ABSTRACT

When performing a respiratory assessment, the patient should be positioned upright (wherever possible). This position not only facilitates lung expansion, but also enables access to the anterior and posterior thorax, enabling assessment of accessory muscles. Alternative positions may distort findings and will need to be acknowledged (in the documentation) and when interpreting data. If appropriate, remove the patient’s clothing, as this may act as a barrier to visible and possible audible (auscultation) assessment, possibly distorting findings. Some patients may be aware that their respiratory function is being assessed and this may lead to a subconscious response that influences their breathing rate. Closed questions should be used as much as possible to minimise any distress in the acutely breathless patient. Questions should be prioritised and the patient should be allowed to rest adequately during questioning. Generally, respiratory assessment can be broken down into four areas – inspection, palpation, percussion and auscultation. Nurses do not perform percussion as a mode of respiratory assessment unless additional training has been undertaken.