NUR 301 Holistic Health Assessment

Review of the Perfusion Assessment The nurse hears a heart murmur on a client and wants to grade this soft but very audible sound. How should this heart murmur be described? A. Grade 2 B. Grade 1 C. Grade 3 D. Grade 4

Review During the cardiac assessment, the nurse finds a client has jugular vein distention. What does this mean to the nurse? A. The client could have fluid overload. B. The client has an infection. C. The client is dehydrated. D. The client is fine.

Review During the cardiac focused interview, the client tells the nurse he has smoked for 30 years. Which of the following would be appropriate for the nurse to respond to this client? A. Smoking has been linked to high blood pressure and other heart problems. B. High dose vitamin therapy reduces the risks of smoking. C. Do you also take recreational drugs? D. Exercise reduces the harmful effects of smoking.

Review The nurse is calculating the cardiac output for a client with a heart rate of 88 beats per minute. What other measurements does the nurse need to complete this calculation? A. Stroke volume B. QT interval C. Cardiac index D. T wave

Review The nurse is instructing a client about his high cholesterol level and wants to include behavioral considerations. Which of the following should be included in this instruction? A. The need for an annual cholesterol panel B. The need for annual flu inoculation C. The need to stop smoking D. The need to reduce stress

What is Oxygenation?

Structures of the Respiratory System

Major Functions of Respiration Supplying oxygen to the body for energy production Removing carbon dioxide as a waste product of energy reactions Maintaining homeostasis (acid-base balance) of arterial blood by supplying oxygen to blood and eliminating excess carbon dioxide, respiration maintains pH or acid-base balance of blood Maintaining heat exchange (less important in humans)

Landmarks-Ant. Thoracic Cage

Landmarks-Post. Thoracic Cage

Thoracic Cavity Mediastinum: middle section of thoracic cavity containing esophagus, trachea, heart, and great vessels Right and left pleural cavities, on either side of mediastinum, contain lungs Lung borders: In anterior chest, apex of lung tissue is 3 or 4 cm above inner third of clavicles Base rests on diaphragm at about sixth rib in midclavicular line Laterally, lung tissue extends from apex of axilla down to seventh or eighth rib

Reference lines

Reference Lines

Lobes of lungs Lungs Paired Not symmetric Right lung shorter than left due to liver Left lung narrower due to heart Right has 3 lobes

Mechanics of Respiration

Respiration-how does it occur? Involuntary, physical act Stimulus to breathe for most of us is an increase of carbon dioxide in blood, or hypercapnia Decrease of oxygen in blood (hypoxemia) also increases respirations but less effective than hypercapnia

Variations in Breathing Sigh Tachypnea Bradypnea Hyperventilation Hypoventilation Cheyne-Stokes respiration Biot’s respiration Chronic obstructive breathing

Subjective What questions should we ask? Why are we asking them?

The Data

Thoracic Cage -Inspection Shape and Configuration Skin Color and Condition Position person takes to breathe Is the Anterior Posterior Diameter less than the Transverse Diameter?

Palpate the Posterior Chest Confirm symmetric chest expansion Tactile Fremitus Palpate the entire chest wall

Percuss the Posterior Chest Percuss at 5 cm intervals Start at apices Side to Side Avoid Scapula and ribs Resonance is a the low pitched sound that predominates Check diaphragmatic excursion

What makes it difficult to auscultate the chest? Examiners breathing or stethoscope tubing Stethoscope tubing bumping together Patient Shivering Patients hairy chest Rustling of patients gown

Breath Sounds Evaluate Presence of normal breath sounds Have person breath through mouth Little deeper than usual Monitor clients breathing Listen to one full respiration at each location Side to Side comparison Rate Rhythm

Normal Sounds Bronchial-heard over trachea and larynx Bronchovesicular- heard over bronchi where fewer alveoli are located Vesicular-heard over peripheral lung fields What am I hearing over this spot? What should I expect to be hearing?

Abnormal Sounds Decreased or Diminished Sounds Absent Sounds Adventitious Sounds 1. Wheezes (rhonchi) 2. Crackles (rales)

Anterior Chest-Inspect Shape and configuration Costal angle 90 degrees Facial expression Skin color and condition Clubbing Assess quality of respirations Retractions?

Abnormal Configurations of the Thorax Barrel chest Pectus excavatum Pectus carinatum Scoliosis Kyphosis

Barrel Chest

Scoliosis

Kyphosis

Palpate Anterior Chest Symmetric chest expansion-thumbs on along costal margins Tactile vocal fremitus Palpate for tenderness, superficial lumps or masses Skin mobility and turgor, temperature and moisture

Percuss Anterior Chest Begin at apices in supraclavicular area Side to side Do not percuss directly over female breast tissue Note borders of cardiac dullness

Auscultate From apices to sixth rib Side to Side Listen for one full respiration in each location Do not place your stethoscope over female breast Forced expiratory time

Assessments Incentive Spirometer Pulse Oximetry Peak flow

Narrative note

Subjective Data: No problems with breathing. Has had no change in breathing in last 6 months or 2 years. Completes all activities without change in breathing. Sleeps with one pillow. No history of problems that affect breathing. No family history of respiratory disease. Has had occasional cold or throat infection. A cold almost every year treated with OTC medication and subsides. Sore throat in high school, treated with antibiotics, no ongoing problems. No cough, no wheezing, no chest pain. No history of allergies. Has never smoked. Works and lives in smoke-free environments. No anxiety. Uses OTC medication for headache, rarely. No change in weight for 5 years. No exposure to fumes or irritants. Objective Data: Height 5 ′ 8 ″, weight 154 lb. Skin of face pink. No nasal flaring, nares patent. Lips pink, moist. Alert and oriented. BP 118/66—P 76—RR 16. Respirations regular, deep, no use of accessory muscles. Chest movement and excursion symmetrical. Transverse to AP diameter 2:1. Scapulae or plane perpendicular to vertebral line. Muscle mass firm. Chest color pink, warm. No masses, lesions, pain, or crepitus. Spine vertically aligned, ribs intact. Symmetrical respiratory expansion. Tactile fremitus strong over trachea, weakening over bronchi, and absent over alveoli. Resonance throughout lung fields to percussion. Diaphragmatic excursion 5 cm bilaterally and parallel. Anterior and posterior breath sounds vesicular over periphery, bronchovesicular between scapulae and lateral to sternum, bronchial sounds next to trachea, tracheal sounds over the trachea. No adventitious sounds

Health Promotion: What can nursing do to promote a health respiratory system?

Health Promotion

Breathing Exercise

Nursing Diagnosis Ineffective Airway Clearance Activity Intolerance Anxiety Fatigue

Case Study Tanisha arrives at the clinic in respiratory distress. She is hunched forward and says she cannot get her breath. She is holding her inhaler but says it is empty. She is crying softly and says she does not want to be admitted to the hospital again. Tanisha tells you that her attack started about 2 hours ago. She used her inhaler 6 times, but it does not seem to help. As you assess her, she is wheezing and in some distress. When she tries to take a breath, she coughs. Her oxygen saturation is 92%.

Case Study Tanisha Robinson, a 14-year-old female, has been seen regularly in the clinic for chronic asthma. Today, Tanisha's mother has accompanied her for a checkup. Tanisha has required two visits to the emergency room (ER) for severe wheezing in the month since her last clinic visit. The physical assessment revealed that the client was in no distress and breath sounds were clear. Her vital signs were BP 126/82 P 84 RR 20.Her skin was warm, dry, and pink in color. Tanisha could speak clearly and seemed relaxed. During the interview the nurse learned that the client has been following her prescribed treatments and has done well except for the two ER visits.

When asked if she could identify any precipitating factors, Tanisha replied, "I know they happened on days that we had gym, but I don't usually have a problem with that." The nurse asked if she had any changes in her routines, activities, or environments. She said, "No, not that I can think of." Her mother stated, "We're so upset. She's been out twice this month." The client then added, "Yes, I hate to have to miss school and get behind. Now my friend and I have to work twice as hard as before to get our project done."

The nurse asked about the project and the client said, "We are working on an art project--collecting materials and doing a thing on textures. It's pretty cool. We collected old clothes from the Salvation Army and a garage sale and we've been cutting them up sort of in a collage." The nurse asked if the work on the project coincided with her recent attacks. The client said, "Gee, I don't know. I never thought about it." Her mother stated, "Oh, we never even thought about that, but on both days, she had been working on the project after school with her friend and really got bad as the evening wore on."