(Answered)Keith Rischer RN answers to assessment & reasoning respiratory system

(Answered)Keith Rischer RN answers to assessment & reasoning respiratory system

 

(Answered) Keith Rischer RN answers to assessment & reasoning respiratory system

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!

lOMoARcPSD|5704064

Student- Respiratory Assessment and Reasoning

Nursing (Spalding University)

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:

 

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:

 

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:

 

 

 

 

© 2019 Keith Rischer/www.KeithRN.com

 

 

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

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