NCM 118: RESPONSES TO ALTERATION/PROBLEMS AND ITS PATHOPHYSIOLOGIC BASIS IN LIFE- THREATENING

CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION

| LECTURE 3 |BSN- 4 | PRELIMS |

RESPIRATORY ASSESSMENT STANDARD 1: ASSESSMENT o Sputum

o RESPIRATORY ASSESSMENT o The nurse caring for acutely and critically ill patients o Weakness
▪ a critical nursing responsibility. collects relevant data pertinent to the patient’s o Specific aggravating or alleviating factors:
o Conduct a thorough assessment to detect both health or situation. o Exertion/activity
Measurement Criteria: o Stress/anxiety
obvious & subtle respiratory changes.
o Data are gathered from the patient, family, other o Body position
HISTORY o Allergies
healthcare providers, and the community to form a
o Build patient's health history with short, open- holistic understanding of the patient’s needs. o Medications
ended questions. o Data collection priorities are based on the patient’s
o Conduct the interview in multiple short sessions if immediate condition and anticipated needs. ORTHOPNEA
needed, based on patient’s condition. o Pertinent and sufficient data are collected using o Ask patient with orthopnea how many pillows they
o Ask family for information if the patient is unable to evidence-based assessment techniques and use to sleep.
provide it. instruments. o The number of pillows reflects the severity (e.g.,
o Chief complaints o Analytical models and problem-solving tools are "three-pillow orthopnea").
o General respiratory employed. COUGH
o Medication questions o Decisions are informed by matching formal o Ask patient:
o Procedure questions knowledge with clinical findings. 1. At what time of day do you cough most often?
o Relevant data are documented and communicated 2. Is the cough productive?
SIGNS AND SYMPTOMS
to other healthcare providers. 3. Has it changed recently (if chronic)? If so, how?
o Patients with respiratory disorders commonly report
GRADING DYSPNEA 4. What makes the cough better?
such complaints as:
o Ask patient to describe how various activities affect 5. What makes it worse?
1. shortness of breath (SOB)
breathing and document using the grading system: o Onset?
2. cough o Duration?
3. sputum production o Grade 0: Not troubled by breathlessness except o Timing?
4. wheezing with strenuous exercise. o Relieved by medications, fluids, rest?
5. chest pain o Grade 1: Troubled by shortness of breath when o Cough characteristics: dry, hacking, wheezing?
6. sleep disturbance hurrying on a level path or walking up a slight hill. o Other manifestations:
SHORTNESS OF BREATH o Grade 2: Walks more slowly on a level path or has 1. Chest pain
o Ask patient to rate usual dyspnea on a scale of 0 to to stop to breathe when walking at their own pace. 2. Fever
10 (0 = no dyspnea, 10 = worst experienced). o Grade 3: Stops to breathe after walking about 100 3. Dyspnea
o Ask patient to rate current level of dyspnea. yards (91 m) on a level path. 4. Sputum production
o Grade 4: Too breathless to leave the house or o Specific aggravating or alleviating factors:
o Other scales assess dyspnea related to activity (e.g.,
breathless when dressing or undressing. 1. Fever
climbing stairs, walking a city block).
2. Body position
o What do you do to relieve shortness of breath?
DYSPNEA 3. Allergies
o How well does it usually work? 4. Medications
o Onset?
o Duration? Timing? HEMOPTYSIS
o Constant vs Episodic? o Duration?
o Relieved by body position or medications? o Sudden vs gradual onset?
o Other manifestations: o Orthostasis?
o Chest pain o Amount?
o Nausea o Color (Bright red, dark red, brown)?
o Cough o Anticoagulant use?

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DABON, A.D.
NCM 118: RESPONSES TO ALTERATION/PROBLEMS AND ITS PATHOPHYSIOLOGIC BASIS IN LIFE- THREATENING
CONDITIONS, ACUTELY ILL/MULTI-ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
| LECTURE 3 |BSN- 4 | PRELIMS |

o Immunosuppressive medications? o Less common causes include rib or vertebral fractures from o Specific aggravating or alleviating factors:
o Possible source: coughing or osteoporosis. 1. Humidity
1. Nose STRIDOR 2. Emotional stress
2. Lungs o Related conditions to consider: 3. Sitting upright
3. Stomach 1. Sleep apnea 4. Seasonal changes
2. Heart failure 5. Medications
WHEEZING
Ask patient:
3. Risk for aspiration PREVIOUS HEALTH STATUS
4. Difficulty swallowing o review patient's health history for:
1. When does wheezing occur?
5. Change in voice character 1. Smoking habit
2. What makes you wheeze?
6. Early morning headaches 2. Exposure to secondhand smoke
3. Do you wheeze loudly enough for others to
7. Excessive sleepiness 3. Allergies
hear it?
8. Weight gain 4. Previous surgeries
4. What helps stop your wheezing? Hoarseness
o 5. Respiratory diseases (e.g., COVID-19, pneumonia,
1. Stridor is a high-pitched noise occurring with PTB)
o Wheezing is a high-pitched noise during expiration. obstruction in or just below the voice box. o Ask about current immunizations (e.g., COVID-19 vaccine,
o Onset? 2. Determine if stridor occurs during inspiration, flu shot, pneumococcal vaccine).
o Duration? expiration, or both to define the level of obstruction. o Determine if the patient uses any respiratory equipment
o Timing? SLEEP DISTURBANCES (e.g., oxygen, nebulizers) at home.
o Relieved by medications or removal of allergen? May be related to: LIFESTYLE PATTERNS
o Sudden vs gradual onset? 1. Obstructive sleep apnea 1. Workplace: Ask about exposure to substances (e.g., coal
o Severity? 2. Other sleep disorders requiring additional mining, construction) that can cause lung disease.
o Other manifestations: evaluation. 2. Home, community, and environmental factors: Inquire
o Chest pain DROWSINESS about influences on managing respiratory problems.
o Cough Ask patient: 3. Interpersonal relationships: Ask about stress management
1. How many hours of continuous sleep do you get at and coping methods.
o Specific aggravating or alleviating factors:
night? 4. Sex habits and drug use: Discuss possible connections to
o Exertion/activity
2. Do you wake up often during the night? acquired immunodeficiency syndrome-related pulmonary
o Emotional stress/anxiety disorders.
o Allergies or irritants 3. Does your family complain about your snoring or
restlessness? EMERGENCY RESPIRATORY ASSESSMENT
o Medications
NASAL AND SINUS COMPLAINTS o If in acute respiratory distress:
CHEST PAIN o Conditions: 1. Assess the ABCs (airway, breathing, circulation).
Ask patient: 1. Nosebleeds (Epistaxis) 2. If absent, call for help and start CPR.
o Where is the pain? 2. Sinus infection o Check for signs of impending crisis:
o What does it feel like? 1. Is the patient having trouble breathing?
3. Hay fever
2. Is the patient using accessory muscles to breathe?
o Is it sharp, stabbing, burning, or aching? 4. Postnasal drip 3. Look for shoulder elevation, intercostal muscle
o Does it move to another area? 5. Rhinitis retraction, scalene, and sternocleidomastoid muscle
o How long does it last? 6. Sneezing use.
o What causes it? 7. Nasal, facial, or referred ear pain 4. Is chest excursion less than normal (11/89 to 23/89
o What makes it better? o OTC or folk remedies tried and degree of success. or 3 to 6 cm)?
o Chest pain from respiratory issues usually results o Other manifestations: 5. Has the patient’s level of consciousness diminished?
from: 1. Foul taste 6. Is the patient confused, anxious, or agitated?
2. Nasal obstruction 7. Does the patient change body position to ease
o Pleural inflammation breathing?
3. Facial pain
o Inflammation of costochondral junctions 8. Does the skin appear pale, diaphoretic, or cyanotic?
4. Headache
o Soreness of chest muscles from coughing
5. Sputum production
o May also be due to indigestion.

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DABON, A.D.