Nursing

Assessment & Reasoning

Respiratory System

John Franklin, 35 years old

Suggested Respiratory Nursing Assessment Skills to Be Demonstrated: • Inspection: Client positioning – tripod, position of comfort; (face) nasal flaring, pursed lips, color of face, lips;

(posterior)level of scapula – rise evenly, use of accessory muscles anterior/posterior, sternal/intercostal

retractions. Quality and pattern of respirations.

• Palpation: (posterior) down the back sequentially checking for tenderness/pain, warmth, crepitus & fremitus (best with ball of hand), chest wall expansion(symmetry) – thumbs over spine and fingers spread like butterfly

wings-pneumonia, pneumothorax. Assess for masses, bulges, muscle tone

• Percussion: Across and down back for resonance vs hyperresonance (pneumothorax), dullness (pneumonia). Avoid percussing over bone.

• Auscultation: Posterior – down the back sequentially from C7 (lung apex) to T10; anterior – above clavicles to sixth rib (xiphoid); flanks from axillae to 8th rib. Ladder type sequence moving right to left for comparison.

Listen for full inspirations and expiration.

• Palpation, percussion and auscultation follow same pattern and avoids scapula and spine (posterior) and mammary tissue (anteriorly) – assess as close to chest wall as possible. Compare left to right for aeration =

Make Learning Active! • Role play or go through the interview/body assessment process – student to student or as a group.

• Review the case study as an application exercise in small groups or together as a class.

• Depending on your program some of this content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Instead use it to promote learning by having students

identify what they do not yet know and provide guidance to where they can find the information in the

textbook or on the internet to address knowledge gaps. This is educational best practice and another way

to scaffold knowledge!

© 2019 Keith Rischer/www.KeithRN.com

Present Problem: John Franklin is a 35-year-old African American male who has a history of hypertension and asthma who smokes ½ ppd since the age of eighteen. He began to feel more short of breath after supper today and began to have a persistent non-

productive cough. He ran out of his albuterol inhaler two months ago and has audible expiratory wheezing when he

comes to the triage window of the emergency department (ED).

John is promptly brought to a room in the ED and you are the nurse responsible for his care.

What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem: Clinical Significance:

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Draw lines to connect.)

PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):

Asthma

Hypertension

Albuterol inhaler 2 puffs

every 4 hours PRN

wheezing

Furosemide 20 mg PO daily

Patient Care Begins:

What vital signs are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion and Maintenance)

Abnormal VS: Clinical Significance:

Current VS: P-Q-R-S-T Pain Assessment: T: 99.1 F-37.3 C (oral) Provoking/Palliative: Denies pain

P: 110 (regular) Quality:

R: 24 (regular) Region/Radiation:

BP: 188/110 Severity:

O2 sat: 91% RA Timing:

You place John on a cardiac monitor, continuous oximetry

and quickly collect the following assessment data:

© 2019 Keith Rischer/www.KeithRN.com

What assessment findings are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data: Clinical Significance:

Put it All Together and Think Like a Nurse!

1. Interpreting relevant clinical data, what is the primary problem? What body system(s) will you assess most thoroughly based on the primary/priority concern?

What’s the

problem?

What’s causing the problem?

(explain pathophysiology in OWN words)

PRIORITY Body

System to Assess:

2. Which specific nursing assessments for this body system are most important? Validate successful completion of each nursing assessment on a manikin (if available) identified with peer or faculty initials.

PRIORITY Nursing Assessments: Rationale: Validate Student

Performance:

Current Assessment:

GENERAL: Appears anxious, body tense, brows furrowed RESP: Coarse inspiratory and expiratory wheezing with prolonged expiratory phase, labored breathing,

diminished aeration in bases, subcostal retractions present

CARDIAC: Skin warm and dry, no edema, heart sounds strong, regular with no abnormal beats/murmurs, pulses 3+ throughout, brisk cap refill

NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen pink, flat, soft/nontender/symmetrical, bowel sounds audible per auscultation in all

four quadrants

GU: Voiding without pain/difficulty, reports urine clear/yellow

INTEGUMENTARY: Cool, moist forehead, skin integrity intact, skin turgor elastic, no tenting present

© 2019 Keith Rischer/www.KeithRN.com

3. What is the current nursing priority and plan of care?

Nursing PRIORITY:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

4. State the rationale and expected outcomes for the medical plan of care. Medical Management: Rationale: Expected Outcome:

Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

Radiology: Chest X-Ray

Results: Clinical Significance:

No infiltrates noted, silhouette of

heart is slightly enlarged

Lab Results: Complete Blood Count (CBC)

WBC HGB PLTs % Neuts Bands

Current: 10.5 14.5 295 78 0

RELEVANT Lab(s): Clinical Significance:

© 2019 Keith Rischer/www.KeithRN.com

Basic Metabolic Panel (BMP)

Na K Gluc. Creat.

Current: 140 3.2 185 1.3

RELEVANT Lab(s): Clinical Significance:

Evaluation: Thirty minutes later…

1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable:

Current VS: Most Recent: Current PQRST: T: 99.1 F-37.3 C (oral) T: 99.1 F-37.3 C (oral) Provoking/Palliative: P: 96 (regular) P: 110 (regular) Quality: Denies R: 20 (regular) R: 24 (regular) Region/Radiation: BP: 146/90 BP: 188/110 Severity: O2 sat: 95% RA O2 sat: 91% RA Timing:

Current Assessment:

GENERAL

APPEARANCE:

Resting comfortably, appears in no acute distress

RESP: Breath sounds have mild expiratory wheezing with equal aeration bilaterally, able to

speak in full sentences with no SOB

CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses

strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO: Alert & oriented to person, place, time, and situation (x4), less anxious

GI: Abdomen pink, flat, soft/nontender/symmetrical, bowel sounds audible per

auscultation in all four quadrants

GU: Voiding without difficulty, urine clear/yellow

SKIN: Skin integrity intact, skin integrity intact, skin turgor elastic, no tenting present

John has received two albuterol/ipratropium nebulizers and IV

methylprednisolone. You collect the following clinical data to reassess his

status.

© 2019 Keith Rischer/www.KeithRN.com

RELEVANT Assessment

Data:

Clinical Significance: TREND: Improve/Worsening/Stable:

1. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified after this evaluation assessment? (Management of Care, Physiological Adaptation)

Evaluation of Current Status: Modifications to Current Plan of Care:

2. What did you learn that you can apply to future patients you care for? Reflect on your current strengths and

weaknesses this case study identified. What is your plan to make any weakness a future strength?

What Did You Learn? What did you do well with this case study?

What could have been done better? What is your plan to make any weakness a future

strength?

  1. RELEVANT Data from Present ProblemRow1:
  2. Clinical SignificanceRow1:
  3. PMH:
  4. Home Meds:
  5. Asthma Hypertension:
  6. Pharm ClassAlbuterol inhaler 2 puffs every 4 hours PRN wheezing Furosemide 20 mg PO daily:
  7. Mechanism of Action own wordsAlbuterol inhaler 2 puffs every 4 hours PRN wheezing Furosemide 20 mg PO daily:
  8. Current VS:
  9. PQRST Pain Assessment:
  10. P 110 regular:
  11. Denies painQuality:
  12. R 24 regular:
  13. Denies painRegionRadiation:
  14. BP 188110:
  15. Denies painSeverity:
  16. O2 sat 91 RA:
  17. Denies painTiming:
  18. Abnormal VSRow1:
  19. Clinical SignificanceRow1_2:
  20. Current Assessment:
  21. GENERAL:
  22. Appears anxious body tense brows furrowed:
  23. RESP:
  24. CARDIAC:
  25. NEURO:
  26. Alert oriented to person place time and situation x4:
  27. GI:
  28. GU:
  29. Voiding without paindifficulty reports urine clearyellow:
  30. RELEVANT Assessment DataRow1:
  31. Clinical SignificanceRow1_3:
  32. Whats the problemRow1:
  33. Whats causing the problem explain pathophysiology in OWN wordsRow1:
  34. PRIORITY Body System to AssessRow1:
  35. PRIORITY Nursing AssessmentsRow1:
  36. RationaleRow1:
  37. Validate Student PerformanceRow1:
  38. Nursing PRIORITY:
  39. PRIORITY Nursing InterventionsRow1:
  40. RationaleRow1_2:
  41. Expected OutcomeRow1:
  42. Medical ManagementRow1:
  43. RationaleRow1_3:
  44. Expected OutcomeRow1_2:
  45. Results:
  46. Clinical SignificanceNo infiltrates noted silhouette of heart is slightly enlarged:
  47. Complete Blood Count CBCRow1:
  48. Current:
  49. RELEVANT LabsRow1:
  50. Clinical SignificanceRow1_4:
  51. Basic Metabolic Panel BMPRow1:
  52. Creat:
  53. Current_2:
  54. 13:
  55. RELEVANT LabsRow1_2:
  56. Clinical SignificanceRow1_5:
  57. Current VS_2:
  58. Most Recent:
  59. Current PQRST:
  60. T 991 F373 C oral:
  61. ProvokingPalliative:
  62. P 96 regular:
  63. P 110 regular_2:
  64. Quality:
  65. R 20 regular:
  66. R 24 regular_2:
  67. DeniesRegionRadiation:
  68. BP 14690:
  69. BP 188110_2:
  70. DeniesSeverity:
  71. O2 sat 95 RA:
  72. O2 sat 91 RA_2:
  73. DeniesTiming:
  74. Current Assessment_2:
  75. Resting comfortably appears in no acute distress:
  76. RESP_2:
  77. CARDIAC_2:
  78. NEURO_2:
  79. GI_2:
  80. GU_2:
  81. Voiding without difficulty urine clearyellow:
  82. SKIN:
  83. RELEVANT VS DataRow1:
  84. Clinical SignificanceRow1_6:
  85. TREND ImproveWorseningStableRow1:
  86. RELEVANT Assessment DataRow1_2:
  87. Clinical SignificanceRow1_7:
  88. TREND ImproveWorseningStableRow1_2:
  89. Evaluation of Current StatusRow1:
  90. Modifications to Current Plan of CareRow1:
  91. What Did You LearnRow1:
  92. What did you do well with this case studyRow1:
  93. What could have been done betterRow1:
  94. What is your plan to make any weakness a future strengthRow1:

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