Respiratory Assessment

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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.