Nursing homework help

/in /by

Title:

Documentation of problem based assessment of the respiratory system.

 

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of respiratory system. Identify abnormal findings.

 

Course Competency:

Apply assessment techniques for the neurological and respiratory systems.

 

Instructions:

 

Content:  Use of three sections:

  • Subjective
  • Objective
  • Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Nursing homework help

ORDER A PLAGIARISM-FREE PAPER NOW

Format:

  • Standard American English (correct grammar, punctuation, etc.)

Resources:

Chapter 5: SOAP Notes: The subjective and objective portion only

Sullivan, D. D. (2012). Guide to clinical documentation.  [E-Book].

 

Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30.

 

Documentation Grading Rubric – 10 possible points

Levels of Achievement
Criteria Emerging Competence Proficiency Mastery
Subjective

(4 Pts)

 Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.

 

 Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
Points: 1 Points:  2 Points: 3 Points: 4
Objective

(4 Pts)

 Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”. Nursing homework help

 

 Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”.  Contains all objective information. May have signs of bias or explanation of findings. Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”.  No bias or explanation for findings evident Contains all objective information Includes all components of assessment for particular system. Detailed information provided.  Avoided use of words such as “normal”, “appropriate”, or “good”.  No bias or explanation for findings evident. All objective information
Points: 1 Points: 2 Points: 3 Points: 4
Actual or     Potential Risk Factors

(2 pts)

 

 Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Brief description of one or two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Points: 0.5 Points: 1 Points: 1.5 Points: 2

Some important things to remember:

  1. Auscultation of the lungs should be performed in a systematic manner, listening side to side, either right to left then right to left or right to left then left to right.
  2. Be sure to listen to the full inspiration and expiration before moving the stethoscope to the next area so you don’t miss anything. There are often end expiratory wheezes, and you might miss them otherwise.
  3. Have the client breathe through their mouth as this will lead to increased air flow. Watch for dizziness though.
  4. Remember where lung tissue is located, There is a small amount above the clavicles, listen downward to about T10 posteriorly, down to the 6th rib anteriorly, and laterally to the 8th rib.
  5. Consider the things that can interfere with sounds – do not listen over clothing (even though you may see it done all the time but it is poor practice). If the chest is hairy, try wetting the hair to decrease the crackling sound. Watch for the tubing bumping together, patient shivering, and your own breathing on the tubing.

When inspecting the respiratory system, the first thing that should be noted is the respiration.

  • Is it smooth, even, regular, how deep are the breaths, and what is the rate?
  • Is the person using accessory muscles (those in the neck region) to draw in air?
  • Do you see any retractions (skin being pulled in between the ribs)?
  • What is the client’s posture?
  • Are they sitting upright or in a tripod position?

The tripod position allows for more leverage so the muscles involved in respiration can aid in expiration

  • What is the client’s skin color?
  • Are they pinkish, red, or cyanotic?
  • Are the finger and toe nails clubbed?
  • What shape is the chest? Nursing homework help