such as textbooks and online tutorials, and participate in continuing education opportunities focusing on respiratory assessment.

• What should I do if I notice a significant change in a patient's respiratory status? Immediately report any significant changes in the patient's respiratory status to the physician or nurse practitioner. Monitor the patient closely and implement appropriate interventions as ordered.

VI. Conclusion: Mastering Respiratory Assessment Documentation

Proficient respiratory assessment and documentation are essential skills for all nurses. By following the guidelines and examples provided in this article, nurses can improve their ability to provide safe, effective, and legally sound respiratory care. Remember that accurate and timely documentation is not merely a procedural requirement; it is a cornerstone of patient safety and the foundation for effective communication and collaboration within the healthcare team. Consistent practice and a commitment to accurate recording will help you become a confident and skilled respiratory assessor. The more experience you gain, the more readily you will be able to identify subtle changes in your patients’ condition, ensuring timely and effective intervention. Continuous learning and reflection on your practice are key to mastering this crucial skill.