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NUR 2180 Rasmussen University Mod 8 Health History Discussion

 

Documentation of Respiratory Assessment

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Reason for Visit:

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Health History

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  • Do 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?

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Physical Assessment

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  • Inspection
    • Inspect 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.
  • Palpation
    • Confirm symtetric chest expansion.
    • Palpate for tactile fremitus.
    • Palpate skin temp and moisture.
    • Palpate for any lumps masses or tenderness in the thorax area.
  • Percussion
    • Percuss over lung fields and note any differences.
  • Auscultation
    • Anterior 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.

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Regional Write-up

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  • Subjective
  • Objective
  • Assessment of risks and plan (at least two risks)

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