I’m working on a nursing case study and need an explanation to help me learn.Documentation of Respiratory
AssessmentundefinedReason for Visit:undefinedHealth HistoryundefinedDo you have any cough?
Do you have any shortness of breath?
Do you experience any chest pain with breathing?
Do you have any history of lung diseases?
Do you or have you ever smoked cigarettes?When did you start?
How many per day?
Have you tried to quit?
Do you have any living or work conditions that affect your breathing?
When was your last TB skin test and flu vaccine?
undefinedPhysical AssessmentundefinedInspectionInspect thoracic cage for symmetry and deformities
Inspect respiratory rate and pattern
Inspect skin and nails (any clubbing?)
Inspect position and facial expression.
Assess level of consciousness.
PalpationConfirm symtetric chest expansion.
Palpate for tactile fremitus.
Palpate skin temp and moisture.
Palpate for any lumps masses or tenderness in the thorax area.
PercussionPercuss over lung fields and note any differences.
AuscultationAnterior lung sounds (at least 8 places)
Posterior lung sounds (at least 8 places)
Axillary (two on each side)
Bronchophony/egophony
Note any adventitious lung sounds.
undefinedRegional Write-upundefinedSubjective
Objective
Assessment of risks and plan (at least two risks)
Requirements: 2-3 pages