Patient is a Caucasian 83 year old female that came into the emergency department from Wynwood assisted living facility with an increase of fatigue, worsening confusion and a 1 day history of a fever. Patient weighs approximately 90 pounds upon admission with a height of 64 inches. Patient has known COPD and is a former heavy smoker that also has a history of pneumonia, hypertension, atrial fibrillation, and dementia. Upon presentation to the emergency department patient has had increased nasal drainage and cough. Patient came into the hospital about a year and a half ago with a diagnosis of right lower lobe pneumonia. Patient was arousable, alert and pleasant, but not a good historian and appears to be quite emaciated. Patient at first had a non productive cough and was put on anti-biotics and began to have a productive cough 2 days post admission. Patient had dyspnea, increase respiration rate, difficulty talking, coarse lungs, and had decreased SpO2 with activity.
Patient lived in Wynwood assisted living facility where she lived almost independently. Patient was able to get around her apartment with a front wheel walker and provided her own care of activities of daily living. With this admission, hospital staff did not recommend patient going back to assisted living as she would not be able to take care of her self until her mobility is back to her normal limits and the dyspnea is decreased.
Ineffective airway clearance r/t bronchospasm, excessive mucous production, tenacious secretions, fatigue AMB dyspnea, increase RR (28), difficulty talking, inability to raise secretions, ineffective cough, adventitious breath sounds.
A. Pt will demonstrate effective coughing and clear breath sounds by end of shift 5/15/10 (3 days) and until discharge. B. Pt will continue to have cyanotic free skin by end of shift on 5/14/10 (2 days) and until discharge. C. Pt will maintain a patent airway at all times by end of shift 5/15/10 (3 days) and until discharge. D. Pt will relate methods to enhance secretion removal (drinking warm fluids) by end of shift 5/15/10 (3 days) and until discharge. E. Pt will relate the significance of changes in sputum to include color, character, amount and odor by end of shift 5/15/10 (3 days) until discharge.
1. RN will auscultate breath sounds Q4 hrs and PRN until discharge. 2. RN and CNA will monitor respiratory patterns, including rate, depth, and effort Q4 hr and PRN until discharge. 3. RN will monitor blood gas values as available and pulse oxygen saturation levels Q8 hr and PRN until discharge. 4. RN and CNA will position the client to optimize respiration (HOB elevated 45 degrees and repositioned every 2 hrs) and PRN until discharge. 5. RN and CNA will help the pt deep breathe and perform controlled coughing Q2hrs until discharge. 6. RN will help the pt use the forced expiratory technique, the “huff cough”. The pt does a series of coughs while saying the word huff q4hr and PRN until discharge. 7. RN or CNA will assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary Q4 hr and PRN until discharge. 8. RN will observe sputum, noting color, odor and volume PRN until discharge.9. RN and CNA will encourage activity and ambulation as tolerated TID and PRN until discharge.
10. RN and CNA will encourage fluid intake of up to 2500 mL/day within cardiac or renal reserve Q2 hrs and PRN until discharge. 11. RN will administer oxygen as ordered until discharge12. RN or RT will administer medications such as bronchodilators or inhaled steroids as ordered until discharged. 13. RN and CNA will monitor the patient’s behavior and mental status for the onset of restlessness, agitation, confusion and extreme lethargy twice a shift and PRN until discharge date. 14. RN and CNA will observe for cyanosis of the skin twice a shift and PRN until discharge. 15. RN or CNA will position patient over bedside table for acute dyspnea PRN until discharge. 16. RN & CNA will help pt eat frequent small meals and use dietary supplements PRN until discharge. 17. RN will teach pt energy conservation techniques and the importance of alternating rest periods with activity by end of shift tomorrow and PRN until discharge.| 1. “The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates a narrowed airway” (Simpson, 2006, p. 487).2. “A normal respiratory rate for an adult without dyspnea is 12-16. With secretions in the airway, the respiratory rate will increase” (Simpson, 2006, p. 486).
3. “An oxygen saturation of less than 90% or a partial pressure of oxygen of less than 80 indicates significant oxygenation problems” (Sanford & Jacobs, 2008, p. 125).4. “An upright position allows for maximal lung expansion; lying flat cause abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe” (Sanford & Jacobs, 2008, p. 125).5. “This technique can help increase sputum clearance and decrease cough spasms. Controlled coughing was the diaphragmatic muscles, making the cough more forceful and effective” (Sanford & Jacobs, 2008, p. 125).6. “This technique prevents the glottis from closing during the cough and is effective in clearing secretions in the central airways” (Sanford & Jacobs, 2008, p. 126).7. “In the debilitated client, gentle suctioning of the posterior pharynx may stimulate coughing and removing secretions” (Sanford & Jacobs, 2008, p. 126).8. “Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious” (Sanford & Jacobs, 2008, p. 126).
9. “Body movements helps mobilize secretions and can be a powerful means to maintain lung health” (Sanford & Jacobs, 2008, p. 126).10. “Fluids help minimize mucosal drying and maximize ciliary action to move secretions. Some pts cannot tolerate increased fluids because of underlying disease” (Sanford & Jacobs, 2008, p. 126).11. “Oxygen has been shown to correct hypoxia, which can be caused by retained respiratory secretions” (Sanford & Jacobs, 2008, p. 126).12. “Bronchodilators decrease airway resistance secondary to broncho-constriction” (Sanford & Jacobs, 2008, p. 126).13. “Changes in behavior and mental status can be early signs of impaired gas exchange. In the late stages the patient becomes lethargic and somnolent” (Sanford & Jacobs, 2008, p. 388).14. “Central cyanosis of the tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may or may not be serious” (Sanford & Jacobs, 2008, p. 388).
15. “Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm. This is called the tripod position and is used during times of distress” (Sanford & Jacobs, 2008, p. 388).16. “Improved nutrition can help increase muscle aerobic capacity and exercise tolerance. Nutritional problems in clients with COPD can be visual; early identification of clients at risk is essential to maintaining BMI” (Sanford & Jacobs, 2008, p. 389).17. “Fatigue is a common symptom of COPD and needs to be assessed and managed” (Sanford & Jacobs, 2008, p. 390).|
In the Article, “Respiratory Assessment,” by Heidi Simpson, intends for the audience to be nurses already working in the field. This article gives an order of a respiratory assessment that works for any nurse, whether they are a new graduating nurse or a nurse who has been working for years. This journal article gives all the required elements in order to do a full respiratory assessment which includes the “initial assessment, history taking, inspection, palpitation, percussion, auscultation, and further investigations” (Simpson, 2006, p. 484). This article is a general information article that focuses towards all and any patient population as all of our patients need to have a respiratory assessment done. This article gives a good breakdown of a respiratory assessment in which I currently use in practice. The article can be a good reminder of how an accurate respiratory assessment should be done and how to get good results in the technique a nurse may use.
Sanford, J.T. & Jacobs, M. (2008). Impaired gas exchange. In B.J. Ackley & G.B. Ladwig (Eds.) Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed., pp. 388-390). St Louis, MO: Elsevier. Sanford, J.T. & Jacobs, M. (2008). Ineffective airway clearance. In B.J. Ackley & G.B. Ladwig (Eds.) Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed., pp. 124-129). St Louis, MO: Elsevier. Simpson, H. (2006). Respiratory assessment. British Journal of
Nursing (BJN), 15(9), 484-488. Retrieved from CINAHL with full text database.