Are you ready to learn how to perform a patient assessment? If so, you’re in the right place, because we are about to break it down for you step by step.

As a Respiratory Therapist (or student), performing a patient assessment is something you’ll do time and time again throughout your shift. With that said, according to the NBRC, there is a specific way that it should be done.

And that is what we have laid out for you below. So if you’re ready, let’s go ahead and dive right in.

Goals of Performing a Patient Assessment:

When performing a patient assessment, here are the goals that you should be striving for:

  • You must be able to interpret, recognize, and perform the right patient assessment procedures that will lead to the appropriate care for the patient.
  • You need to be able to make therapeutic recommendations such as administering therapy in an effective manner.
  • And, last but not least, you must evaluate the patient’s progress, as well as recognize adverse reactions to any therapy that they provide.

Sound like a lot, huh? It’s not so bad once we break it all down. So let’s go ahead and go through the steps of performing a patient assessment.

1. Check for the Doctor’s Order

This applies to pretty much anything you will do as a student or as a Respiratory Therapist. You should always verify the doctor’s order before you proceed.

Before entering the patient’s room, you should be able to accurately locate the patient’s chart and obtain and interpret all the information that is relative to the case at hand.

2. Enter the Patient’s Room

Obviously, you want to knock before going in. Wash your hands, then proceed to introduce yourself to the patient.

Get into the habit of washing your hands when entering the patient’s room. Then wash them again before leaving the patient’s room.

Be sure to download a copy of this (free) Patient Assessment Study Guide. 

3. Gather Subjective Information From the Patient

This is the information that the patient tells you through communication. It is not measurable.

For example, the patient says, “I’m having trouble breathing.”

This is subjective information.

4. Gather Objective Information from the Patient

Objective information, on the other hand, is measurable. It includes all the vital signs that you will measure during your assessment. “Measure” is the key word here.

You should obtain the following vital signs on every patient:

  • Heart rate
  • Oxygen saturation
  • Respirations
  • Breath sounds

Each of these vital signs can be classified as objective information. They are very important when it comes to performing the patient assessment and treating the patient. 

As I’m sure you most likely already know, in order to properly assess a patient’s lungs during auscultation, you need a high-quality stethoscope. Here’s our top recommendation:

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5. Use the Information that you Have Obtained to Interpret and Develop an Analysis

Now it’s time to put what you learned to the test. How were the patient’s vital signs? Was their heart rate in the normal range? How about their oxygen saturation? Were they breathing too fast or too slow? Did you hear in wheezing in their breath sounds?

This is all stuff you should take into consideration to form your analysis of the patient.

This eBook contains premium TMC Practice Questions to cover the topic of Patient Assessment.

6. Use the Information from Your Assessment to Develop a Plan for the Patient

Now it’s time to make a plan for the patient. Do you see all the questions we asked in step 5? Now is the time to answer those questions in order to help make a plan for the patient. 

Was their oxygen level low? If so, now would be the time to provide the patient with a higher FiO2. Was the patient wheezing? If so, you can administer a short-acting bronchodilator via small-volume nebulizer, in this case.

Use everything you gathered in your assessment to help develop a proper action plan to treat the patient in the most effective way possible. 

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Final Thoughts

So there you have it. Now you know how to perform a patient assessment the right way as a Respiratory Therapist or student. Hopefully, you can take what you learned from this article to become more confident each and every time you assess a patient.

This information is not only useful now, but once you get the hang of it, it will serve you throughout your entire career as a Respiratory Therapist. 

Thank you so much for reading and as always, breathe easy my friend. 

References

The following are the sources that were used while doing research for this article:

  • Faarc, Heuer Al PhD Mba Rrt Rpft. Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017 [Link].
  • Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020. [Link]
  • Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019. [Link]
  • Neonatal and Pediatric Respiratory Care. Saunders; 5 edition, 2018. [Link]
  • Toney-Butler, Tammy. “Nursing Admission Assessment and Examination – StatPearls – NCBI Bookshelf.” NCBI, 30 July 2019, www.ncbi.nlm.nih.gov/books/NBK493211.

Disclosure: The links to the textbooks are affiliate links which means, at no additional cost to you, we will earn a commission if you click through and make a purchase.

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