Checklist for Respiratory Assessment

Use the checklist below to review the steps for completion of a “Respiratory Assessment.”^[1]

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1. Gather supplies: stethoscope and pulse oximeter.
2. Perform safety steps:
   • Perform hand hygiene.
   • Check the room for transmission-based precautions.
   • Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
   • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
   • Explain the process to the patient and ask if they have any questions.
   • Be organized and systematic.
   • Use appropriate listening and questioning skills.
   • Listen and attend to patient cues.
   • Ensure the patient’s privacy and dignity.
   • Assess ABCs.
3. Obtain subjective data related to history of respiratory diseases, current symptoms, medications, and history of smoking using the suggested interview questions in Table 10.3a.
4. Obtain and analyze vital signs, including the pulse oximetry reading. Act appropriately on unexpected findings outside the normal range.
5. Assist the patient to a seated position if tolerated. Provide privacy while exposing only those areas of assessment.
   • Assess level of consciousness for signs of hypoxia/hypercapnia
   • Count respiratory rate for one minute
   • Observe respirations for rhythm pattern, depth, symmetry, and work of breathing
   • Observe configuration and symmetry of the chest. Compare anterior-posterior diameter to the transverse diameter
   • Inspect skin color lips, face, hands, and feet

   Note that early signs of hypoxia may include anxiety, confusion, restlessness, change in mental status, and/or level of consciousness (LOC).

6. Palpate:
   • Inspect anterior/posterior chest wall for areas of tenderness, crepitus, lumps, or masses
   • Compare for bilaterally equal chest expansion
7. Auscultate: Use correct stethoscope placement directly on the skin over designated auscultation areas. Identify any adventitious sounds.
8. Assist the patient back to a comfortable position, ask if they have any questions, and thank them for their time.
9. Ensure safety measures when leaving the room:
   • CALL LIGHT: Within reach
   • BED: Low and locked (in lowest position and brakes on)
   • SIDE RAILS: Secured
   • TABLE: Within reach
   • ROOM: Risk-free for falls (scan room and clear any obstacles)
10. Perform hand hygiene.
11. Document the assessment findings. Report any concerns according to agency policy.