Respiratory - Assessments #2

Question 1

What do we assess under the “C” of the rapid assessment when considering a patient with respiratory problems?

Answer 1

C=Circulation
We will assess:
General appearance, Heart Rate, Blood pressure, and Renal function `

Question 2

What are we assessing under “general appearance” when considering the circulation of a patient with respiratory problems.

Answer 2

Skin colour (flushed, cyantonic)
Temperature (raised - core, Peripherally cool)
Cap refill
Diaphoresis

Question 3

What are we assessing under “heart rate” when considering the circulation of a patient with respiratory problems.

Answer 3

Tachycardia/bradycardia
Rhythm (regular/irregular)
Quality (weak/bounding)

Question 4

What are we assessing under “Blood pressure” when considering the circulation of a patient with respiratory problems.

Answer 4

Hypertension
Normotension
Hypotension

Question 5

What are we assessing under “renal function” when considering the circulation of a patient with respiratory problems.

Answer 5

Urine output
eGFR (measurement of how well the kidneys filter blood)
Fluid balance

Question 6

What are the 3 main classes of interventions of circulatory problems related to respiratory distress?

Answer 6

Hydration, Administer prescribed medication, and Mobilising

Question 7

Whats involved in the intervention “Hydration” when considering a patients circulatory health when this patient has respiratory distress?

Answer 7

Encourage fluids and administer intravenous fluid if prescribed. This is done to prevent dehydration. When a patient is dehydrated their blood retains more sodium, thickening the blood and making it harder for their blood to circulate through their body. i.e to ensure adequate tissue perfusion

Question 8

Whats involved in the intervention “Administer prescribed medications” when considering a patients circulatory health when this patient has respiratory distress?

Answer 8

Consider DVT prophylaxis - Using these treatments we can treat or prevent DVT for this patient. i.e to ensure adequate tissue perfusion

Question 9

Whats involved in the intervention “Mobilising” when considering a patients circulatory health when this patient has respiratory distress?

Answer 9

Foot pedalling, Frequent mobilisation as able, and regular repositioning. This is done to prevent DVT and Pressure injurys i.e to ensure adequate tissue perfusion

Question 10

What are the 3 main assessments we would do under “D” of the rapid assessment for a patient who has respiratory distress?

Answer 10

D = Disability

Level of Consciousness, Assessment of Anxiety, and Pain assessment

Question 11

What would we assess in terms of “level of consciousness” under “disability” for a patient with respiratory distress?

Answer 11

AVPU
Are they orientated to time, person and place?
Restlessness/agitation (hypoxaemia)

Question 12

What would we assess in terms of “anxiety” under “disability” for a patient with respiratory distress?

Answer 12

Is the patient: 
Breathless
Have a fear of dying
Dyspnoea
Have increased work of breathing
Changes to mood
and do they have a SNS response

Question 13

What would we assess in terms of “pain” under “disability” for a patient with respiratory distress?

Answer 13

COLDSPA (for any identified pain)
Assess for - Pleuritic pain
Assess for - opioid analgesia

Question 14

What are the 2 types of interventions we would use for a patient with respiratory distress when considering disability?

Answer 14

Pain management and Anxiety reduction to reduce SNS response

Question 15

Whats involved in the intervention “Pain management” when considering Disability for a patient who has respiratory distress?

Answer 15

Selecting the appropriate analgesia and administering analgesia as prescribed.
This is to maintain patient safety and prevent further complications.

Question 16

Whats involved in the intervention “Anxiety reduction” when considering Disability for a patient who has respiratory distress?

Answer 16

Provide patient education, keep the patient informed of the plan, and involve the family/whanau in their care. This is to maintain patient safety and prevent further complications

Question 17

Would saying “For my intervention I would - Reassure the patient” be adequate?

Answer 17

No, you would need to say something like “For my intervention I would try to reduce anxiety by providing patient education, communicating the patient plan, and involve the family/whanau”

Question 18

What are the 3 main assessments we would do under “E” of the rapid assessment for a patient who has respiratory distress?

Answer 18

E = Environment

1. Patient risk assessment
2. Past medical/surgical history
3. Early warning score

Question 19

Why would the early warning score be something that we assess under “Environment” for a patient?

Answer 19

Because it can tell us where this patient needs to go, i.e to ICU, home, to another ward.

Question 20

Whats involved in a patient risk assessment when considering the environment of a patient experiencing respiratory distress?

Answer 20

Assessing falls risk, braden scale (skin), and smoking risk.

Question 21

Whats involved in a past medical/surgical history assessment when considering the environment of a patient experiencing respiratory distress?

Answer 21

Asking about previous respiratory issues (using COLDSPA), medications, drug reactions, and allergies

Question 22

Whats involved in a early warning score assessment when considering the environment of a patient experiencing respiratory distress?

Answer 22

Taking the patients vital signs, calculating the EWS and looking at trends and whether any action is required

Question 23

What are some other assessments that we may do when considering the environment of a patient with respiratory distress?

Answer 23

Asking for occupation
Assess living situation
Assess family/whanau supports 
Assess self-management of health issues 
Assess alc and drug use 
and Assess cultural and spiritual needs

Question 24

Why would we assess the cultural and spiritual needs of a patient with a respiratory problem?

Answer 24

To ensure we are providing safe and cultural care for the patient

Question 25

What are the expected findings under “Airway” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 25

Airway:

Patent but potentially under threat if LOC lowers due to hypercapnia/hypoxaemia

Question 26

What are the expected findings under “Breathing” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 26

Breathing:
Increased WOB due to hypercapnia
Pursed lip breathing to assist with expiration and overcome gas trapping - creates PEEP
Tachypnoeic (resp over 20/min, likely to be over 30/min in his case)
SpO2 under 90 due to hypoxaemia
Positioned upright or tripod to expand thoracic cavity and maximise air entry for gas exchange
Adventitious sounds - wheeze due to bronchoconstriction, possible rhonchi
Possible decreased air entry on auscultation due to alveolar collapse, resonant percussion due to lung hyperinflation.

Question 27

What are the expected findings under “Circulation” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 27

Circulation:
Cool pale peripheries and/or cyanosis due to hypoxaemia
CRT (cap refill) > 3 seconds due to peripheral vasoconstriction
Possible elevated core temperature due to increased metabolic rate or infection
Diaphoresis due to increased WOB or hypercapnia
Tachycardia (>100bpm) due to hypoxaemia and/or bronchodilators
Possible hypertension due to hypoxaemia
or Possible hypotension due to systemic inflammatory response

Question 28

What are the expected findings under “Disability” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 28

Disability:
Possible disorientation or confusion due to hypoxaemia > hypoxia
Reduced LOC due to hypercapnia and/or hypoxaemia
Anxiety or fear of dying due to dyspnoea

Question 29

What are the expected findings under “Environment” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 29

Environment:
Elevated EWS due to inc RR, HR and lowering SpO2
Increased falls risk due to dyspnoea, dizziness, and/or confusion
Increased braden score due to corticosteroids, reduced mobility and possible oedema
COLDSPA of irritants/triggers and previous exacerbations (plus treatment/length of hospital stay) to help inform nursing plan of care
Identified allergies or drug reactions to avoid further complications

Question 30

What are some interventions under “airway” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 30

Airway:

Positioning - tripod and sitting upright - to open the airway and maintain patency

Question 31

What are some interventions under “breathing” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 31

Breathing:
Ensure john is upright to optimise air entry and facilitate gas exchange
Enchourage pursed lip breathing to facilitate exhalation of CO2 (Reduce gas trapping) and to reduce dyspnoea.
Administer O2 as prescribed to reverse hypoxaemia
Administer bronchodilators as prescribed for relaxation of smooth muscle in airways to facilitate gas exchange
Administer corticosteroids as prescribed to reduce inflammation in respiratory system

Question 32

What are some interventions under “circulation” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 32

Administer IV fluids as prescribed/encourage oral fluids to prevent dehydration and to thin secretions.
Administer DVT prophylaxis as prescribed to prevent clot formation from venous stasis
Administer antibiotics as prescribed to treat infectious exacerbation
Encourage patient to foot pedal to encourage venous return to prevent venous stasis

Question 33

What are some interventions under “disability” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 33

Disability:
Maintain a low stimulus environment to reduce anxiety and further dyspnoea
Educate the patient on interventions and plan of care to reduce anxiety and encourage compliance with therapeutic interventions.
Consider hospital aide special or a family member to sit with the patient if confused to maintain patient safety and/or to reduce anxiety and further dyspnoea

Question 34

What are some interventions under “environment” for john?

(john was admitted to your ward overnight following an acute exacerbation of his COPD, you have just received a shift report and proceed to johns room to assess him)

Answer 34

environment:
Ensure regular position changes as appropriate to prevent pressure injurys
Ensure hazards are away from bedside, call bell is in reach and patient is educated on falls prevention
Refer patient to physiotherapist/OT for rehab
Identify a self-management plan with the patient to prevent further exacerbations and recognise early warning signs of deterioration

Question 35

When picking interventions what do we need to do?

Answer 35

Consider which interventions are priority interventions. With the main focus on immediate patient safety first.