C

Nursing Assessment and Pathophysiology

Introduction to Nursing Process

  • Application of nursing skills in various contexts through assessment and care delivery.
  • Importance of communication skills, cultural considerations, safety, and comfort while performing assessments.

Example Scenario

Client Description

  • Client JB: 27-year-old male exercise trainer
  • Works in a gym teaching 8-12 clients daily.
  • Calls triage line claiming to be quite sick.

Clinical Symptoms and History

  • Symptoms:

    • Productive cough with mucus present.
    • Sudden onset of overwhelming fatigue and fever.
    • Feels unable to sleep due to:
    • Fever
    • Headache
    • Severe joint and muscle pain
    • Painful cough
    • Stuffy nose that obstructs breathing when lying down.

  • Vital Signs:

    • Temperature: 104°F
    • Pulse: 105 bpm
    • Respirations: 20 breaths per minute
    • Blood Pressure: 122/86 mmHg
    • SpO2: 96%
    • Chest Pain (upon cough): 8/10

  • Medical History:

    • Vaccination: Not up to date.
    • Family Health History: None reported.
    • Alcohol: No use.
    • Substance Abuse: None reported.

Assessment Findings

  • Respiratory Assessment:
    • Respirations: Unlabored
    • Chest Expansion: Symmetric
    • Breath Sounds: Vesicular over peripheral lung fields; loud low-pitched gurgling crackles over fourth and fifth intercostal space.

Key Questions for Assessment

1. Concerning Findings

  • Symptoms indicating acute illness:

    • Sudden onset of overwhelming fatigue and fever.
    • Painful cough with productive mucus.
    • Stuffy nose that obstricits while lying down.

  • Vital sign concerns:

    • Febrile (fever present).
    • Tachycardic pulse (high heart rate).
    • Chest pain rating of 8/10.
    • Possible respiratory infection potential (e.g., influenza, COVID-19).

2. Education for the Client

  • Importance of hand hygiene:
    • Frequent hand washing with soap and water.
  • Cough etiquette:
    • Cover coughs/sneezes with tissue or elbow.
  • Mask-wearing to limit virus transmission.
  • Need to stay home to prevent spreading illness (especially in gym environment).
  • Advice on prop positioning:
    • Prop themselves with pillows for better breathing.
  • Medication adherence:
    • Continue any prescribed medications for pain or inflammation (e.g., ibuprofen, steroids).
  • Hydration recommendations:
    • Encourage intake of fluids (water and electrolyte beverages).
  • Vaccination recommendations:
    • Educate on importance of annual flu and COVID-19 vaccinations.

Assessment Findings Identification

Clinical Findings Graph

  • Top Row Identification:
    • Pulmonary Embolism: Blood clot in lungs.
    • Atelectasis: Collapsed lung area.
    • Pneumothorax: Deflated lung due to air.
    • Pleural Effusion: Fluid accumulation in pleural space.
    • Pneumonia: Consolidation in lung.

Bottom Row Identification:

  • Dyspnea: Shortness of breath noted (person clenching chest).
  • Finger Clubbing: Indicator of chronic respiratory conditions (e.g., emphysema).
  • Cyanosis: Blue skin coloration indicating oxygen deprivation.

Subjective and Objective Assessment Findings

Subjective Findings

  • Reported cough and nasal congestion:
    • Notable absence of shortness of breath or chest pain.
    • Respiratory history indicates minimal colds per year.
    • Works in a well-ventilated space; history of moderate smoking.

Objective Findings

  • Inspection Findings:

    • AP diameter is less than transverse diameter (normal).
    • Respiratory rate: 20 breaths/min.

  • Palpation Findings:

    • Chest expansion symmetric.
    • Tactile fremitus equal bilaterally.
    • No tenderness, lumps, or lesions.

  • Percussion Findings:

    • Resonant over right lung; dull over left lower lobe.

  • Auscultation Findings:

    • Crackles noted in left lower lobe (abnormal).

Highlighting Abnormal Findings

  • Subjective:

    • Persistent cough and nasal congestion.
    • Smoking history affects respiratory function.

  • Objective:

    • Respiratory rate at top end of normal.
    • Dullness on percussion over left lobe might suggest pneumonia.
    • Crackles in lung auscultation further indicate potential infection.

Conclusion on Abnormal Findings

  • Concerns about possible pneumonia indicated by:
    • Increased respiratory effort and sound irregularities.

Anatomy and Physiology Review

Lung Structure Overview

  • Paired organ: Similar structures on both sides.
  • Lobes in Lungs:
    • Left Lung: 2 lobes (upper, lower).
    • Right Lung: 3 lobes (upper, middle, lower).

Assessment Techniques

  • Patient as control: Compare right and left lung findings.
  • Examination conducted on both thoracic front and back while focusing on:
    • Quality of breath and sound.
    • Patient comfort and environmental issues during assessment.

Assessment History Questions

Essential Questions

  • Current respiratory diseases or issues.
  • Experience with shortness of breath (at rest or exertion).
  • Any history of respiratory discomfort.
  • Cough consistency and medications.
  • Environmental allergies and recent travel history.
  • Current lifestyle considerations (e.g., occupational risks).

Normal vs Abnormal Findings

Inspection Findings

Normal Respiratory Characteristics

  • Regular rhythm and 12-20 breaths per minute.
  • Effortless breathing without accessory muscle usage.
  • Symmetrical chest movement and relaxed posture.

Abnormal Respiratory Characteristics

  • Irregular breathing rhythm indicating respiratory issues.
  • Bradypnea (less than 12 breaths/min) or tachypnea (more than 20 breaths/min).
  • Increased accessory muscle use or difficulty in chest expansion.

Palpation and Percussion Findings

Normal Findings

  • Symmetric chest expansion upon inhalation.
  • Resonance in percussion on lung fields.

Abnormal Findings

  • Unequal chest expansion indicating atelectasis or other pathologies.
  • Dull sounds on percussion suggesting pleural effusion or pneumonia.

Auscultation Findings

Normal Lung Sounds

  • Clear and even bilaterally; no abnormal sounds present.

Abnormal Adventitious Sounds

  • Crackles, wheezes, stridor noted in conditions like pneumonia or exacerbated asthma.

Common Respiratory Patterns and Documentation

Respiratory Patterns

  • Cheyne-Stokes Respiration: Cycle of deeper and shallower breaths alternating with periods of apnea. Often occurring in heart failure.
  • Biot’s Respiration: Irregular respirations following the same waxing and waning pattern with differing cycle lengths.

Documentation Sample

  • Subjective Findings: No cough, shortness of breath, no hear-related disease history.
  • Objective Findings: Inspecting and noting normal respiratory rates, absence of pain or lesions during thorough evaluation.

Developmental Considerations for Respiratory Assessment

  • Infants: Higher respiratory rates, reliance on abdominal breathing until age 2.
  • Children: Age-dependent variations; respiratory rates decrease with age.
  • Pregnant Women: Respiratory depth increases due to anatomical changes but does not hinder normal activities.
  • Older Adults: Reduced lung capacity, increased fatigue during assessment due to altered thoracic mobility.

Practice Questions

Question 1

  • Question context related to a COPD patient and expected findings: Pursed lip breathing signifies effective management of COPD.

Question 2

  • Query about stridor; anticipates louder sounds over the neck due to upper airway obstruction.

Question 3

  • Monitoring patient descriptions indicating paroxysmal nocturnal dyspnea as symptomatic of ventricle overload conditions.

Question 4

  • Expected definition of adventitious sounds: Uncommon sounds arising from air interaction with lung secretions or deflated airways.

Question 5

  • Increased tactile fremitus suggests pneumonia from fluid buildup in lung tissue responsible for better sound conduction.

Obtaining Support for Nursing Study

  • Encourage communication with instructors or peers for clarification and assistance with challenging concepts.
  • Utilize available resources for practice questions and reviews.