Page 40 - Critical Care Nursing Demystified

Chapter 2 CARE OF THE PATIENT WITH CRITICAL RESPIRATORY NEEDS 25

Assessment Skills for the High-Risk Respiratory Patient

1 When patients are critically ill with a disease that alters the functions of
normal ventilation, assessment of the efficiency or inefficiency of respiration
is crucial and mandatory. All nurses must possess strong assessment skills (see
Tables 2–1 and 2–2).

TABLE 2–1 Physical Assessment
History and Determine the patientʼs chief complaint. Example: hemoptysis
interview or bloody sputum, dyspnea, or chest pain.
Discover elements relating to the patientʼs present problem such
as intensity, duration of symptoms, and precipitating factors.
Observe for clues to current health and emotional status
during the interview. Example: tearful, angry, or evasive with
responses.
Question social and family history such as occupational condi-
tions, diet, medications, recreational drug use, alcohol or
tobacco use, and previous medical/surgical history.
Inspection Observe the patientʼs general state of health and respiratory Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
distress pattern.
Inadequate nutrition and physical appearance (such as muscu-
lar atrophy, kyphosis, barrel chest) should also be noted.
Inspect the patient from both the front and the back observing
for any breathing difficulties or the obvious use of accessory
muscles.
Observe breath sounds, which should be smooth and regular
with12–20 breaths per minute.
Factors that may reflect breathing difficulties include:
a. Orthopnea or leaning forward to breathe.
b. Asymmetry with lung expansion from a collapsed lung,
fluid, or solid mass.
c. Lip pursing along with an increased expiratory effort. This is
often associated with chronic obstructive lung disease.
d. Nasal flaring or air hunger from increased work of breathing
due to extensively compromised alveoli.
e. Inspect for signs of cyanosis in highly vascular areas such as
the lips, nail beds, tip of the ear, and underside of the
tongue.
f. Examine the fingers for signs of “clubbing.” This is often
associated with chronic fibrotic lung disease, cystic fibrosis,
and congenital heart disease with cyanosis.