Using the guidelines in Wilson & Giddens’ Ch. 11 and videos, perform a respiratory assessment process on a patient or a significant other. Write up your findings following the guidelines and post them here. It is important for nurses in all practice settings to be able to perform a basic respiratory assessment. This includes taking a pertinent patient history and using the techniques of inspection, palpation, percussion, and auscultation. Immediately upon meeting a patient I am looking to see if they are able to ambulate without signs or symptoms of respiratory distress and I find out if they have had a recent breathing treatment that is working to temporarily relieve their condition – it is important to keep in mind that they may deteriorate faster than originally anticipated.
Important questions for respiratory assessment include: past and current medical problems- do they have a diagnosis of asthma, emphysema, chronic obstructive pulmonary disorder, or lung cancer? Were they recently diagnosed with an upper respiratory infection, bronchitis, or pneumonia? Do they currently have a cough- strong or weak, for how long, and is it productive or non- productive? If there is sputum production- what is the color and consistency? Has there been any hemoptysis? Is there any wheezing or increased shortness of breath with exertion- from talking and/ or walking? Have they experienced any chest pain? If yes I ask about strength, location, duration, is it reproducible?
Is it relieved by anything or made worse by anything? I ask if they have experienced any night sweats or if they have noted any swelling in their upper or lower extremities. I find out about their smoking habits- do they smoke currently? If they say they have quit then I ask when and how many packs per a day for how many years did they smoke prior to quitting? Also, I like to find out if they are around second hand smoke. Do they use drugs- especially ones that are inhaled. What do they have for allergies? If none to drugs I ask about environmental, animal, and work related irritants. Is there any family history of lung disease, cancer, tuberculosis, cystic fibrosis, emphysema, or asthma?
I also ask the patient whether or not they have had an annual flu and/ or pneumonia vaccine. After the interview is completed, I proceed through the steps of a respiratory physical assessment: inspection, palpation, percussion, and auscultation. Ideally, I would position the patient upright and have them breathe through their mouth to better observe respiratory rate, pattern, effort, and chest expansion. I am looking for clubbing, weight loss, unevenly developed muscles, skin & mucous membrane changes, and the general appearance of the patient.
I use my stethoscope to listen to breath sounds- I’m comparing the anterior, posterior, and lateral thorax. I am listening for quality, intensity, and the possible presence of adventitious sounds. I palpate the trachea, thoracic muscles, and thoracic wall looking for proper position, symmetry and tactile fremitus, as well as, any signs of tenderness or bulges. (Wilson & Giddens, 2013, pp. 191- 216) My practice patient is a 28 year old healthy appearing male who is able to ambulate with a steady & independent gait free of any acute respiratory distress. He denies any past or current medical problems. He also denies any family history of lung problems but later admits that he was adopted so he “doesn’t actually know”. He has no known drug allergies but states that he usually suffers from seasonal allergies in the spring time
. This patient denies smoking and drug use but adds “I do enjoy smoking hookah now and then.” As previously mentioned this is a healthy appearing male patient who is well developed and whose skin, lips, and nails are appropriate color. His breathing is quiet and effortless with a regular rate. Thoracic expansion is symmetric bilaterally. His thorax is symmetric with ribs sloping downward at 45 degrees relative to the spine. His trachea is midline.
He denies any tenderness and no bulges are noted with palpation. Breath sounds are clear bilaterally- vesicular sounds heard over most lung fields, bronchovesicular sounds heard in the posterior chest over the upper center area of the back and around the sternal border, and bronchial breath sounds heard over the trachea. (2013, pp. 217) 2. What are the “patient’s” respiratory risk factors? What lifestyle changes could lower these risks? What would it take to make even some minor changes in their lifestyle to benefit their health status? The patient above was healthy but still has risk factors.
He is adopted and does not know his birth parents medical history and although he initially responded no to smoking he did eventually admit that he “enjoys smoking hookah.” Hookah is a centuries-old tradition that involves smoking flavored tobacco through a water pipe “an upright device with a small platform where tobacco is burned, a metal body, a base half-filled with water, and a hose with a mouthpiece for inhaling”(Dugas, Tremblay, Low, Cournoyer, O’Loughlin, 2010).
Researchers have found that hookah is more popular among people who are under thirty, male, speak English, do not live with their parents, and have a higher household income. (2010) According to Doctor Lowell Dale from the Mayo Clinic (2013) “Hookah smoking is not safer than cigarette smoking. Hookah smoke contains high levels of toxic compounds, including tar, carbon monoxide, heavy metals and cancer-causing chemicals (carcinogens). In fact, hookah smokers are exposed to more carbon monoxide and smoke than cigarette smokers.”
As with cigarette smoking, hookah smoking is linked to lung and oral cancers, heart disease, and other serious illnesses. Hookah smoking can possibly lead to tobacco dependence because the participant is receiving as much nicotine as someone who smokes cigarettes. And hookah pipes used in hookah bars and cafes may not be cleaned properly which increases the risk of contracting an infectious disease. (2013) My patient simply has to stop smoking hookah to significantly decrease his risks and benefit his health- that’s my bias. When asked about the frequency of his hookah use my patient responds “I don’t smoke that often- probably once every couple months when out with friends.” 3. With the knowledge you have gained thus far in holistic nursing and self-care practices how could you coach the client to improve upon their own self-care?
Use Dossey and Keegan Chapters 9-10 to help facilitate their lifestyle risk factor change process? I would use motivational interviewing because the fundamental premise is that a patient’s ambivalence affects their motivation and readiness to alter behavior. (Dossey & Keegan, 2013, pp. 207) When using motivational interviewing the nurse must resist the urge to jump in with a solution to the problem because it is the patient who should be recognizing the need and setting goals toward change.
The nurse must explore the patient’s concerns, perceptions, and motivation- allowing them to see themselves making the changes is the key of the partnership. The nurse must focus on being a good listener and showing empathy. “The nurse helps the patient discover how change can happen… Providing ongoing encouragement to foster the belief that goals are achievable can help the patient carry out a plan to change behavior.” (2013, pp 207) 4. Using Dossey and Keegan Ch. 23, p. 535, consider all of the areas for “nurse healer reflections” and supporting clients through smoking cessation.
What holistic steps could be used to support an individual with the desire to stop smoking? In preparing to use smoking cessation interventions the nurse must first assess not only the patient’s level of addiction to cigarettes, but also the actual emotional meaning of smoking to the patient, their attitudes and beliefs about successful smoking cessation, their motivation to learn, their current stage of change, their exercise and eating habits, existing stress management patterns, and support network. (Dossey & Keegan, 2013, pp. 530)
It is important to taking time to employ “pre-quitting” strategies such as a diary- this helps provide insight into feelings surrounding the actual act of smoking, brain storm with the patient regarding strategies that they think would help them quit, have the patient pay special attention to diet and exercise- cleanse the body and car and house off all things nicotine – pay attention to smell- encourage them to practice small acts of delaying gratification to build up their feelings of self-control and remind them to use family and friends as support. Have the patient choose the quit date and sign a contract.
Practice relaxation and visual imagery skills. Discuss high risk situations and come up with ways to prevent a relapse. Work together to establish goals of behavior changes and new habit creations. Create a schedule of rewards for meeting their personal goals. Evaluate, encourage, support, and reinforce. Helping the patient address their underlying emotional issues and mood disturbances is most important to helping the patient achieve a new level of self-awareness, enhance healing, and prevent relapse. (2013, pp. 531-534)
Dossey B M Keegan L 2013 Holistic nursing a handbook for practiceDossey, B., & Keegan, L. (2013). Holistic nursing a handbook for practice (6 ed.). Burlington, MA: Jones & Bartlett Learning. Dugas, E., Tremblay, M., Low, N., Cournoyer, D., O’Loughlin, J. (2010) Water-pipe smoking among North American youths. Pediatrics.125(6):1184-9. Lowell, D. (2012) Is hookah Smoking Safer Than Smoking Cigarettes? Mayo Clinic Expert Answers. Retrieved 10/02/2013 from http://www.mayoclinic.com/health/hookah/AN01265 Wilson, S., & Giddens, J. (2013). Health assessment for nursing practice (5 ed.). St. Louis, MO: Mosby
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