Documentation of problem based assessment of the respiratory sys ✓ Solved

Documentation of problem based assessment of the respiratory sys

Learn the required components of documenting a problem based subjective and objective assessment of the respiratory system. Identify abnormal findings. Apply assessment techniques for the neurological and respiratory systems. Use three sections: Subjective, Objective, and Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Paper For Above Instructions

The respiratory system plays a crucial role in maintaining the overall health of an individual. In clinical practice, documenting assessments accurately is essential for patient safety and effective care delivery. This paper provides a problem-based assessment of the respiratory system, detailing subjective and objective findings, as well as identifying potential risk factors.

Subjective Assessment

Subjective data is gathered through patient interviews and reflects the patient's experiences and perceptions regarding their respiratory health. It is important to collect comprehensive biographic data, including the patient's age, gender, and medical history, which may contribute to respiratory issues. For instance, a 65-year-old male with a history of smoking and chronic obstructive pulmonary disease (COPD) might report shortness of breath, chest tightness, and a productive cough. He may describe the frequency and nature of his symptoms using the PQRSTU method:

  • Pain: Describes a sensation of tightness in the chest.

  • Quality: Characterizes the cough as wet with yellowish sputum.

  • Region: Symptoms localized in the chest area.

  • Severity: Rates the shortness of breath as a 6 out of 10.

  • Timing: Symptoms occur mostly in the morning.

  • Understanding: Patient indicates feeling anxious when experiencing shortness of breath.

Additionally, the patient has allergies to dust and molds, which may exacerbate his symptoms. Documenting medications like bronchodilators and corticosteroids used for management is critical and should be included in the assessment.

Objective Assessment

The objective assessment involves physical examination and diagnostic tests performed by healthcare professionals. Vital signs should be measured, including respiratory rate, oxygen saturation, and heart rate. For instance, the patient may demonstrate:

  • Respiratory rate: 24 breaths per minute, indicating tachypnea.

  • Oxygen saturation: 88% on room air, suggesting hypoxemia.

  • Using accessory muscles while breathing, indicating increased work of breathing.

Upon auscultation, abnormal lung sounds such as wheezes or crackles may be present, indicating airway obstruction or fluid in the alveoli. Further objective evaluations, such as chest X-rays or pulmonary function tests, can be utilized to assess lung function and detect abnormalities like hyperinflation or signs of infection.

Actual or Potential Risk Factors

Identifying actual or potential risk factors is crucial in formulating a comprehensive care plan. Based on the aforementioned assessment findings, the following factors may be identified:

  • Smoking History: The patient's long-term smoking increases the risk of developing lung cancer and exacerbating COPD-related symptoms.

  • Environmental Allergens: Allergies to dust and molds may lead to increased respiratory distress and asthma exacerbations, necessitating individualized environmental control measures.

A thorough description of these risk factors aids in understanding the patient's condition and tailoring interventions to mitigate these risks. For example, smoking cessation programs and education about allergens in the home can significantly improve respiratory health outcomes.

Conclusion

Effective documentation of the respiratory assessment is imperative in clinical practice. Accurate subjective and objective findings, along with identification of risk factors, facilitate the provision of appropriate patient care and management strategies. By employing techniques such as the PQRSTU method and maintaining precision in language during documentation, healthcare professionals can enhance communication and comprehension among care teams.

References

  • 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.

  • American Lung Association. (2021). Understanding COPD. Retrieved from https://www.lung.org

  • National Heart, Lung, and Blood Institute. (2020). Asthma. Retrieved from https://www.nhlbi.nih.gov

  • Centers for Disease Control and Prevention. (2020). Smoking and Respiratory Disease. Retrieved from https://www.cdc.gov

  • Bateman, E. D., & Eisenthal, A. (2020). Evidence-Based Approaches to Managing COPD. Journal of Respiratory Medicine, 164(1), 31-45.

  • Gold, P. M., & Celli, B. R. (2017). Global Strategy for the Diagnosis, Management, and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease.

  • Hernandez, P., et al. (2019). Use of assessment tools in managing respiratory diseases. Respiratory Therapy, 20(3), 160-170.

  • Schroeder, J. R. (2018). Documentation in nursing: Essentials and best practices. Nursing Clinics of North America, 53(1), 1-12.

  • American Academy of Family Physicians. (2020). Encounter Documentation. Retrieved from https://www.aafp.org