Assessment & Reasoning Respiratory System

Keith Rischer RN Answers To Assessment & Reasoning Respiratory System

Keith Rischer RN Answers To Assessment & Reasoning Respiratory System

Assessment & Reasoning

Respiratory System

John Franklin, 35 years old

Suggested Respiratory Nursing Assessment Skills to Be Demonstrated: • Inspection: Client positioning – tripod, position of comfort; (face) nasal flaring, pursed lips, color of face, lips;

(posterior)level of scapula – rise evenly, use of accessory muscles anterior/posterior, sternal/intercostal

retractions. Quality and pattern of respirations.

Palpation: (posterior) down the back sequentially checking for tenderness/pain, warmth, crepitus & fremitus (best with ball of hand), chest wall expansion(symmetry) – thumbs over spine and fingers spread like butterfly

wings-pneumonia, pneumothorax. Assess for masses, bulges, muscle tone

• Percussion: Across and down back for resonance vs hyperresonance (pneumothorax), dullness (pneumonia). Avoid percussing over bone.

• Auscultation: Posterior – down the back sequentially from C7 (lung apex) to T10; anterior – above clavicles to sixth rib (xiphoid); flanks from axillae to 8th rib. Ladder type sequence moving right to left for comparison.

Listen for full inspirations and expiration.

• Palpation, percussion and auscultation follow same pattern and avoids scapula and spine (posterior) and mammary tissue (anteriorly) – assess as close to chest wall as possible. Compare left to right for aeration =

Make Learning Active! • Role play or go through the interview/body assessment process – student to student or as a group.

• Review the case study as an application exercise in small groups or together as a class.

• Depending on your program some of this content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Instead use it to promote learning by having students

identify what they do not yet know and provide guidance to where they can find the information in the

textbook or on the internet to address knowledge gaps. This is educational best practice and another way

to scaffold knowledge!


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