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PHYSICAL DATA

*Vital signs, including comprehensive description of respiratory rate and tempo
*Lung evaluation, listen particularly for wheezing
rates, rhonchi, look for the use of accessory
muscular tissues to breathe, and extented expiraiion
*Any sputum production (including consistency and coloring)
*Level of awareness

HEALTH CARE BACKGROUND

Onset, duration, rate of recurrence, and severity of
symptoms
What has been carried out so far to deal with the
problem
All current medications, including any recent
variations
Precipitating and relieving elements
Whether or not patient is utilizing oxygen (O2), and what
are O2 configurations
Pulse oximetry results (current and previous)
All current diagnoses
Any recent lab or diagnostic exams

When listening to sounds of the lungs you want to
place your stethoscope over the following places:
Right Upper Lobe ……. Left Upper Lobe
Right Middle Lobe
Right Lower Lobe…….. Left Lower Lobe

Listen
. Crackles: These are high pitched,
discontinuous sounds similar to the sound
made by rubbing your hair between your
flngers (atso known as Rales).
. Wheezes: These are usually high pitched and
“musical” in quality.
Stridor is an inspiratory
wheeze affiliated with upper airway
blockage (croup).
Rhonchi: These typically have a snoring, or
“gurgling” quality. Any excess sound that is not
a crackle or a wheeze is probably a rhonchi.

Look
. Resident is unable to speak at all or cannot
converse in sentences because of shortness of
breath.
. Inhalation patterns such as Cheyne-stokes,
hyperventilation.
. Observe the resident for signs of cyanosis,
molting, etc.

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