Clinical judgement and reasoning
My nursing assessment will be based on case study three. The case involved a 32 year old woman who had been suffering from asthma since childhood. The patient said that she lives with his mother and that she works as a cleaner at a private aged care facility. The father to the patient died due to complications that arose out of asthma when he was only 40 years old. The mother is however in good health though with some mild high blood pressure.
Generally, the health condition of Lucy is just fine and the only previous medical condition include appendectomy at the time she was 16 years old .Lucy weighs 63 kg and has a height of 145 cm. She usually swims 2km three time in a single week and walks 5km three times a week. She eats a well-balanced diet and neither does she smoke but drinks alcohol under moderation. To effectively control her asthma, Lucy uses beclomethasone. Whenever she experiences cold, she uses salbutamol to bring the situation under control. Lucy is also on flu injection that is administered once every year.
Lucy always try as much as possible to avoid people suffering from flu and colds. Her mother was however diagnosed with the same flu recently .A week later, Lucy started feeling unwell and she became dyspneic as well and had a temperature of 39 degree Celsius. She wheezed and coughed and experienced tightness in her chest. She then adopted her asthma rescue plan as usual but the condition worsened. It is at this point that the mother decided to take her to the emergency department.
During assessment, Lucy had a temperature of 38 degree Celsius, the pulse was at 115 and 32 respirations. The Blood pressure was 160/90 and the Sa02 was 91%.Besides, Lucy was also using the accessory muscles to help her breathe and on auscultation, it was established that she had decreased breath sounds and both were inspiratory and expiratory wheezes. The ABGs that were taken during assessment were as follows: PH 7.5, Pa CO 2 28, Pc O2 74 and the HCO3 25.
The oxygen saturation dropped to 88% and Lucy was then administered with salbutamol through the IV. Oxygen was also given and corticosteroids as well. Her chest was then auscultated and it was established that even though she had a loud expiratory wheeze, she had a better air flow. She was however still using the accessory muscles. After treatment by the IV medication therapy, her respiratory rate massively dropped to 28 while her pulse was 110.There was continued monitoring and after four hours in the Emergency department, her condition began to deteriorate and salbutamol was again provided to her .Some of the vitals were as follows: 38.2 Degree Celsius, Pulse of 145, respiratory rate of 38 and the Blood Pressure was 180/90.Oxygen saturation was at 87%.
Sequencing Of The Assessment
Lucy has a slight tremor in both of her two hands and she was using her accessory muscles and she was experiencing difficulties when speaking .She appeared very tired and anxious. Her medication was then reviewed and she was offered IV ipratropium, methyl prednisone and an antibiotic. Another four hours saw her health condition improve. Her observations had stabilized and she no longer had difficulties in breathing. After 20 hours, she could no longer use her accessory muscles to breathe and was able to speak easily without dyspnea. Her vital signs include 37.2 degrees Celsius, 90 pulse, 16 respiration rate and a blood pressure of 140/85.The Oxygen saturation was at 99% on room air. Lucy was then discharged and returned to work 2 days later.
During the assessment of the patient. I will use or follow the order Inspection, Palpation, Percussion and finally Auscultation. Visual inspection is the first step and this will just include examining the patient using the eyes .So many abnormalities can be identified under this step by just examining the thorax as the patient breathes.
Palpation is the next step and this will now involve touching the patient .Under this step I will touch the thorax and the accessory muscles to find out if the patient is experiencing any difficulties during breathing (Wu, Enskär, Lee, & Wang, 2015) . This step is very important since some of the systemic health problems can be detected. Mechanical breathing problems can also be detected during this step.
Percussion will be the third step in assessment of the patient. Percussion is an assessment technique with objective of producing sounds that are diagnostic to a particular health problem. This involves tapping the chest wall to produce sound dependent on the amount of air in the lungs. This technique usually set the chest wall together with some underlying tissues into motion and this produce audible sounds as well as palpable vibrations. This technique is used to find out if indeed the underlying tissues are filled with air, fluid or solid material.
Auscultation will be the finally assessment technique. This is the last assessment technique and it generally involve listening to sounds from the body. This is usually achieved by using a stethoscope. This technique is carried out with sole objective to find out deformities in the respiratory system. Since the patient in this case is suffering from asthma, this technique will come in handy.
Questions Asked In Relation To The Health History.
During the assessment. This are the questions that I was to ask the client.
- What is the Reason for hospitalization?
This question informs my planned assessment on the sole reason as to why the client is at the hospital .It provides a clue on what kind of assessment that as a nurse will start from.
- Do you smoke?
This question informs my assessment on some of the risk factors for the disease. Studies show that smoking contributes to asthma among most of the patients.
- Has any of your family members suffered from asthma?
This kind of question will inform my proposed assessment on the genetic links of the health problem. A disease like asthma for example is genetic and will therefore assist me to assess the source of the infection.
- What type of work do you do? Are there any pollutants or irritants that are you exposed to at your work?
This question has a lot of information and will generally assist my proposed assessment to find out the likely risk factors for the health condition. Dust particles are the most risk factors for asthma. In case the patient or the client works in a dusty environment, it will be necessary to educate her on the necessary precautionary measures.
- Do you have any Specific medical history like dyspnea?
This kind of question will assist me to gauge what I should expect on percussions stage. Dyspnea is characteristic to asthma and will therefore greatly assist me understand the condition of the patient better.
There were important findings during the clinical assessment of the patient. Anxiety was one of the key finding. Anxiety is a condition that has been associated with asthma as from several studies .Asthma is a condition in which there is narrowing of the airways thus making it difficult for the patient to breath. According to studies, it has been established that anxiety usually trigger the body to release different chemical substances such as the histamines and the leukotrienes that usually trigger the narrowing of the airways (Yorke, Fleming, & Shuldham, 2006). Anxiety might be due to changes in the environment, changes in the health status, Hypoxia and finally respiratory distress. It can be evidenced through different signs that include apprehensiveness, dyspnea which was evident in this case study as well as restlessness (Polivka & Wills, 2014) .It is therefore the role of the nurse to ensure that the client use an effective coughing mechanism, the patient verbally reduce the level of anxiety she is experiencing and finally the client should demonstrate reduced level of anxiety as shown by a calm and a demeanor cooperative behavior. The nursing intervention for this nursing problem are explained in details below.
Analysis Of The Findings
Dyspnea is an indication of ineffective breathing pattern in the client. Other signs and symptoms for ineffective breathing patterns include nasal flaring, use of the accessory muscles which was seen in the case study, tachypnea, prolonged expiration and finally nasal flaring.
Asthma is a chronic disease that affects the airways. This condition then causes muscles in the airways to tighten then the lining of the airways become inflamed and produce sticky mucus .This in return leads to narrowing of the airways and this is the reason to ineffective breathing patterns that are shown by dyspnea and use of accessory muscles to breathe like was the case in the case study (Stolt & Suhonen, 2018). Some of the notable causes include family history of asthma. This coincides with findings in the case study since Lucy told us that her father dies due to complications from asthma. Upper respiratory tract infections, viral infections and allergens such as house dust can cause the condition (Weldam, Lammers, Zwakman, & Schuurmans, 2017) .There should therefore be necessary interventions to control the health problem of ineffective breathing .The desired outcome is that the client is able to maintain an optimal breathing pattern that can be shown by normal respiratory rate patterns and absence of dyspnea.
Fatigue was another key finding that was made during the assessment. According to studies, asthma is associated with narrowing of the airways and thus causes the patient to work hard so as to breath. This strenuous breathing is the one that leads to fatigue among the patients as was evidenced by the case of Lucy. Fatigue or tiredness is usually evidenced by lethargy, inability to speak properly as well as prolonged dyspnea. The desired outcome during the nursing interventions in this case is that the client is able to engage in normal activities without fatigue.
Anxiety is one of the health problem identified in the case study. There should be necessary nursing interventions to control the condition. Under this problem, the nurse should assess for different signs of anxiety that include feelings of panic, fear or uneasiness (Harris et al., 2018). The nurse should also look for tachycardia, cold or sweaty hands and feet and then shortness of breath. Restlessness should also be assessed (Strunk, 2008). The rationale for this assessment is because anxiety can worsen asthma since it leads to rapid as well as shallow breathing.
The nurse should assess the level of theophylline in the body and monitor the level of oxygen saturation and provide comfortable measures by providing a calm and quiet environment as well as soft music. The rationale for this assessment is that theophylline that ranges from 10-20 mcg/ml in the body leads to elevated levels of anxiety (Harris et al., 2015). An increase the anxiety on the other hand is a clear indication of hypoxia. Finally, providing a calm environment usually maintain calm that reduces the rate of oxygen consumption as well as the work of breathing.
The nurse is supposed to explain to the patient every procedure using simple language and in a concise manner (Pascal & Frécon Valentin, 2011). This is because the anxiety of the patient can reduce if he or she understands the treatment of relaxation techniques such as progressive muscle relaxation as indicated and diaphragmatic and pursed lip breathing are necessary (Yeh, Ma, Huang, Hsueh, & Chiang, 2016). The rationale behind this is that different relaxation techniques are the best way to reduce anxiety.
Staying with the client and encouraging her how to deep breath slowly while assuring the client the importance of close and consistent monitoring is another important intervention (Blissitt, 2011). The rationale for this intervention is that presence of a trusted and reliable person gives the client a sense of security (McClure, Lutenbacher, O’Kelley, & Dietrich, 2017). Updating family members on the progress is very important since when the family members experience anxiety, it is likely to be transferred to the patient as well.
Ineffective breathing pattern was another major health problem identified in the case study. The nursing interventions in this case include assessment of the vital signs as required while in distress (Klijn et al., 2017). The nurse should also assess the respiratory rate, depth and rhythm of the client. The rationale for this intervention to find out potential respiratory distress which is shown by changes in the respiratory rate (Knafl et al., 2016). Assessing the level of anxiety in the client is still important as this might indicate struggles of difficulties in breathing.
Assessment of the breathing sounds as well as the wheezing sounds are necessary. The nurse should also assess the relationship between inspiration and expiration (Redding et al., 2017). The objective in this case is to find out the presence of wheezing sounds which indicate worsening condition or an additional health problem like pneumonia (“Hospital cleaners at risk of wheeze, asthma and asthma score,” 2011). Wheezing sounds occur due to bronchospasm and incase there are signs of diminishing wheezing sounds, this might suggest an impeding respiratory failure. Reactive airways on the other hand usually allows air to easily flow into the lungs but difficult to move out (Petsky, Li, Kynaston, Turner, & Chang, 2007). Assessment of the inspiration and expiration patterns therefore will assist the nurse no note if the patient is gasping for air so that instructions for effective breathing are provided.
Activity intolerance as a health problem needs swift nursing interventions. The nurse in this case is supposed to assess the presence of weakness as well as fatigue that is due to the airway problems. The rationale behind this intervention is to get important information on how energy reserves wear out with time due to dyspnea and breathing. The nurse should also encourage activities such as quiet plays, reading as well as watching movies (Aaron et al., 2017). This is just to avoid variations in the respiratory status as well as energy depletion as a result of excessive activities.
The nurse should also provide care for once and spread the sessions. The aim of this is to enable the client reserve energy and reduce on interruption in rest. The nurse should also provide resting periods in a calm and peaceful environment (Normansell, Walker, Milan, Walters, & Nair, 2014). This is to ensure the patient has enough rest and decrease the stimuli. The nurse should also explain the reason as to the why the client should conserve energy and avoid getting tired to the client. This is just aimed at promoting an understanding of the effects of activity on breathing as well as the need for rest so as to prevent fatigue.
References
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