Keith Rischer RN assessment & reasoning respiratory sytem
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!
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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 nonproductive 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:
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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
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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:
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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.
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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?
Acute Asthma Exacerbation: A Case Study in Respiratory Assessment and Management
Introduction
Asthma is a chronic inflammatory condition of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing (National Heart, Lung, and Blood Institute, 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Acute exacerbations can be life-threatening and require prompt treatment. This case study examines the assessment and management of a 35-year-old male presenting with an acute asthma exacerbation.
Case Presentation
John Franklin is a 35-year-old African American male with a past medical history of hypertension and asthma who presents with increased shortness of breath and a persistent cough after eating dinner. He reports running out of his albuterol inhaler two months ago and audible expiratory wheezing is noted on examination. Vital signs on admission show tachycardia, tachypnea, elevated blood pressure, and oxygen saturation of 91% on room air. Lung auscultation reveals coarse inspiratory and expiratory wheezing with prolonged expiration and diminished breath sounds at the lung bases.
Assessment and Interpretation
The primary problem is an acute exacerbation of asthma as evidenced by the history presented and physical exam findings on admission. Key signs include onset of symptoms, past history of asthma, and audible wheezing. The respiratory system requires priority assessment given involvement of the lungs and airways. Abnormal vital signs reflect increased work of breathing and decreased oxygenation. Lab results are non-contributory with normal chest x-ray and basic metabolic panel (Kumar et al., 2020).
Management and Evaluation
Treatment is initiated with nebulized bronchodilators and steroids to reverse bronchoconstriction and reduce inflammation. Vital signs, breath sounds, and oxygen saturation are reassessed after 30 minutes and show improvement, indicating response to therapy. Continued monitoring and intervention are warranted but the patient’s condition is stabilizing appropriately with the prescribed treatment plan (National Asthma Education and Prevention Program, 2007).
Ace my homework – Write my paper – Online assignment help tutors – Discussion
This case study demonstrates the importance of thorough respiratory assessment in acute asthma exacerbations to identify severity and guide management. Timely treatment with bronchodilators and steroids can reverse symptoms and prevent complications. Regular follow-up care and medication adherence are key to preventing future exacerbations. Further education is also needed on proper inhaler technique and medication usage (Global Initiative for Asthma, 2021).
Conclusion
Nurses play a vital role in assessing and stabilizing patients during acute asthma exacerbations. This case provided the opportunity to apply knowledge of respiratory assessment skills and interpret relevant clinical data to formulate a priority nursing diagnosis and individualized treatment plan. Ongoing evaluation ensured appropriate response to interventions was achieved.
