1. Purpose.
    A. Detect both subtle and gross changes in respiratory function.
    B. Determine the adequacy of patient’s gas exchange as well as evaluate his response to respiratory therapy
    C. Provide safe, suppportive care protecting the patient from injury

2. Components of a respiratory assessment - on admission and at least every 4 hours:
    A. Identify the type of artificial airway and supplemental oxygen device.
         a. Verify against physician’s order
          b. Oxygen delivery device-proper type, functioning and settings
          c. Endotracheal or tracheal tube- size, position, stability and air leaks   
    B. Inspect respirations for depth, rhythm, rate and symmetry.
         a. Note use of accessory muscles and difficulty on inspiration or expiration
    C. Observe color, amount consistency and odor of sputum.
         a.Yellow or green with foul odor- suspect infectious process
          b.Frothy pink – suspect pulmonary edema         
          c. Hemoptysis- suspect bruising or bleeding in airways related to tumor, infectious process, vigorous coughing    
          d. Blood-tinged sputum – often result of aggressive airway suctioning   
    D. Palpate the chest and neck for presence of subcutaneous emphysema.   
    E. Auscultate lungs for equality of breath sounds and adventitious sounds. Unequal- suspect atelectasis, pneumothorax, hemothorax, tension pneumothorax, pleural effusion, or intubation of right mainstem bronchus. Adventitious breath sounds

1. Rales, also called crackles, are sounds produced when fluid or exudate is present on terminal bronchioles or alveoli; heard on inspiration; classified as fine, coarse or medium.

2. Rhonchi- are produced by passage of air through fluid-filled, narrow air passages; heard on inspiration and expiration; described as musical, squeaky, gurgling,rattling, high-pitched, or low pitched; wheeze (high pitched with musical or whistling tone during expiration)

3. Pleural friction rub- produced by pleural inflammation; on inspiration and expiration; described as rough or grating; varies with position.

F. Assess chest drainage system for proper functioning. (A chest tube removes air and fluid from the pleural space, allowing lung to reexpand.)

• Fluctuation with respirations- normal
• Air leak- can be detected in the water seal chamber
• Color and amount of drainage- monitor closely and report abnormal volumes or color changes to physician immediately
• Suction- maintain level as ordered

G. Document all pertinent information, teaching and patient response every shift

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2. Estimated FIO2 with various oxygen delivery systems.

3. Assess the effectiveness of oxygen therapy.

• Confusion or restlessness – first sign of hypoxia
• Tachypnea, shortness of breath, use of accessory muscles, central cyanosis are compensatory signs
• Check for complications – hypoventilation, absorption atelectasis, and oxygen toxicity.

4. Prepare for respiratory deterioration.

A. Have airway management equipment at the bedside

Oral airways

Oropharyngeal or nasopharyngeal airway

Resuscitation mask or ambu bag with appropriate size mask attached

Suction canister and suction catheters of appropriate size

Be familiar with unit/hospital crash cart and emergency transport box supplies

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