Pulmonary System

Steve Williams is a patient currently in the hospital. He suffers from Chronic Obstructive Pulmonary Disease.

Inpatient Hospital Room

1. Identify the components of a focused respiratory assessment, including inspection, palpation, percussion (if applicable), and auscultation.
2. Perform a systematic pulmonary assessment, observing respiratory rate, rhythm, depth, use of accessory muscles, and chest expansion.
3. Auscultate breath sounds in anterior and posterior lung fields, identifying normal (vesicular, bronchial, bronchovesicular) and abnormal sounds (e.g., crackles, wheezes, rhonchi, stridor).
4. Assess for signs of respiratory distress, including cyanosis, nasal flaring, intercostal retractions, or altered level of consciousness.
5. Use therapeutic communication to explain the procedure, promote comfort, and inquire about respiratory history or current symptoms.
6. Identify and report abnormal findings that may require further evaluation or intervention.
7. Document assessment findings accurately, including respiratory rate, oxygen saturation, lung sounds, and any deviations from baseline.

1. Demonstrate accurate technique in auscultating all appropriate lung fields.
2. Recognize and describe abnormal breath sounds and correlate with potential respiratory conditions.
3. Identify signs of respiratory distress and communicate findings to the instructor or provider using SBAR.
4. Engage in patient-centered communication, asking about dyspnea, cough, smoking history, and recent illness.
5. Monitor oxygen saturation using a pulse oximeter and interpret results within the context of clinical assessment.
6. Document all findings thoroughly in narrative or charting tool, including subjective and objective data.