oxygenationNursing process

ASSESSMENT

Nursing history

Physical examination

Diagnostic test NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS IMPLEMENTATIONS EVALUATIONS

oxygenationASSESSMENT

NURSING HISTORYNursing history should be focused on the patient’s

ability to meet the oxygen needs.

On the following points history should be collected from the patient to assess the respiratory status:

1. Chest pain2. Fatigue3. Dyspnea4. Cough5. Wheezing

6. Respiratory infection

7. Allergies8. Health risks9. Medications10.Others (i.e.

smoking and environmental and geographical exposure)

oxygenationASSESSMENT

history

CHEST PAIN

History regarding the chest pain should include: location, duration, radiation and frequency. some of the descriptions regarding chest pain are as follows

1. Chest pain in male usually occur on the left side of the chest and radiate to the left arm.

2. Chest pain (heart attack) usually associated with breathlessness, jaw or back pain and radiate to left arm.

contd.

oxygenationASSESSMENT

history

3. Pericardial pain results from inflammation of the pericardial sac, occurs on inspiration and does not radiate.

4. Pleuritic chest pain radiate to the scapular region. Coughing, yawning sighing worsen the pleuritic chest pain.

5. Pleuritic chest pain usually sharp knife like pain always associated with inspiration.

oxygenationASSESSMENT

history

FATIGUE

Fatigue is the term used for tiredness.

It is a subjective sensation used as the early sign of cardiopulmonary impairment.

It occurs in response to the decreased cellular metabolism due to lack or decreased oxygen supply to the tissue.

oxygenationASSESSMENT

history

DYSPNOEA(difficulty in breathing)

It is a subjective data indicates the hypoxia.

It is associated with cardiopulmonary diseases, neuromuscular conditions and anemia.

While collecting the history about dyspnoea ask about any stressful event, exercises or any respiratory infections.

Ask the patient about sleeping pattern whether dyspnoea affects his ability to lie flat and feeling comfortable in semi fowler's position.

Dyspnoea can be made objective data if nasal flaring, use of accessory muscles in respiration, rate and rhythm of respiration is assessed.

oxygenationASSESSMENT

history

WHEEZINGWheezing is an objective data

Wheezing is the whistle sound produced when a high pressure of air moves through the narrow bronchus.

It is usually present in the condition of the asthma, acute bronchitis or pneumonia.

It may occur during inspiration, expiration or both.

Wheezing indicates the bronchoconstricitons or bronchospasm.

oxygenationASSESSMENT

history

COUGHCough is a sudden audible expulsion of air from the lungs.

Cough is a protective reflex to clear the trachea, bronchi and lugs of irritants and secretions.

Following facts regarding the cough are helpful in assessing the respiratory disorder:

1. Patient with chronic sinusitis usually cough only in morning.

2. Patient with chronic bronchitis cough and produce the sputum all the day.

3. If sputum is present inspect the sputum for color such as green or blood tinged, consistency is thick or thin, amount (increased or decreased), smell (none or foul).

contd.

Following diagnosis can be suspected while inspecting the sputum: Sputum can be: Bloody (Hemoptysis)

blood-streaked sputum - inflammation of throat, bronchi; lung cancer;

Pink sputum - sputum evenly mixed with blood, from alveoli, small bronchi;

massive blood - cavitary tuberculosis of lung, lung abscess, bronchiectasis, infarction, embolism.

Rusty colored - usually caused by pneumococcal bacteria (in pneumonia)

contd.

oxygenationASSESSMENT

historysputum

Purulent - containing pus. The colour can provide hints as to effective treatment in Chronic Bronchitis Patients:

a yellow-greenish (mucopurulent) color suggests that treatment with antibiotics can reduce symptoms. Green color is caused by Neutrophil.

a white, milky, or opaque (mucoid) appearance often means that antibiotics will be ineffective in treating symptoms. (This information may correlate with the presence of bacterial or viral infections, though current research does not support that generalization.)

Foamy white - may come from obstruction or even edema.

Frothy pink - pulmonary edema

oxygenationASSESSMENT

historysputum

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history

SMOKINGWhile collecting the history regarding smoking

following information should be collected:

1. No. of years with smoking

2. No. packets smoked per day

This both are recorded as pack year history.

(i.e. packages per day × years smoked)

Ask about the second hand smoke.

oxygenationASSESSMENT

history

RESPIRATORY INFECTIONFrequency of cold and fluOn an average patient have four cold per yearObtain the history regarding HIV transmission• IV drug users• Multiple sexual partners

Note: patients with AIDS are on grater risk for pneumocystis carinii pneumonia or mycoplasma pneumonia.

oxygenationASSESSMENT

history

ALLERGIES

Collect the history regarding: Types of allergens Response to the allergens Relief measures

Patient with allergies usually exhibits watery eyes, running nose, sneezing, or respiratory symptoms like cough or wheezing.

oxygenationASSESSMENT

history

HEALTH RISK

Collect the history regarding the respiratory disease such as emphysema, lung cancer

If the family members have the disease ask about the level of health or age at the time death

Obtain the data regarding any communicable disease in the family especially TB.

oxygenationASSESSMENT

history

MEDICATIONS

Collect the history of prescribed drug, over the counter drug, herbal therapies or alternatives therapies.

Because such drugs may increase or decrease the effect of other drugs and some time may produce the life threatening conditions too.

Obtain the data for any drug abuse such as marijuana, Opioid or cocaine.

oxygenationASSESSMENT

physical examination

INSPECTIONPurpose:-observation ofSkin and mucus membrane colorGeneral appearanceLevel of consciousnessAdequacy of systemic circulationBreathing patternChest wall movement

oxygenationASSESSMENT

physical examination

INSPECTIONCyanosisClubbing of the fingerUse of accessory

muscles during breathing

Chest wall retraction (sinking of the soft tissue of the chest between Intercostal space )

oxygenationASSESSMENT

physical examination

INSPECTIONParadoxical breathing(chest wall contracts

during inspiration and expand during exhalation)

Shape of the chest(barrel chest)

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physical examination

PALPATIONThrough the chest palpation following

data can be can be documentedThoracic excursionTendernessTactile fremitusThrillsHeaves

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physical examination

THORACIC EXCURSIONThoracic excursion is the

assessment of chest wall movement during respiration

Place hands on the patient's back with thumbs pointed towards the spine.

First rub hands together so that they are not too cold prior to touching the patient.

Hands should lift symmetrically outward when the patient takes a deep breath.

Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. Air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree.

oxygenationASSESSMENT

physical examination

TACTILE FREMITUS

Normal lung transmits a palpable vibratory sensation to the chest wall. This is referred to as fremitus

It can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the words "Ninety-Nine."

This maneuver is repeated until the entire posterior thorax is covered.

The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations.

TACTILE FREMITUS

CONDITION THAT ALTER TACTILE FREMITUS:-

In the presence of consolidation, fremitus becomes more pronounced.

Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue, most commonly in the setting of pneumonia. If a large enough segment of parenchyma is involved, it can alter the transmission of air and sound.

Fremitus over an effusion will be decreased.

Pleural fluid: Fluid, known as a pleural effusion, can collect in the potential space that exists between the lung and the chest wall, displacing the lung upwards.

THRILLS

Thrills are vibratory sensations caused by the heart and felt on the body surface.  Thrills are always associated with murmurs.

Palpate for thrills as follows: Place the patient in the supine position. Use the proximal part of your hand (not

fingers)and press gently over the anterior chest wall over the heart.

Note any thrills appreciated.

HEAVES

Heave is a precordial impulse that may be felt (palpated) in patients with cardiac or respiratory disease.

Precordial impulses are visible or palpable pulsations of the chest wall, which originate from the heart or the vena cava, pulmonary artery or aorta (collectively known as the great vessels).

IT is mostly seen in right ventricular hypertrophy

COPD, mitral stenosis, and myopathies.

HEAVES

TechniqueA parasternal impulse may be

felt when the heel of the hand is rested just to the left of the sternum with the fingers lifted slightly off the chest.

Normally no impulse or a slight inward impulse is felt. The heel of the hand is lifted off the chest wall with each systole.

oxygenationASSESSMENT

physical examination

A few things to remember for percussion:

If you're percussing with your right hand, stand a bit to the left side of the patient's back.

Ask the patient to cross their hands in front of their chest, grasping the opposite shoulder with each hand. This will help to pull the scapulae laterally, away from the percussion field.

Work down the "alley" that exists between the scapula and vertebral column, which should help you avoid percussing over bone.

contd.

oxygenationASSESSMENT

physical examination

A few things to remember for percussion:

Strike the distal inter-phalangeal joint (i.e. the last joint) of your left middle finger with the tip of the right middle finger.

When percussing any one spot, 2 or 3 sharp taps should suffice, though feel free to do more if you'd like. Then move your hand down several inter-spaces and repeat the maneuver.

After you have percussed the left chest, move yours hands across and repeat the same procedure on the right side.

If you detect any abnormality on one side, it's a good idea to slide your hands across to the other for comparison.

In general, percussion is limited to the posterior lung fields. However, if auscultation reveals an abnormality in the anterior or lateral fields, percussion over these areas can help identify its cause.

oxygenationASSESSMENT

physical examination

FINDINGS:

This technique makes use of the fact that striking a surface which covers an air-filled structure (e.g. normal lung) will produce a resonant note

Percussion over fluid or tissue filled cavity generates a relatively dull sound.

If the normal, air-filled tissue has been displaced by fluid (e.g. pleural effusion) or infiltrated with white cells and bacteria (e.g. pneumonia), percussion will generate a deadened tone.

Chronic (e.g. emphysema) or acute (e.g. pneumothorax) air trapping in the lung or pleural space, respectively, will produce hyper-resonant (i.e. more drum-like) notes on percussion.

oxygenationASSESSMENT

physical examination

AuscultationAuscultation is the listening to the sounds the

body makes to detects variations.

Auscultation of the heart includes assessment of normal heart sound, murmurs, rubs and gallops

Auscultation of respiratory system includes the normal air entry, adventitious breath sound.

oxygenationASSESSMENTdiagnostic test

Diagnostic test confirms the findings of physical examination.

There are certain diagnostic test which suggests the alteration in oxygenations. Chest X-ray Complete blood count ECG ABG analysis Pulmonary function test Thoracentasis Sputum analysis Serum electrolytes Lung scan Bronchoscopy