Nursing Respiratory Assessment Documentation
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Create a respiratory assessment documentation for patient with [respiratory condition].

Patient details:
- Diagnosis: [respiratory condition]
- Oxygen requirement: [room air/L/min/delivery device]
- SpO2: [%]
- Respiratory rate: [breaths/min]
- Breathing pattern: [regular/irregular]
- Work of breathing: [unlabored/labored]
- Breath sounds: [clear/describe findings]
- Cough: [productive/nonproductive/absent]
- Sputum: [color/amount/consistency]
- Position of comfort: [HOB elevation]

RESPIRATORY ASSESSMENT

1. SUBJECTIVE
   - Patient complaint: [dyspnea/chest pain/cough]
   - Onset and duration
   - Aggravating and relieving factors
   - Comparison to baseline

2. OBJECTIVE FINDINGS
   - Vital signs: [complete set]
   - Appearance: [color/diaphoresis/accessory muscle use]
   - Auscultation findings by lobe
   - Peak flow if applicable: [value]

3. INTERVENTIONS
   - Oxygen adjusted to: [amount and device]
   - Positioning: [HOB elevated to X degrees]
   - Respiratory treatments: [type and time]
   - Incentive spirometry: [completed]
   - Coughing and deep breathing: [encouraged]
   - Suctioning: [if performed]

4. RESPONSE TO TREATMENT
   - SpO2 after intervention: [%]
   - Subjective improvement: [yes/no]
   - Repeat assessment findings

5. COMMUNICATION
   - Physician notified: [if deterioration]
   - SBAR communication: [if used]
   - Respiratory therapy consulted: [if applicable]

Note: Placeholder information only — no real PHI

Source: https://promptzyo.com/prompt/nursing-respiratory-assessment-documentation