10.3 Respiratory Assessment
Open Resources for Nursing (Open RN)
With an understanding of the basic structures and primary functions of the respiratory system, the nurse collects subjective and objective data to perform a focused respiratory assessment.
Subjective Assessment
Collect data using interview questions, paying particular attention to what the patient is reporting. The interview should include questions regarding any current and past history of respiratory health conditions or illnesses, medications, and reported symptoms. Consider the patient’s age, gender, family history, race, culture, environmental factors, and current health practices when gathering subjective data. The information discovered during the interview process guides the physical exam and subsequent patient education. See Table 10.3a for sample interview questions to use during a focused respiratory assessment.[1]
Table 10.3a Interview Questions for Subjective Assessment of the Respiratory System
| Interview Questions | Follow-up |
|---|---|
| Have you ever been diagnosed with a respiratory condition, such as asthma, COPD, pneumonia, or allergies?
Do you use oxygen or peak flow meter? Do you use home respiratory equipment like CPAP, BiPAP, or nebulizer devices? |
Please describe the conditions and treatments. |
| Are you currently taking any medications, herbs, or supplements for respiratory concerns? | Please identify what you are taking and the purpose of each. |
| Have you had any feelings of breathlessness (dyspnea)? | Note: If the shortness of breath is severe or associated with chest pain, discontinue the interview and obtain emergency assistance.
Are you having any shortness of breath now? If yes, please rate the shortness of breath from 0-10 with “0” being none and “10” being severe? Does anything bring on the shortness of breath (such as activity, animals, food, or dust)? If activity causes the shortness of breath, how much exertion is required to bring on the shortness of breath? When did the shortness of breath start? Is the shortness of breath associated with chest pain or discomfort? How long does the shortness of breath last? What makes the shortness of breath go away? Is the shortness of breath related to a position, like lying down? Do you sleep in a recliner or upright in bed? Do you wake up at night feeling short of breath? How many pillows do you sleep on? How does the shortness of breath affect your daily activities? |
| Do you have a cough? | When you cough, do you bring up anything? What color is the phlegm?
Do you cough up any blood (hemoptysis)? Do you have any associated symptoms with the cough such as fever, chills, or night sweats? How long have you had the cough? Does anything bring on the cough (such as activity, dust, animals, or change in position)? What have you used to treat the cough? Has it been effective? |
| Do you smoke or vape? | What products do you smoke/vape? If cigarettes are smoked, how many packs a day do you smoke?
How long h