13.18 : 呼吸评估 II

Begin the assessment by explaining the purpose of the assessment and obtaining informed consent.

The respiratory assessment involves assessing the anterior, posterior, and lateral thorax. First, observe for signs of respiratory distress or difficulty breathing.

Perform hand hygiene to avoid cross-infection. Provide a comfortable position to the patient.

Ask the patient about any history of respiratory problems, including asthma, chronic bronchitis, or emphysema.

Start the assessment by inspecting the patient's chest for symmetry in shape and movement with respiration.

Assess for cyanosis around the lips or nail beds, which may suggest low oxygen levels in the bloodstream. 

Next, palpate the chest wall for tenderness or abnormal expansion.

Then, percuss the chest to detect areas of dullness or hyperresonance, which could indicate a consolidation or pleural effusion.

Lastly, auscultate lungs with a stethoscope for abnormal breath sounds such as rhonchi, wheezes, or crackles, which may suggest airway obstruction or infection.

Replace the equipment and perform hand hygiene.

Document findings in the medical record.