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Respiratory Assessment

Oct 19, 2022

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Subjective:

The patient complains of stabbing chest pains that get worse when breathing heavily or coughing.

  • Reports of constant breathlessness especially when climbing stairs or talking for a long time.
  • Acute cough productive of rusty sputum.
  • Confusion, rapid, and shallow breathing.
  • Reports experiencing fever, night sweats, and morning headache.
  • No previous diagnosis of similar episodes and treatment. 
  • No past Hx of thoracic, nasal, laryngotracheal, or hospitalization for pulmonary disorders.
  • No Hx of endoscopy, tracheostomy, and lobectomy.
  • Denies Hx of respiratory disease, and lung surgery.
  • No family Hx of respiratory diseases.

Objective:

  • The patient’s temperature is above 99.6 F.
  • Heartbeat is regular with a rate of 86 beats/minute.
  • Breathing is uneven and labored at a rate of 18 breaths per minute at rest. 
  • Oxygen saturation of the blood is 90% on room air.
  • Normal blood pressure 125/82.
  • Adventitious lung sounds such as wheezing, stridor, and pleural rub.
  • Murmur and gallop rhythm sounds are heard.
  • Asymmetrical chest expansion with accessory muscle use.
  • Tenderness and pain with palpation.
  • Dull sounds heard in high-density regions

Assessment:

  • Willingness to undertake health-promoting behaviors.
  • Chest X-ray to diagnose pneumonia.
  • Assessment of sounds from the lungs.

Diagnosis:

  • The patient was diagnosed with Bacterial lobar Pneumonia. The disease presents with an inflammatory exudate in the intra-alveolar space. The bacteria affect a huge area of the lungs, especially in the lung lobes (Ackley, 2022)
  • The patient has a fever of 98.8 F, a rapid heart rate, a rusty cough, and night sweats, which are signs and symptoms of pneumonia.

Plan:

  • Provide a treatment plan for the patient. The patient should take the antibiotic offered because the disease is caused by bacteria. Antibiotics are effective in fighting against bacteria.
  • The patient should take aspirin to control the fever. Aspirin is effective on managing fever
  • The patient should drink warm beverages and take steamy baths and use a humidifier. These will help open up the airways and ease the patient’s breathing.
  • The patient should avoid rooms with smoke or smoking. Smoke will block the airways and choke the patient to death. Preventing smoking makes the lungs heal and recover.
  • The patient should get enough rest. The patient might need a comfortable bed and lie in a comfortable position to avoid pain.
  • The patient should avoid extraneous activities not to strain the lungs. When doing these kinds of activities, one needs a lot of energy. As a result, they will need more oxygen to break down food to produce energy. They will damage the lungs.
  • The patient experiences difficulty in breathing, he, therefore, needs supplemental oxygen using a nasal cannula at a flow rate of 2 liters per minute to maintain his oxygen level above 95% to lessen the work of breathing.
  • Administer an intravenous antibacterial therapy when the patient is admitted. The therapy should be administered within 4 hours after the patient has been admitted.

Reference

Ackley, B.J et al. (2022). Nursing diagnosis handbook: Planning care (12th ed). Elsevier.

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