- Normal (eupnea): Regular and comfortable at 12–20 breaths/min.
- Tachypnea: >20 breaths/min.
- Bradypnea: <12 breaths/min.
- Hyperventilation: Rapid, deep respiration >20 breaths/min.
- Apneustic: Neurological: sustained inspiratory effort.
- Cheyne–Stokes: Neurological: alternating patterns of depth separated by brief periods of apnea.
- Kussmaul: Rapid, deep, and labored: common in DKA.
- Air trapping: Difficulty during expiration: emphysema.
Lung Sounds-Differential Diagnosis
| Rales/Crackles | Simulated by rolling hair near ear between two fingers, best heard on inspiration in lower bases, unrelieved by coughing (e.g., CHF, pneumonia). |
| Wheezes | High-pitched, squeaking sound, best heard on expiration over all lung fields, unrelieved by coughing (e.g., asthma, COPD, emphysema). |
| Rhonchi | Coarse, harsh, loud gurgling or rattling, best heard on expiration over bronchi and trachea, often relieved by coughing (e.g., bronchitis, pneumonia). |
| Stridor | Life-Threatening! Harsh, high-pitched, easily audible on inspiration, progressive narrowing of upper airway requiring immediate attention (e.g., partial airway obstruction, croup, epiglottitis). |
| Unilaterally Absent or Diminished | Inability to hear equal, bilateral breath sounds (e.g., pneumothorax, tension pneumothorax, hemothorax, or history of pneumectomy). |
| Documentation | Rate, rhythm, depth, effort, sounds (indicate if sound is inspiratory and/or expiratory), and fields of auscultation. |
Wound Assessment
| Appearance | Color (pink, healing; yellow/green, infection; black, necrosis), sloughing, eschar, longitudinal streaking. |
| Size | Length, width, and depth in cm. |
| Incisions | Approximated edges, dehiscence, or evisceration. |
| Undermining | Use a sterile, cotton-tipped applicator to probe gently underneath edges until resistance is met; with a felttipped pen, mark where applicator can be felt under skin. |
| Induration | Abnormal firmness of tissues with margins. Assess by gently pinching tissue distal to wound edge; if indurated, you will be unable to pinch fold of skin. |
| Tissue Edema | Note whether edema is pitting or nonpitting.
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| Granulation | Bright red, shiny, and granular; an indication that wound is healing.
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| Drainage | Type (sanguineous, serosanguineous, purulent), amount, color, and consistency. |
| Odor |  Foul odor indicates infection. |
| Staging | See the section that immediately follows, Areas Susceptible to Pressure Ulcers. |