How do you document a normal lung assessment?

How do you document a normal lung assessment?

Documentation of a basic, normal respiratory exam should look something along the lines of the following: The chest wall is symmetric, without deformity, and is atraumatic in appearance. No tenderness is appreciated upon palpation of the chest wall. The patient does not exhibit signs of respiratory distress.

What is a normal respiratory assessment?

A respiratory rate of 12-18 breaths per minute in a healthy adult is considered normal (Blows, 2001). Tachypnoea: the rate is regular but over 20 breaths per minute. Bradypnoea: the rate is regular but less than 12 breaths per minute.

How do you describe lung assessment?

A thorough respiratory assessment consists of inspection, palpation, percussion, and auscultation in conjunction with a comprehensive health history. Use a systematic approach and compare findings between left and right so the patient serves as his own control. If possible, have him sit up.

How do you do a full respiratory assessment?


  1. Check the rate of respiration.
  2. Look for abnormalities in the shape of the patient’s chest.
  3. Ask about shortness of breath and watch for signs of labored breathing.
  4. Check the patient’s pulse and blood pressure.
  5. Assess oxygen saturation. If it is below 90 percent, the patient likely needs oxygen.

What is a normal feature of the right lung that the nurse should be aware of?

What is a normal feature of the right lung that the nurse should be aware of? The right lung is shorter than the left lung because of the presence of the liver, which sits just under the right lung. The right lung has three, not two, lobes: an upper, middle, and lower lobe.

How do you write a respiratory assessment?

What is respiration rate and what are normal ranges?

Respiratory rate: A person’s respiratory rate is the number of breaths you take per minute. The normal respiration rate for an adult at rest is 12 to 20 breaths per minute. A respiration rate under 12 or over 25 breaths per minute while resting is considered abnormal.

What is included in a nursing respiratory assessment?

The ability to carry out and document a full respiratory assessment is an essential skill for all nurses. The elements included are: an initial assessment, history taking, inspection, palpation, percussion, auscultation and further investigations.

What do nurses need to know about lung assessment?

The nursing assessment skill of assessing lungs sounds is an important part of the nursing head-to-toe assessment. The nurses is assessing for normal breath sounds vs abnormal breath sounds (which includes crackles, wheezes, pleural friction rub, stridor etc).

What do you need to know about chest assessment?

This assessment is part of the nursing head-to-toe assessment you have to perform in nursing school and on the job. During the chest assessment you will be assessing the following structures: Overall appearance of the chest. Lung Sounds: includes abnormal lung sounds. Heart Sounds.

What is a nursing health assessment of the respiratory system?

of the Respiratory System. A nursing health assessment of the respiratory system involves the examination of the thorax and the lungs. A respiratory assessment is performed as part of a routine head-to-toe assessment. At times a more focused assessment of the respiratory system is necessary.

Which is the best measure of lung function?

Vital capacity (VC) is another useful measure in determining patients’ lung status. Forced vital capacity (FVC) represents the total amount of air exhaled at force from a maximum inhalation (total lung capacity) to maximum exhalation (residual volume), measured against time.

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