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Nursing Assessment of Patient With Respiratory Disease

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Nursing Assessment of Patient With Respiratory Disease

Subjective Findings

The subjective data used in nursing diagnosis typically refers to the visual examination of patients and their reported symptoms. In this case, subjective data included in the diagnosis was the reported shortness of breath and difficulty breathing that the patient indicated upon admission to the emergency department. The nurses subjective data input was an observation of Mr. Ritters anxiety, which they confirmed by watching the patient sitting in a tripod position.

Objective Findings

Objective findings of a patients examination informing the nursing diagnosis come from standard medical tests and evaluations. For instance, the patients degree of respiratory distress could be evaluated by the retracting respiration rate of 26 breaths per minute, a high pulse of 120 beats per minute, and extremely low oxygen saturation. Further objective input into the patients diagnosis was given by the X-ray test showing the signs of atelectasis in the patients lungs. Identifying hyper-resonance in the patients chest wall and evaluating skin and nailbed color is also objective evidence.

Pathophysiology of the Patients Disease Process

As the patient has a history of COPD diagnosis, it is vital to consider the pathophysiology of his disease process through the prism of potential exacerbations of COPD. Güder and Stöck (219) noted that COPD triggers the destruction and remodeling processes in the bronchiolar architecture of the patients lungs, leading to impaired air inhalation. The outcome of such a process is thoracic muscle exhaustion, inadequate oxygenation, and dyspnea. Because of these pathophysiological processes, COPD often leads to the development of congestive heart failure and pulmonary embolism caused by blood vessel destruction. Dentali et al. (2020) also confirmed that COPD is an independent risk factor for pulmonary embolism, posing significant health risks.

Smoking-related COPD is characterized by airway inflammation, evidenced by the increase of CD8+ T cells, macrophages, neutrophils, and B cells at later stages of COPD development (Santus et al., 2019). The primary site of COPD inflammation is small airways, the ones escaping adequate biopsy assessment, so the COPD treatment should be selected in a way that manages mechanical stress. Such an approach can reduce the risk of inflammation and asthma development (Santus et al., 2019). Another health outcome of COPD progression is pulmonary emphysema, which affects distal air spaces of the terminal bronchiole and causes abnormal enlargement. At the same time, the airway walls and lung parenchyma get destroyed, with evidenced loss of lung elasticity and accompanying pulmonary problems (Pahal et al., 2018).

Nursing Diagnosis

Nursing Diagnosis 1:ineffective breathing pattern
Goals:

  • To help the patient restore maximum ling expansion and adequate ventilation
  • To ensure diaphragmatic pursed-lip breathing
  • To restore the feeling of comfort in breathing
  • To keep a regular breathing pattern during ADLs
  • To maintain the patients respiratory rate within the clinical standards

Outcome: Restoration of an adequate breathing pattern, with the patient reporting comfortable breathing and exhibiting maximum lung expansion with adequate ventilation. Relaxed breathing at a regular rate and depth. No signs of dyspnea.
Nursing Interventions: (How am I going to fix this problem?)

  1. Help the patient take a healthy position to restore the healthy breathing pattern.
  2. Train the patient to undertake sustained deep breaths via slow inhalation, air holding, and subsequent passive exhalation. Use of yawning and incentive spirometer for deep breathing stimulation.
  3. Educate the patient about diaphragmatic breathing.
  4. Deliver medications for the respiratory diseases treatment and extra oxygen in compliance with the doctors treatment plan.
  5. Avoid high oxygenation.
 Rationales: (Why did I choose these interventions? Why will they work?)

  1. A proper sitting position can help the patient breathe easier because it allows maximum lung excursion and gives space for unobstructed chest expansion.
  2. Deep breathing increases oxygenation and helps manage atelectasis. This method prevents air trapping.
  3. Correct diaphragmatic breathing is beneficial in terms of muscle relaxation and sustainable increase of the oxygen level.
  4. The use of beta-adrenergic agonists helps open the obstructed air passages and relax the smooth muscles of affected airways.
  5. In patients with COPD, careless oxygen administration can cause the development of apnea.
Evaluation:(How do I know my interventions were effective?)

  • Goal # 1

    • The respiratory rate and depth of the patient should remain within the range of 10 to 20 breaths per minute.
  • Goal # 2

    • The patient can maintain a healthy physical position for deep, unobstructed breathing.
  • Goal #3

    • Breath sounds auscultation should not reveal abnormal sounds like bronchospasm, rales, or wheezing.
  • Goal #4

    • The patient should not feel exhausted or use accessory muscles for comfortable breathing.
  • Goal #5

    • Airways should be clear and free from secretions.
  • Goal #6

    • The patient should be able to breathe deeply and comfortably without respiratory medications.
Nursing Diagnosis 2:risk of impaired cardiovascular function
  • Goals:
  • Outcome:
Nursing Interventions: (How am I going to fix this problem?)

  1. Monitor the patient for signs of tachycardia
  2. Assess the heart rhythm, palpitations, and irregular heartbeat.
  3. Monitor the patients BP level.
  4. Inspect the patients skin for mottling, pallor, and cyanosis.
  5. Monitor the quality and regularity of urine output.
 Rationales: (Why did I choose these interventions? Why will they work?)

  1. Tachycardia is the first sign of heart failure, so urgent interventions should be taken upon its identification.
  2. The nurse needs to conduct a continuous evaluation to identify the early signs of atrial fibrillation, which causes thrombus formation.
  3. If the patient experiences heart failure, they will have an elevated BP level because of increased systemic vascular resistance (SVR).
  4. Mottling, pallor, and cyanosis are signs of low cardiac output and systemic hypoperfusion.
  5. Decreased urine output may suggest kidney problems, such as reduced renal perfusion.
Evaluation:(How do I know my interventions were effective?)

  • Goal # 1

    • Adequate heart rate and BP without symptoms of tachycardia.
  • Goal # 2

    • The absence of cyanosis, mottling, and pallor symptoms suggests adequate oxygenation of the patients organism.
  • Goal #3

    • Adequate, regular urine output signaling the proper kidney operation.
Nursing Diagnosis 3:impaired spontaneous ventilation
  • Goals: improve gas exchange, maintain clear airways, minimize anxiety, and avoid cardiac or pulmonary complications
  • Outcome: The patients airways are clear, spontaneous ventilation occurs naturally and without obstruction, and the patients comfortable breathing pattern is observed.
Nursing Interventions: (How am I going to fix this problem?)

  1. Assess the patients respiratory rate and depth and establish the breath pattern.
  2. Evaluate the patients use of accessory muscles.
  3. Evaluate the heart rate and BP level of the patient.
  4. Auscultate the lungs for abnormal breath sounds.
  5. Regularly monitor ABG and oxygen saturation.
  6. Apply intubation if impaired breathing persists after emergency help.
  7. Prepare the patient for intubation and get the equipment ready.
 Rationales: (Why did I choose these interventions? Why will they work?)

  1. These evaluations help measure the patients respiratory distress degree.
  2. The use of accessory muscles can help increase the patients chest excursions, thus giving them the first aid for obstructed breathing.
  3. Heart rate and BP levels indicate the patients risk of tachycardia.
  4. Lung auscultation is a precise method for monitoring breathing improvements or deterioration.
  5. Tight control over oxygenation is vital for decision-making about measures for improving tissue oxygenation.
  6. If the patient cannot breathe autonomously and the level of cyanosis increases, intubation is required.
  7. Proper patient positioning, patient education about the process, and the choice of proper ET tubes are vital for intubation success.
Evaluation:(How do I know my interventions were effective?)

  • Goal # 1

    • The patient exhibits spontaneous gas exchange with reduced dyspnea and sufficient oxygenation values without assistance.
  • Goal # 2

    • The client does not show any signs of complications resulting from mechanical ventilation.
  • Goal #3

    • The client has a normal ABG level.

References

Dentali, F., Pomero, F., Di Micco, P., La Regina, M., Landini, F., Mumoli, N., Pieralli, F., Giorgi-Pierfranceschi, M., Re, R., Vitale, J., Fabbri, L. M., Fontanella, A., & Arioli, D. (2020). Prevalence and risk factors for pulmonary embolism in patients with suspected acute exacerbation of COPD: A multi-center study. European Journal of Internal Medicine, 80, 54-59.

Güder, G., & Störk, S. (2019). COPD and heart failure: Differential diagnosis and comorbidity. Herz, 44, 502-508.

Pahal, P., Avula, A., & Sharma, S. (2018). Emphysema. StatPearls Publishing.

Santus, P., Pecchiari, M., Tursi, F., Valenti, V., Saad, M., & Radovanovic, D. (2019). The airways mechanical stress in lung disease: Implications for COPD pathophysiology and treatment evaluation. Canadian Respiratory Journal, 1-8.

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