Chapter 26 Nursing Assessment Respiratory System

Lungs: Demonstrate good air entry. Faint end-expiratory wheeze throughout all lung fields. No rales or rhonchi. Symmetric chest expansion. Breathing nonlabored.

-Use of indiscriminate sedatives, benzos, and opioid’s, especially in post-op patient who retains Co2, may suppress the ventilator drive and lead to respiratory failure

The patient did have black soot around his nose and mouth. Thats when first responders started manual ventilation's via BVM and 02 at 15 LPM. At this time Medic 1 assumed patient care. Medic 1 assigned first responders to obtaining vitals signs that are stated in the vital section of the report. It was at this time that Medic 1 applied a OPA after first measuring on what size to use. First responders also applied fast patches to the patients right upper chest and left midaxillary line At this time Medic 1 assigned first responders to start chest compressions a 15:2 ratio. Medic 1 at this time started a IO in the patients plateau region of the right leg. The Plateau region is inferior and lateral to the knee cap. At this time Normal Saline bolus was started with a 60 drop per ML set. Medic 1 found the patient to be in a sinus rhythm At this time miscommunication with Medic 1 and first responders happen with chest comparisons started. We then secured the patient on the cot via 4 straps and transported a code red patient to the nearest hospital. While enroute to hospital radio report was given with chief compliant and treatments listed in the appropriate category of the report. Vitals was continued to be taken every 5

Check for normal breathing, taking no more than 10 seconds: Look for chest motion, listen for breath sounds, and

As Mr C is due to undergo a surgical procedure an assessment of his observations should be carried out including a respiratory function. The nurse should ask the patient if he has a history of respiratory illness and if so how it was treated. He should also be asked if he has any productive coughs. An assessment of blood pressure, pulse and oxygen

Admitted through the Emergency Room at 4 PM to a semi-private room is Maggie P., a 78-year-old retired Registered Nurse with end-stage Chronic Obstructive Pulmonary Disease (COPD). Her temperature is 98.7, B/P 130/92, heart rate 124 and respirations are labored and irregular at 37 per minute. She appears frail and weighs 89 pounds. She is pale with a bluish hue to her lips and nail beds. Oxygen at 3 liters per minute is applied via nasal cannula. She is alert and oriented to time, place, and person. She coughs intermittently, expectorating copious amount of thick gray, blood-tinged sputum. She complains of back and rib pain and 5mg of Morphine Sulfate in administered intramuscularly. On assessment the nurse lists, between

Moving further into the physical assessment I’d inspect the integumentary system for indications of cyanosis, or pallor, I’d also not mucosa membranes, and nail beds including capillary refill. I’d auscultate all lung lobes for adventitious sounds, percuss to determine if there the appropriate resonance or an abnormal finding that would warrant further assessment. Palpating for crepitus, tactile fremitus, or tenderness also aid in identifying underlying lung complications. Noting if the patient has sputum production is also helpful in identifying the cause of dyspnea, it is important to inspect produced sputum and possibly collect for further lab testing (Ignatavicius & Workman,

b. Your patient is restless and complaining of feeling cold. What measures can you take to prepare your patient for the exam to ensure that you get a good reading? (5 points)

The right side of heart will increase in size as the muscle builds up and the heart rate will increase due to compensation for the left ventricle. With auscultation, the lungs will sound crackly from the liquid in the alveoli and interstitial space and when assessing respiration rate it is likely to be above thirty breaths per minute (Lewis et al., 2014). The patient may report that they are experiencing dyspnea, nocturia, fatigue, and a productive coughing. They may appear anxious and their skin may look pale (Lewis et al., 2014).

Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Symmetric chest expansion. Breathing nonlabored. Diminished breath sounds in all lung fields. Resonant to percussion.

194-195). The fourth nursing diagnosis that pertains to her is anxiety related her inability to breath adequately without support, the unknown outcome, her inability to speak from intubation, a change in the environment, a change in health status, and her not having insurance, and this is evidenced by restlessness, being unable to sedate her, and her uncooperative behavior(Gulanick & Myers, 2014, p. 416). The last nursing diagnosis for this patient is risk for decreased cardiac output related to her mechanical ventilation (Gulanick & Myers, 2014, p.

The patient will be able to tolerate ambulation to the bathroom and to the shower with minimal shortness of breath

Progress inside the bronchi generally makes this affected individual experience less than breathing. They should find them selves breathing problems along with breathing problems, experiencing ache in stomach place or, using some circumstances, breathing problems along with paying blood. Others will present signs along with signs

This essay will now analyze the nursing intervention that requires for the acutely ill patient to prevent an exacerbation of chronic obstructive pulmonary disease. The nurse carried out an initial assessment of a full history, taking in consideration that the patient was over 35 years of age who has been, or still is, a cigarette smoker, with vascular related diseases and had symptoms of breathlessness on exertion, chest tightness, wheezing, coughing, sputum production especially in the morning and chest infection (Currie 2009). A physical examination was done to check the patient respiration rate, depth and rhythm, blood pressure, pulse, temperature and oxygen saturation (Lynes 2007). The acutely ill patient’s respiration was between 30-34 breaths per minute, blood pressure 580/98, pulse 110 beat per minute and saturation levels 80-82%. Increase respiration indicates that the patient was in fear, pain and anxious. Anxiety causes stimulation of sympathetic nervous activation which forces bronchioles

is Pneumonia. This is based on the patient’s subjective and objective data. The collaborative diagnosis to address this problem is Pneumonia r/t immobilization; r/t pleural effusion, and r/t debilitation (Carpenito, 2013, p. 859-860). The nursing goal for this patient on the day of care is to control and reduce the complication of pneumonia (Carpenito, 2012, p. 860). The nurse will monitor the patient’s respiratory status while assessing for sign and symptoms of infection, and inflammation (Carpenito, 2012, p.