Assessment & Reasoning
Respiratory System
John Franklin, 35 years old
Suggested Respiratory Nursing Assessment Skills to Be Demonstrated:
g; g; g; g; g; g; g;
• Inspection: g;Inspect g;thorax g;for g;symmetry g;and g;configuration- g;Check g;to g;see g;if g;he g;if g;using g;accessory
g;muscles g;or g;if g;breathing g;is g;labored.
•
• Palpation: g;Palpate g;over g;anterior g;and g;posterior g;chest g;for g;any g;lump, g;masses, g;tenderness g;& g;crepitus
•
• Percussion: g;Percuss g;over g;posterior g;to g;check g;for g;tactile g;fremitus
•
• Auscultation:
• Auscultate g;all g;lung g;fields
•
Make Learning Active!
g; g;
https://www.coursehero.com/file/70918278/Clinical-3-Case-studydocx/
, Present Problem:
g;
John g;Franklin g;is g;a g;35-year-old g;Africang;American g;male g;who g;has g;a g;history g;of g;hypertension g;and g;asthma g;who g;smokes
g;½ g;ppd g;since g;the g;age g;of g;eighteen. g;He g;began g;to g;feel g;more g;short g;of g;breath g;after g;supper g;today g;and g;began g;to g;have
g;a g;persistent g;non- g;productive g;cough. g;He g;ran g;out g;of g;his g;albuterol g;inhaler g;two g;months g;ago g;and g;has g;audible
g;expiratory g;wheezing g;when g;he g;comes g;to g;the g;triage g;window g;of g;the g;emergency g;department g;(ED).
John g;is g;promptly g;brought g;to g;a g;room g;in g;the g;ED g;and g;you g;are g;the g;nurse g;responsible g;for g;his g;care.
What g;data g;from g;the g;present g;problem g;are g;RELEVANT g;and g;must g;be g;interpreted g;as g;clinically g;significant g;by g;the
g;nurse?
(Reduction g;of g;Risk g;Potential)
RELEVANT g;Datag;fromg;Present g;Problem: Clinical g;Significance:
History g;of g;Hypertension g;and g;asthma Having g;the g;history g;of g;asthma g;and g;because g;he g;smokes, g;this g;confirm
g;Smokes g;½ g;ppd g;since g;18 g;that g;he g;is g;having g;an g;asthma g;attack g;that g;could g;have g;flared g;up.
Shortness g;of g;breath, g;persistent g;nonproductive Having g;the g;nonproductive g;cough g;is g;consistent g;with g;asthma
g;cough g;attacks, g;if g;it g;were g;productive, g;it g;would g;be g;linked g;to
Ran g;out g;of g;albuterol g;inhaler g;two g;months g;ago g;pneumonia.
g;Audible g;expiratory g;wheezing Client g;had g;no g;way g;to g;treat g;his g;asthma g;because g;he g;ran g;out g;of g;his
g;medicine. g;His g;wheezing g;was g;so g;loud g;no g;stethoscope g;needed g;to g;be
g;used. g;Means g;his
condition g;was g;bad.
What g;is g;the g;RELATIONSHIP g;of g;your g;patient’s g;past g;medical g;history g;(PMH) g;and g;current g;meds?
(Which g;medication g;treats g;which g;condition? g;Draw g;lines g;to g;connect.)
PMH: Home g;Meds: Pharm. g;Class: Mechanism g;ofg;Action g;(own g;words):
Asthma Albuterolg;inhaler g;2 g;puffs adrenergic relaxes g;smooth g;muscles g;it g;the g;bronchial
g;every g;4 g;hours g;PRN g;bronchodilators g;tree g;and g;peripheral g;vasculature g;by
g;Hypertension g;wheezing g;stimulating g;adrenergic g;receptors g;of g;the
g;sympathetic g;nervous g;system.
Furosemide g;20 g;mg g;PO loop g;diuretics Furosemide g;is g;a g;potent g;loop g;diuretic
g;daily g;that
acts g;on g;the g;kidneys g;to g;ultimately
g;increase g;water g;loss g;from g;the g;body.
You place John on a cardiac monitor, continuous oximetry
and quickly collect the following assessment data:
Patient Care Begins:
g; g;
Current g;VS: P-Q-R-S-T g;Pain g;Assessment:
T: g;99.1 g;F-37.3 g;C g;(oral) Provoking/Palliative: Denies g;pain
P: g;110 g;(regular) Quality:
R: g;24 g;(regular) Region/Radiation:
BP: g;188/110 Severity:
O2 g;sat: g;91% g;RA Timing:
What g;vital g;signs g;are g;abnormal? g;What g;is g;the g;reason g;(pathophysiology) g;for g;these g;findings?
(Reduction g;of g;Risk g;Potential/Health g;Promotion g;and g;Maintenance)
Abnormal g;VS: Clinical g;Significance:
BP: g;188/10
Oxygen g;saturation g;low, g;client’s g;airway g;may g;be g;blocked, g;low g;amount g;of g;oxygen g;in g;the
g;blood.
02 g;sat: g;91% g;RA
Client g;is g;taking g;a g;lot g;of g;breaths
R: g;24
This study source was downloaded by 100000816649994 from CourseHero.com on 04 -16-2021 00:06:26 GMT -05:00
https://www.coursehero.com/file/70918278/Clinical-3-Case-studydocx/
Respiratory System
John Franklin, 35 years old
Suggested Respiratory Nursing Assessment Skills to Be Demonstrated:
g; g; g; g; g; g; g;
• Inspection: g;Inspect g;thorax g;for g;symmetry g;and g;configuration- g;Check g;to g;see g;if g;he g;if g;using g;accessory
g;muscles g;or g;if g;breathing g;is g;labored.
•
• Palpation: g;Palpate g;over g;anterior g;and g;posterior g;chest g;for g;any g;lump, g;masses, g;tenderness g;& g;crepitus
•
• Percussion: g;Percuss g;over g;posterior g;to g;check g;for g;tactile g;fremitus
•
• Auscultation:
• Auscultate g;all g;lung g;fields
•
Make Learning Active!
g; g;
https://www.coursehero.com/file/70918278/Clinical-3-Case-studydocx/
, Present Problem:
g;
John g;Franklin g;is g;a g;35-year-old g;Africang;American g;male g;who g;has g;a g;history g;of g;hypertension g;and g;asthma g;who g;smokes
g;½ g;ppd g;since g;the g;age g;of g;eighteen. g;He g;began g;to g;feel g;more g;short g;of g;breath g;after g;supper g;today g;and g;began g;to g;have
g;a g;persistent g;non- g;productive g;cough. g;He g;ran g;out g;of g;his g;albuterol g;inhaler g;two g;months g;ago g;and g;has g;audible
g;expiratory g;wheezing g;when g;he g;comes g;to g;the g;triage g;window g;of g;the g;emergency g;department g;(ED).
John g;is g;promptly g;brought g;to g;a g;room g;in g;the g;ED g;and g;you g;are g;the g;nurse g;responsible g;for g;his g;care.
What g;data g;from g;the g;present g;problem g;are g;RELEVANT g;and g;must g;be g;interpreted g;as g;clinically g;significant g;by g;the
g;nurse?
(Reduction g;of g;Risk g;Potential)
RELEVANT g;Datag;fromg;Present g;Problem: Clinical g;Significance:
History g;of g;Hypertension g;and g;asthma Having g;the g;history g;of g;asthma g;and g;because g;he g;smokes, g;this g;confirm
g;Smokes g;½ g;ppd g;since g;18 g;that g;he g;is g;having g;an g;asthma g;attack g;that g;could g;have g;flared g;up.
Shortness g;of g;breath, g;persistent g;nonproductive Having g;the g;nonproductive g;cough g;is g;consistent g;with g;asthma
g;cough g;attacks, g;if g;it g;were g;productive, g;it g;would g;be g;linked g;to
Ran g;out g;of g;albuterol g;inhaler g;two g;months g;ago g;pneumonia.
g;Audible g;expiratory g;wheezing Client g;had g;no g;way g;to g;treat g;his g;asthma g;because g;he g;ran g;out g;of g;his
g;medicine. g;His g;wheezing g;was g;so g;loud g;no g;stethoscope g;needed g;to g;be
g;used. g;Means g;his
condition g;was g;bad.
What g;is g;the g;RELATIONSHIP g;of g;your g;patient’s g;past g;medical g;history g;(PMH) g;and g;current g;meds?
(Which g;medication g;treats g;which g;condition? g;Draw g;lines g;to g;connect.)
PMH: Home g;Meds: Pharm. g;Class: Mechanism g;ofg;Action g;(own g;words):
Asthma Albuterolg;inhaler g;2 g;puffs adrenergic relaxes g;smooth g;muscles g;it g;the g;bronchial
g;every g;4 g;hours g;PRN g;bronchodilators g;tree g;and g;peripheral g;vasculature g;by
g;Hypertension g;wheezing g;stimulating g;adrenergic g;receptors g;of g;the
g;sympathetic g;nervous g;system.
Furosemide g;20 g;mg g;PO loop g;diuretics Furosemide g;is g;a g;potent g;loop g;diuretic
g;daily g;that
acts g;on g;the g;kidneys g;to g;ultimately
g;increase g;water g;loss g;from g;the g;body.
You place John on a cardiac monitor, continuous oximetry
and quickly collect the following assessment data:
Patient Care Begins:
g; g;
Current g;VS: P-Q-R-S-T g;Pain g;Assessment:
T: g;99.1 g;F-37.3 g;C g;(oral) Provoking/Palliative: Denies g;pain
P: g;110 g;(regular) Quality:
R: g;24 g;(regular) Region/Radiation:
BP: g;188/110 Severity:
O2 g;sat: g;91% g;RA Timing:
What g;vital g;signs g;are g;abnormal? g;What g;is g;the g;reason g;(pathophysiology) g;for g;these g;findings?
(Reduction g;of g;Risk g;Potential/Health g;Promotion g;and g;Maintenance)
Abnormal g;VS: Clinical g;Significance:
BP: g;188/10
Oxygen g;saturation g;low, g;client’s g;airway g;may g;be g;blocked, g;low g;amount g;of g;oxygen g;in g;the
g;blood.
02 g;sat: g;91% g;RA
Client g;is g;taking g;a g;lot g;of g;breaths
R: g;24
This study source was downloaded by 100000816649994 from CourseHero.com on 04 -16-2021 00:06:26 GMT -05:00
https://www.coursehero.com/file/70918278/Clinical-3-Case-studydocx/
