NURSING > STUDY GUIDE > Clinical #3 Case study-Assessment & Reasoning Respiratory System-REVIEWED BY EXPERTS-VERIFIED A+ (All)

Clinical #3 Case study-Assessment & Reasoning Respiratory System-REVIEWED BY EXPERTS-VERIFIED A+

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Assessment & Reasoning Respiratory System John Franklin, 35 years old Suggested Respiratory Nursing Assessment Skills to Be Demonstrated:  Inspection: Inspect thorax for symmetry and configuration- Check to see if he if using accessory muscles or if breathing is labored.  Palpation: Palpate over anterior and posterior chest for any lump, masses, tenderness & crepitus  Percussion: Percuss over posterior to check for tactile fremitus  Auscultation:  Auscultate all lung fields  Make Learning Active! 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: History of Hypertension and asthma Smokes ½ ppd since 18 Shortness of breath, persistent nonproductive cough Ran out of albuterol inhaler two months ago Audible expiratory wheezing Having the history of asthma and because he smokes, this confirm that he is having an asthma attack that could have flared up. Having the nonproductive cough is consistent with asthma attacks, if it were productive, it would be linked to pneumonia. Client had no way to treat his asthma because he ran out of his medicine. His wheezing was so loud no stethoscope needed to be used. Means his condition was bad. 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 adrenergic bronchodilators loop diuretics relaxes smooth muscles it the bronchial tree and peripheral vasculature by stimulating adrenergic receptors of the sympathetic nervous system. Furosemide is a potent loop diuretic that acts on the kidneys to ultimately increase water loss from the body. Patient Care Begins: 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: 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: BP: 188/10 02 sat: 91% RA R: 24 P: 110 Oxygen saturation low, client’s airway may be blocked, low amount of oxygen in the blood. Client is taking a lot of breaths Client is very anxious You place John on a cardiac monitor, continuous oximetry and quickly collect the following assessment data:

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