RESPIRATORY- Nursing Assessment Guideline
Whenever a resident has respiratory symptoms (runny nose, cough, watery eyes, shortness of breath, earache, increased respirations), the following evaluation should be completed before the decision is made either to observe and treat with nursing measures or to call the provider on call.
1. What are the specific signs and symptoms?
2. When did these signs and symptoms start?
3. Were any nursing measures tried and did they work? (fluids, PRN medications, inhalers, oxygen)
4. Is the resident tube fed or is there a history of dysphagia? Any recent choking episodes?
5. Is there a history of COPD or CHF?
6. Is there a change in mental status?
7. Is the resident currently receiving diuretics, antibiotics, inhalers?
8. Is the resident of Coumadin? If YES what is the most recent INR?
9. Is the resident on dialysis?
10. Are there others on unit with respiratory infection?
11. What are the vital signs, including pulse oximetry?
12. If diabetic, what is the Accucheck reading?
13. Assess and describe cough and nasal discharge if present.
14. Are there new abnormal lung sounds? (wheezes, rales/crackles, rhonci)
15. Any increase in edema (periorbital, hands, lower extremities)?
A. Treat symptoms with PRN medications.
B. If accompanied by severe symptoms, not responding to PRNs or accompanied by decline in overall status call on-call provider.
Emergency: For dyspnea or SOB unrelieved by PRNs or sudden drop in pulse goniometry.
Routine: Worsening condition or no improvement within 72-hour period or to obtain initial PRN orders.