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HLT-RESP80-06 · Lesson 2 · 38 clock hours · demo

Patient Assessment: History, Physical Examination, and Vital Signs

Objective. Students will conduct a structured respiratory patient assessment on a simulated patient, collecting and accurately recording chief complaint, history, auscultation findings, respiratory rate, SpO2, blood pressure, and level of consciousness.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

VoTechWorks program approval and accreditation are still in progress. Credentials are issued only by the certifying bodies named in each program, after their own exams.

Why Structured Assessment Comes First

Every safe clinical decision in respiratory therapy begins with a thorough patient assessment. Skipping or rushing this step risks missing a life-threatening change in a patient's condition. A structured approach ensures nothing is overlooked, creates a reliable baseline, and gives you legally defensible documentation. The framework used in clinical practice — and tested on credentialing exams — follows a consistent sequence: chief complaint, history, physical examination (including auscultation), and vital signs.

Chief Complaint and Patient History

Begin by identifying the chief complaint: the patient's own words describing why they sought care. Ask open-ended questions first — "Tell me what's been bothering you" — then follow up with focused questions about onset, duration, severity, and anything that makes symptoms better or worse.

A complete respiratory history includes:

Document the history in objective, factual language. Never paraphrase in a way that changes the patient's meaning.

Vital Signs: What to Measure and Why

Respiratory rate (RR): Count chest rises for a full 60 seconds. Normal adult range is approximately 12–20 breaths per minute. Rates above 20 (tachypnea) or below 12 (bradypnea) signal potential compromise. Count discreetly — patients alter their breathing rate when they know they are being watched.

Pulse oximetry (SpO₂): A non-invasive estimate of arterial oxygen saturation. Normal values are generally 95–100% in healthy adults. Values below 90% are considered clinically significant and typically warrant intervention. Be aware of limitations: nail polish, poor perfusion, carbon monoxide poisoning, and motion artifact can reduce accuracy.

Blood pressure (BP): Measured in mmHg, reported as systolic over diastolic (e.g., 120/80). Respiratory distress can elevate BP; severe hypoxia or tension pneumothorax can cause dangerous drops. Use the correct cuff size — a cuff that is too small reads falsely high.

Heart rate and temperature: Tachycardia often accompanies hypoxemia and bronchospasm. Fever suggests infection, which can precipitate respiratory decompensation.

Level of consciousness (LOC): Use the AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive) or the Glasgow Coma Scale (GCS) when indicated. Altered LOC in a respiratory patient — confusion, agitation, or somnolence — can indicate hypoxia or hypercapnia and demands immediate escalation.

Physical Examination of the Chest

Physical assessment follows the sequence inspect, palpate, percuss, auscultate.

Inspection: Observe work of breathing. Look for use of accessory muscles (sternocleidomastoid, scalene), nasal flaring, pursed-lip breathing, retractions (supraclavicular, intercostal, subcostal), cyanosis, clubbing, and barrel chest.

Palpation: Feel for chest wall symmetry and tactile fremitus (vibration transmitted through lung tissue). Asymmetric expansion suggests unilateral pathology such as pneumothorax or effusion.

Percussion: Dullness suggests consolidation or fluid; hyperresonance suggests air trapping or pneumothorax.

Auscultation: Place the stethoscope directly on skin, not over clothing. Listen at each lung field systematically, comparing side to side.

Putting the Assessment Together: Clinical Reasoning

After gathering all findings, identify the primary respiratory problem. Ask: What pattern do these findings create?

Document every finding accurately and immediately. Falsifying or delaying documentation is an ethical and legal violation that can endanger patients and end your career.

Safety Priorities

Key terms10

Chief complaintThe patient's primary reason for seeking care, documented in the patient's own words.
TachypneaA respiratory rate above the normal adult range (generally above 20 breaths per minute), indicating increased breathing effort or demand.
SpO₂Peripheral oxygen saturation measured non-invasively by pulse oximetry, expressed as a percentage; estimates arterial hemoglobin saturation.
AVPU scaleA rapid tool for assessing level of consciousness: Alert, responds to Voice, responds to Pain, Unresponsive.
AuscultationThe act of listening to internal body sounds, typically with a stethoscope, to assess airflow and detect abnormal lung sounds.
Crackles (rales)Discontinuous, popping or clicking lung sounds heard on auscultation, associated with fluid in alveoli, atelectasis, or fibrosis.
StridorA high-pitched, harsh sound produced by turbulent airflow through a narrowed or obstructed upper airway; audible without a stethoscope and considered a medical emergency.
Accessory musclesMuscles not primarily used in normal breathing (such as the sternocleidomastoid and scalene muscles) that are recruited during increased work of breathing.
Tactile fremitusVibration felt on the chest wall when a patient speaks, used during palpation to detect areas of consolidation or fluid.
Clinical reasoningThe process of integrating assessment findings — history, physical exam, and vital signs — to identify a patient's primary problem and guide appropriate care.

Worked examples3

1. A patient's respiratory rate is counted at 8 breaths in 30 seconds. What is the rate per minute, and is it within normal limits?
  1. Multiply the count by 2 to convert to breaths per minute: 8 × 2 = 16 breaths per minute.
  2. Compare to the normal adult range of approximately 12–20 breaths per minute.
  3. 16 falls within that range, so the rate is normal.
Answer: 16 breaths per minute — within normal limits.
2. A patient has a pulse oximetry reading of 88% on room air. How many percentage points below the lower end of the normal range (95%) is this, and what action is indicated?
  1. Subtract the patient's SpO₂ from the lower limit of normal: 95% − 88% = 7 percentage points below normal.
  2. Values below 90% are clinically significant. 88% is below the 90% threshold.
  3. Per safety protocol, notify supervising staff immediately and prepare to provide supplemental oxygen as ordered.
Answer: The reading is 7 percentage points below the lower limit of normal and falls below the 90% clinical action threshold; immediate notification of supervising staff is required.
3. During a six-station assessment rotation, a student correctly identifies the primary problem and records accurate findings at the following stations: Station 1 — passes (5 of 6 parameters correct); Station 2 — fails (4 of 6 parameters correct); Station 3 — passes (5 of 6); Station 4 — passes (6 of 6); Station 5 — fails (3 of 6); Station 6 — passes (5 of 6). Does the student meet the competency standard of passing at least four of six stations with at least five of six parameters correct?
  1. Identify passing stations (≥5 of 6 parameters correct): Stations 1, 3, 4, and 6 pass. Stations 2 and 5 do not pass.
  2. Count passing stations: 4 out of 6.
  3. Compare to the requirement: at least 4 of 6 stations passed. The student meets exactly the minimum threshold.
  4. Confirm parameter accuracy on passing stations: 5/6, 5/6, 6/6, and 5/6 — all meet the ≥5 requirement.
Answer: Yes — the student passes exactly 4 of 6 stations with the required parameter accuracy, meeting the minimum competency standard.

The math in this lesson1

Learners convert breaths counted in 30 seconds to a per-minute respiratory rate.
6.RP.3
In class: Instructor demonstrates a head-to-toe respiratory assessment on a standardized patient (classmate or manikin), narrating each step; students document findings on a clinical assessment form and compare with instructor's reference findings. · Students rotate in pairs through six assessment stations—each with a different simulated presentation (COPD exacerbation, asthma attack, post-op hypoventilation, pneumonia, pulmonary edema, normal baseline)—recording findings and identifying the primary respiratory problem at each station. · Using recorded lung sound audio files (crackles, wheezes, rhonchi, stridor, diminished), students listen, identify, and document the correct descriptive term and its clinical significance on a matching worksheet.
Materials: Stethoscopes, pulse oximeters, blood pressure cuffs, clinical assessment forms, lung-sound audio library (AARC or equivalent), simulated patient manikin or standardized patient volunteer, assessment rubric
Check: Instructor-observed checklist during the six-station rotation; students must correctly identify the primary problem and document at least five of six assessment parameters accurately at four of six stations — 67% station pass rate with 83% parameter accuracy per station required.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Patient Assessment and Diagnosis
1. During auscultation, you hear discontinuous, popping sounds in the bilateral lung bases during late inspiration. These sounds are best described as:
Patient Assessment and Diagnosis
2. A post-operative patient is unresponsive to verbal stimulation but withdraws from a sternal rub. Using the AVPU scale, how would you document this patient's level of consciousness?
Patient Assessment and Diagnosis
3. You are assessing a patient with suspected asthma exacerbation. Which combination of findings is most consistent with this diagnosis?
Patient Assessment and Diagnosis
4. Which of the following is a known limitation of pulse oximetry that could cause an inaccurately high SpO₂ reading?
Emergency and Critical Care
5. A student is auscultating a patient and hears a loud, high-pitched sound that is audible even before the stethoscope touches the chest. The correct action is to:
Patient Assessment and Diagnosis
6. When counting respiratory rate, why is it recommended to do so discreetly without informing the patient?
Patient Assessment and Diagnosis
7. A patient presents with bilateral crackles, an SpO₂ of 86% on room air, frothy pink-tinged sputum, and jugular venous distension. The primary respiratory problem most consistent with these findings is:
Professional and Legal Responsibilities
8. According to scope-of-practice principles, when a student respiratory therapist identifies a critical assessment finding such as SpO₂ below 90%, the appropriate initial action is to:
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