Keith Rischer RN
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:
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:
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:
You place John on a cardiac monitor, continuous oximetry
and quickly collect the following assessment data:
© 2019 Keith Rischer/www.KeithRN.com
What assessment findings are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:
Put it All Together and Think Like a Nurse!
1. Interpreting relevant clinical data, what is the primary problem? What body system(s) will you assess most thoroughly based on the primary/priority concern?
What’s the
problem?
What’s causing the problem?
(explain pathophysiology in OWN words)
PRIORITY Body
System to Assess:
2. Which specific nursing assessments for this body system are most important? Validate successful completion of each nursing assessment on a manikin (if available) identified with peer or faculty initials.
PRIORITY Nursing Assessments: Rationale: Validate Student
Performance:
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
CARDIAC: Skin warm and dry, no edema, heart sounds strong, regular with no abnormal beats/murmurs, pulses 3+ throughout, brisk cap refill
NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen pink, flat, soft/nontender/symmetrical, bowel sounds audible per auscultation in all
four quadrants
GU: Voiding without pain/difficulty, reports urine clear/yellow
INTEGUMENTARY: Cool, moist forehead, skin integrity intact, skin turgor elastic, no tenting present
© 2019 Keith Rischer/www.KeithRN.com
3. What is the current nursing priority and plan of care?
Nursing PRIORITY:
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
4. State the rationale and expected outcomes for the medical plan of care. Medical Management: Rationale: Expected Outcome:
Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)
Radiology: Chest X-Ray
Results: Clinical Significance:
No infiltrates noted, silhouette of
heart is slightly enlarged
Lab Results: Complete Blood Count (CBC)
WBC HGB PLTs % Neuts Bands
Current: 10.5 14.5 295 78 0
RELEVANT Lab(s): Clinical Significance:
© 2019 Keith Rischer/www.KeithRN.com
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.
Current: 140 3.2 185 1.3
RELEVANT Lab(s): Clinical Significance:
Evaluation: Thirty minutes later…
1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable:
Current VS: Most Recent: Current PQRST: T: 99.1 F-37.3 C (oral) T: 99.1 F-37.3 C (oral) Provoking/Palliative: P: 96 (regular) P: 110 (regular) Quality: Denies R: 20 (regular) R: 24 (regular) Region/Radiation: BP: 146/90 BP: 188/110 Severity: O2 sat: 95% RA O2 sat: 91% RA Timing:
Current Assessment:
GENERAL
APPEARANCE:
Resting comfortably, appears in no acute distress
RESP: Breath sounds have mild expiratory wheezing with equal aeration bilaterally, able to
speak in full sentences with no SOB
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4), less anxious
GI: Abdomen pink, flat, soft/nontender/symmetrical, bowel sounds audible per
auscultation in all four quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, skin integrity intact, skin turgor elastic, no tenting present
John has received two albuterol/ipratropium nebulizers and IV
methylprednisolone. You collect the following clinical data to reassess his
status.
© 2019 Keith Rischer/www.KeithRN.com
RELEVANT Assessment
Data:
Clinical Significance: TREND: Improve/Worsening/Stable:
1. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified after this evaluation assessment? (Management of Care, Physiological Adaptation)
Evaluation of Current Status: Modifications to Current Plan of Care:
2. What did you learn that you can apply to future patients you care for? Reflect on your current strengths and
weaknesses this case study identified. What is your plan to make any weakness a future strength?
What Did You Learn? What did you do well with this case study?
What could have been done better? What is your plan to make any weakness a future
strength?
RELEVANT Data from Present ProblemRow1:
Clinical SignificanceRow1:
PMH:
Home Meds:
Asthma Hypertension:
Pharm ClassAlbuterol inhaler 2 puffs every 4 hours PRN wheezing Furosemide 20 mg PO daily:
Mechanism of Action own wordsAlbuterol inhaler 2 puffs every 4 hours PRN wheezing Furosemide 20 mg PO daily:
Current VS:
PQRST Pain Assessment:
P 110 regular:
Denies painQuality:
R 24 regular:
Denies painRegionRadiation:
BP 188110:
Denies painSeverity:
O2 sat 91 RA:
Denies painTiming:
Abnormal VSRow1:
Clinical SignificanceRow1_2:
Current Assessment:
GENERAL:
Appears anxious body tense brows furrowed:
RESP:
CARDIAC:
NEURO:
Alert oriented to person place time and situation x4:
GI:
GU:
Voiding without paindifficulty reports urine clearyellow:
RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_3:
Whats the problemRow1:
Whats causing the problem explain pathophysiology in OWN wordsRow1:
PRIORITY Body System to AssessRow1:
PRIORITY Nursing AssessmentsRow1:
RationaleRow1:
Validate Student PerformanceRow1:
Nursing PRIORITY:
PRIORITY Nursing InterventionsRow1:
RationaleRow1_2:
Expected OutcomeRow1:
Medical ManagementRow1:
RationaleRow1_3:
Expected OutcomeRow1_2:
Results:
Clinical SignificanceNo infiltrates noted silhouette of heart is slightly enlarged:
Complete Blood Count CBCRow1:
Current:
RELEVANT LabsRow1:
Clinical SignificanceRow1_4:
Basic Metabolic Panel BMPRow1:
Creat:
Current_2:
13:
RELEVANT LabsRow1_2:
Clinical SignificanceRow1_5:
Current VS_2:
Most Recent:
Current PQRST:
T 991 F373 C oral:
ProvokingPalliative:
P 96 regular:
P 110 regular_2:
Quality:
R 20 regular:
R 24 regular_2:
DeniesRegionRadiation:
BP 14690:
BP 188110_2:
DeniesSeverity:
O2 sat 95 RA:
O2 sat 91 RA_2:
DeniesTiming:
Current Assessment_2:
Resting comfortably appears in no acute distress:
RESP_2:
CARDIAC_2:
NEURO_2:
GI_2:
GU_2:
Voiding without difficulty urine clearyellow:
SKIN:
RELEVANT VS DataRow1:
Clinical SignificanceRow1_6:
TREND ImproveWorseningStableRow1:
RELEVANT Assessment DataRow1_2:
Clinical SignificanceRow1_7:
TREND ImproveWorseningStableRow1_2:
Evaluation of Current StatusRow1:
Modifications to Current Plan of CareRow1:
What Did You LearnRow1:
What did you do well with this case studyRow1:
What could have been done betterRow1:
What is your plan to make any weakness a future strengthRow1: