Assessment & Reasoning Respiratory v v v v
System
JohnvFranklin,v35vyearsvold
Suggested Respiratory Nursing Assessment Skills to Be Demonstrated:
v v v v v v v
• Inspection:vInspectvthoraxvforvsymmetryvandvconfiguration-
vCheckvtovseevif vhevif vusingvaccessoryvmusclesvorvif vbreathingvisvlabored.
•
• Palpation:vPalpatevovervanteriorvandvposteriorvchestvforvanyvlump,vmasses,vtendernessv&vcrepitus
•
• Percussion:vPercussvovervposteriorvtovcheckvforvtactilevfremitus
•
• Auscultation:
• Auscultatevallvlungvfields
•
Make Learning Active!
v v
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94mfrom v CourseHero.comv onv 04-16-2021v 00:06:26v GMTv -05:00
https://www.coursehero.com/file/70918278/Clinical-3-Case-studydocx/
, Present Problem:
v
vJohnvFranklinvisvav35-year-
oldvAfricanvAmericanvmalevwhovhasvavhistoryvofvhypertensionvandvasthmavwhovsmokesv½vppdvsincevthevagevofveighteen.vH
evbeganvtovfeelvmorevshortvofvbreathvaftervsuppervtodayvandvbeganvtovhavevavpersistentvnon-
productivevcough.vHevranvoutvofvhisvalbuterolvinhalervtwovmonthsvagovandvhasvaudiblevexpiratoryvwheezingvwhenvhevcome
svtovthevtriagevwindowvofvthevemergencyvdepartmentv(ED).
JohnvisvpromptlyvbroughtvtovavroomvinvthevEDvandvyouvarevthevnursevresponsiblevforvhisvcare.
WhatvdatavfromvthevpresentvproblemvarevRELEVANTvandvmustvbevinterpretedvasvclinicallyvsignificantvbyvthevnurse?
(ReductionvofvRiskvPotential)
RELEVANTvDatavfromvPresentvProblem: ClinicalvSignificance:
HistoryvofvHypertensionvandvasthmavSmoke Havingvthevhistoryvofvasthmavandvbecausevhevsmokes,vthisvconfirmvthatvhevi
sv½vppdvsincev18 svhavingvanvasthmavattackvthatvcouldvhavevflaredvup.
Shortnessvofvbreath,vpersistentvnonproductivevco Havingvthevnonproductivevcoughvisvconsistentvwithvasthmavattacks,vi
ugh fvitvwerevproductive,vitvwouldvbevlinkedvtovpneumonia.
RanvoutvofvalbuterolvinhalervtwovmonthsvagovAu Clientvhadvnovwayvtovtreatvhisvasthmavbecausevhevranvoutvofvhisvmedicine.vHi
diblevexpiratoryvwheezing svwheezingvwasvsovloudvnovstethoscopevneededvtovbevused.vMeansvhis
conditionvwasvbad.
WhatvisvthevRELATIONSHIPvofvyourvpatient’svpastvmedicalvhistoryv(PMH)vandvcurrentvmeds?
(Whichvmedicationvtreatsvwhichvcondition?vDrawvlinesvtovconnect.)
PMH: HomevMeds: Pharm.vClass: MechanismvofvActionv(ownvwords):
AsthmavHypertensio Albuterolvinhalerv2vpuffsveve adrenergicvbroncho relaxesvsmoothvmusclesvitvthevbronchialvtr
ryv4vhoursvPRNvwheezing dilators eevandvperipheralvvasculaturevbyvstimulati
n ngvadrenergicvreceptorsvofvthevsympatheti
Furosemidev20vmgvPOvdaily cvnervousvsystem.
loopvdiuretics Furosemidevisvavpotentvloopvdiureticvthat
actsvonvthevkidneysvtovultimatelyvincreasev
watervlossvfromvthevbody.
You place John on a cardiac monitor, continuous oximetry a
v v v v v v v v v
nd quickly collect the following assessment data:
v v v v v v
Patient Care Begins:
v v
CurrentvVS: P-Q-R-S-TvPainvAssessment:
T:v99.1vF-37.3vCv(oral) Provoking/Palliative: Deniesvpain
P:v110v(regular) Quality:
R:v24v(regular) Region/Radiation:
BP:v188/110 Severity:
O2vsat:v91%vRA Timing:
Whatvvitalvsignsvarevabnormal?vWhatvisvthevreasonv(pathophysiology)vforvthesevfindings?
(ReductionvofvRiskvPotential/HealthvPromotionvandvMaintenance)
AbnormalvVS: ClinicalvSignificance:
BP:v188/10
Oxygenvsaturationvlow,vclient’svairwayvmayvbevblocked,vlowvamountvofvoxygenvinvthevblood.
02vsat:v91%vRA
Clientvisvtakingvavlotvofvbreaths
R:v24
Clientvisvveryvanxious
P:v110
Thisvstudyvsourcevwasvdownloadedvbyv100000816649994vfromvCourseHero.comvonv04-16-2021v00:06:26vGMTv-
05:00
https://www.coursehero.com/file/70918278/Clinical-3-Case-studydocx/
System
JohnvFranklin,v35vyearsvold
Suggested Respiratory Nursing Assessment Skills to Be Demonstrated:
v v v v v v v
• Inspection:vInspectvthoraxvforvsymmetryvandvconfiguration-
vCheckvtovseevif vhevif vusingvaccessoryvmusclesvorvif vbreathingvisvlabored.
•
• Palpation:vPalpatevovervanteriorvandvposteriorvchestvforvanyvlump,vmasses,vtendernessv&vcrepitus
•
• Percussion:vPercussvovervposteriorvtovcheckvforvtactilevfremitus
•
• Auscultation:
• Auscultatevallvlungvfields
•
Make Learning Active!
v v
Thi©
sv st2u0
dy1s9ouK
rcee iw
thasRdoiswcnhloeadr/ew
d v bwyw
10.K
00e0i0t 8h1R
66N4 .9c9 o
94mfrom v CourseHero.comv onv 04-16-2021v 00:06:26v GMTv -05:00
https://www.coursehero.com/file/70918278/Clinical-3-Case-studydocx/
, Present Problem:
v
vJohnvFranklinvisvav35-year-
oldvAfricanvAmericanvmalevwhovhasvavhistoryvofvhypertensionvandvasthmavwhovsmokesv½vppdvsincevthevagevofveighteen.vH
evbeganvtovfeelvmorevshortvofvbreathvaftervsuppervtodayvandvbeganvtovhavevavpersistentvnon-
productivevcough.vHevranvoutvofvhisvalbuterolvinhalervtwovmonthsvagovandvhasvaudiblevexpiratoryvwheezingvwhenvhevcome
svtovthevtriagevwindowvofvthevemergencyvdepartmentv(ED).
JohnvisvpromptlyvbroughtvtovavroomvinvthevEDvandvyouvarevthevnursevresponsiblevforvhisvcare.
WhatvdatavfromvthevpresentvproblemvarevRELEVANTvandvmustvbevinterpretedvasvclinicallyvsignificantvbyvthevnurse?
(ReductionvofvRiskvPotential)
RELEVANTvDatavfromvPresentvProblem: ClinicalvSignificance:
HistoryvofvHypertensionvandvasthmavSmoke Havingvthevhistoryvofvasthmavandvbecausevhevsmokes,vthisvconfirmvthatvhevi
sv½vppdvsincev18 svhavingvanvasthmavattackvthatvcouldvhavevflaredvup.
Shortnessvofvbreath,vpersistentvnonproductivevco Havingvthevnonproductivevcoughvisvconsistentvwithvasthmavattacks,vi
ugh fvitvwerevproductive,vitvwouldvbevlinkedvtovpneumonia.
RanvoutvofvalbuterolvinhalervtwovmonthsvagovAu Clientvhadvnovwayvtovtreatvhisvasthmavbecausevhevranvoutvofvhisvmedicine.vHi
diblevexpiratoryvwheezing svwheezingvwasvsovloudvnovstethoscopevneededvtovbevused.vMeansvhis
conditionvwasvbad.
WhatvisvthevRELATIONSHIPvofvyourvpatient’svpastvmedicalvhistoryv(PMH)vandvcurrentvmeds?
(Whichvmedicationvtreatsvwhichvcondition?vDrawvlinesvtovconnect.)
PMH: HomevMeds: Pharm.vClass: MechanismvofvActionv(ownvwords):
AsthmavHypertensio Albuterolvinhalerv2vpuffsveve adrenergicvbroncho relaxesvsmoothvmusclesvitvthevbronchialvtr
ryv4vhoursvPRNvwheezing dilators eevandvperipheralvvasculaturevbyvstimulati
n ngvadrenergicvreceptorsvofvthevsympatheti
Furosemidev20vmgvPOvdaily cvnervousvsystem.
loopvdiuretics Furosemidevisvavpotentvloopvdiureticvthat
actsvonvthevkidneysvtovultimatelyvincreasev
watervlossvfromvthevbody.
You place John on a cardiac monitor, continuous oximetry a
v v v v v v v v v
nd quickly collect the following assessment data:
v v v v v v
Patient Care Begins:
v v
CurrentvVS: P-Q-R-S-TvPainvAssessment:
T:v99.1vF-37.3vCv(oral) Provoking/Palliative: Deniesvpain
P:v110v(regular) Quality:
R:v24v(regular) Region/Radiation:
BP:v188/110 Severity:
O2vsat:v91%vRA Timing:
Whatvvitalvsignsvarevabnormal?vWhatvisvthevreasonv(pathophysiology)vforvthesevfindings?
(ReductionvofvRiskvPotential/HealthvPromotionvandvMaintenance)
AbnormalvVS: ClinicalvSignificance:
BP:v188/10
Oxygenvsaturationvlow,vclient’svairwayvmayvbevblocked,vlowvamountvofvoxygenvinvthevblood.
02vsat:v91%vRA
Clientvisvtakingvavlotvofvbreaths
R:v24
Clientvisvveryvanxious
P:v110
Thisvstudyvsourcevwasvdownloadedvbyv100000816649994vfromvCourseHero.comvonv04-16-2021v00:06:26vGMTv-
05:00
https://www.coursehero.com/file/70918278/Clinical-3-Case-studydocx/
