Page 358 - ACCCN's Critical Care Nursing

Respiratory Assessment and Monitoring 335

‘increased pressure’ oedema, where there is an increase in treatment. Depending on a patient’s situation, assess-
hydrostatic or osmotic forces (e.g. left heart ventricular ment can be either brief or detailed.
dysfunction or volume overload); and ‘increased perme-
ability’ oedema, that results from increased membrane PATIENT HISTORY
permeability of the epithelium or endothelium in the History-taking determines a patient’s baseline respiratory
lung, allowing accumulation of fluid (also called ‘non- status on admission to ICU. If the patient is in distress
cardiogenic’). Resulting clinical syndromes are acute lung only a few questions may be asked but, if the patient is
injury (ALI) or acute respiratory distress (ARDS) (see able, a more comprehensive interview can be performed,
Chapter 14 for further discussion). focusing on four areas: the current problem, previous

Changes to Respiratory Function problems, symptoms and personal and family history.
Question a family member or close friend if a patient is
During the early exudative phase of ALI/ARDS, tachy- not able to provide their own history.
pnoea, signs of hypoxaemia (apprehension, restlessness)
and an increase in the use of accessory muscles are usually When introducing yourself, ask the patient’s name, seek
evident as a result of infiltration of fluids into the alveoli. eye contact and create a rapport with the patient and the
With impaired production of surfactant during the pro- family. Ensure that the patient is in a comfortable posi-
liferative phase, respiratory function deteriorates, and tion, ideally sitting up in the bed. Provide privacy so that
dyspnoea, agitation, fatigue and the emergence of fine the interview is confidential and the physical examina-
crackles on auscultation are common. 1,11 Airway resis- tion can be done while maintaining the patient’s dignity
tance is increased when oedema affects larger airways. and modesty. To minimise distress for a patient who is
Lung compliance is reduced as interstitial oedema inter- acutely breathless, the use of short closed questions is
feres with the elastic properties of the lungs, and patients preferable.
may be quite a challenge to adequately ventilate. Infiltra-
tion of type II alveolar cells into the epithelium may lead
21
to interstitial fibrosis on healing, causing chronic lung Practice tip
dysfunction.
History-taking is a nursing interview and an interactive experi-
Respiratory Dysfunction: Changes to ence, especially the initial interview where both the patient
Work of Breathing and the nurse learn a lot about each other. This knowledge
has a considerable influence on building rapport between the
If respiratory compromise is not reversed, there will be patient and the nurse.
significant increases to the work of breathing. Clinical
manifestations include tachypnoea, tachycardia, dys-
pnoea, low tidal volumes and diaphoresis. Hypercapnia Current Respiratory Problems
will ensue, which further compromises respiratory muscle
function and precipitates diaphragmatic fatigue. Oxygen Begin by asking why the patient is seeking care. If possi-
consumption during breathing can be so great that reserve ble, let the patient describe the respiratory problem in
capacity is reduced. If patients with preexisting COPD his or her own words. Be focused and listen actively.
(who may breathe close to the fatigue work level) experi- Ask for location, onset and duration of the respiratory
ence an acute exacerbation, this can easily tip them into symptoms.
a fatigued state. Early identification and management of
respiratory compromise before these stages improves Previous Respiratory Problems
patient outcomes. 19 Many respiratory disorders can be chronic and pulmo-
nary diseases may recur (e.g. tuberculosis), and new dis-
ASSESSMENT eases can complicate old ones. Ask about problems with
22
breathing and their chest, number of hospitalisations,
Respiratory insufficiency is a common reason for admis- treatments, and childhood respiratory diseases.
sion to a critical care unit, for either a potential or an
actual problem, so comprehensive and frequent respira- Symptoms
tory assessments are an essential practice role. This section Assess any presenting symptoms in relation to: onset and
outlines history, physical examination, bedside monitor- duration, pattern, severity, and episodic or continuous.
ing and diagnostic testing focused on a critically ill patient Also ask about the patient’s perception of their respira-
with respiratory dysfunction. tory problem, their opinion about its cause and if the
symptoms cause fatigue, anxiety or stress. Ask the patient
Assessment is a systematic process comprising history
taking of a patient’s present and previous illnesses, and specifically about: dyspnoea, cough, sputum production,
physical examination of their thorax, lungs and related haemoptysis, wheezing, chest pain or other pain, sleep
systems. History taking and physical examination can be disturbances and snoring.
done simultaneously if the patient is very ill. Related Dyspnoea (shortness of breath) is subjective and there-
diagnostic findings inform an accurate and comprehen- fore difficult to grade. The mechanism that underlies the
sive assessment. A thorough assessment, followed by sensation of dyspnoea is poorly understood but it is
22
accurate ongoing monitoring, enables early detection of extremely uncomfortable and frightening. Assess the
condition changes and assessment of the impact of severity of dyspnoea by asking about breathing in