In order to provide the best possible care, respiratory therapists must be able to perform a comprehensive assessment of each individual patient.
This assessment includes taking the patient’s medical history, evaluating their current condition, and assessing their risk for future problems. By performing a thorough assessment, respiratory therapists can develop an individualized treatment plan that will address the specific needs of each patient.
This article will provide an overview of the step-by-step process for performing a patient assessment as a respiratory therapist.
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Goals of Performing a Patient Assessment:
The primary goal of performing a patient assessment is to gather information that will help the respiratory therapist develop an individualized treatment plan. This includes:
- Interpreting, recognizing, and performing the correct procedures
- Making appropriate therapeutic recommendations
- Administering therapy in an effective manner
- Evaluate the patient’s progress
- Recognizing any adverse reactions
Each patient is different, so it is important that the respiratory therapist tailor the assessment to meet the specific needs of each individual.
Steps for Performing a Patient Assessment
In order to perform a patient assessment, the respiratory therapist will need to take the following steps:
- Check for the doctor’s order
- Enter the patient’s room
- Gather subjective patient information
- Gather objective patient information
- Develop an analysis of the obtained information
- Develop a care plan for the patient
Each step of the patient assessment process is important and will be discussed in further detail below.
1. Check for the Doctor’s Order
The first step in performing a patient assessment is to check for the doctor’s order. This applies to pretty much every procedure performed by respiratory therapists.
You must always verify the doctor’s order before proceeding.
This means that, before entering the patient’s room, you should be able to accurately locate the patient’s medical record. Then you can obtain and interpret all the information that is relative to the case at hand.
2. Enter the Patient’s Room
Knocking is the first step of entering a patient’s room. You must always knock before going in. Then you can wash your hands and introduce yourself to the patient.
Tell them your name, job title (i.e., respiratory therapist), and explain what you will be doing. It is important to establish a rapport with the patient and put them at ease. You can do this by speaking in a calm and friendly manner.
3. Gather Subjective Patient Information
The next step is to gather subjective patient information. This includes anything that the patient tells you about their condition. Subjective data is not measurable.
For example, if the patient were to say, “I’m having trouble breathing.”
This is subjective information. In order to gather this information, you will need to ask the patient questions about their symptoms.
It is important to ask open-ended questions that cannot be answered with a simple “yes” or “no.” This will help encourage the patient to give you more detailed information about their condition.
4. Gather Objective Patient Information
In addition to subjective patient information, you will also need to gather objective patient information. This is data that can be measured and observed.
For example, a patient’s vital signs would be considered objective data because they can be measured. And measuring vital signs is an important step of each patient assessment, including:
- Heart rate
- Oxygen saturation
- Lung sounds
Blood pressure is another important vital sign, although it is usually measured by nurses, not respiratory therapists.
All respiratory therapists should invest in a high-quality stethoscope in order to perform auscultation during a patient assessment. Our top recommendation is the 3M Littmann Classic III Stethoscope.
This is our top-recommended stethoscope for medical professionals.
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5. Develop an Analysis of the Obtained Information
After gathering both subjective and objective patient information, you will need to develop an analysis of this information. This step is important because it helps you determine what the patient’s problem might be.
For example, if the patient’s oxygen saturation is low and they are reporting shortness of breath, this will require immediate intervention.
By performing an analysis of the patient information, you can develop a working diagnosis and plan that involves the most appropriate treatment methods.
6. Develop a Care Plan for the Patient
The final step of the patient assessment process is to develop a care plan for the patient. This care plan will be based on the information that you gathered and analyzed during the assessment.
The care plan will outline what treatments or interventions need to be performed in order to help the patient.
Going back to the previous example, if the patient’s oxygen saturation is low and they are reporting shortness of breath, the care plan might involve administering supplemental oxygen.
Or, if you previously discovered that the patient has expiratory wheezes on auscultation, the care plan might involve administering a bronchodilator medication. During this step, you will use everything that you have learned about the patient to develop a plan that will help them improve their condition.
Performing a patient assessment is an important step in delivering high-quality respiratory care. By following the steps outlined in this article, you can be sure that you are performing a thorough and accurate assessment.
By taking the time to perform a thorough patient assessment, you can be sure that you are providing the best possible care for your patients.
Be sure to read our comprehensive guide on patient vital signs if you want to learn more about this important topic. Thanks for reading!
John Landry, BS, RRT
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
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