Notes Nursing assessment


Thorough assessment of each patient and critical analysis of findings are required to ensure that you make patient centred clinical decisions for safe nursing care.
The nursing assessment includes collecting history of patients normal and present cardiopulmonary functioning, past impairments in circulatory or respiratory functioning, review of drug, food, allergies, physical exanimation and review of laboratory and diagnostic tests.
The nursing history includes:
1.     History of respiratory function:

This includes presence of:
·        shortness of breath
·        dyspnoea
·        wheezing  
·        pain environmental exposures  
·       frequency of respiratory tract infections
·        past respiratory problems  
·        current medication use

·        smoking history or second hand smoke exposure
2.     History of cardiac function:
·        Pain and characteristics of pain
·         Fatigue
·        Peripheral circulation
·        Cardiac risk factors
·        Presence of past or concurrent cardiac condition  
3.     Cough:
·        Sudden, audible expulsion of air from the lungs
·    Protective reflex to dear trachea, bronchi and lungs of irritants and secretions
·        Determine how frequently it occurs and whether it is productive or non productive 
·     Productive - results in sputum (material coughed up from the lungs) production.
·        Sputum contains mucus, debris, microorganisms, and sometimes pus or blood.
4.     Presence of cough:
·        How often and how much do you cough?
·        Is it productive, that is, accompanied by sputum or non-productive, that is dry?
·         Does the cough occur during certain activity or at certain times of the day?
·        Collect data about the .type and quantity of sputum:
·        Inspect the sputum for colour such as green or blood tinged, consistency such as thin or thick, odour such as none or foul and the amount such as increased or decreased.
·         If haemoptysis (bloody sputum) is present, determine if it is associated with coughing and bleeding from the upper respiratory tract, sinus drainage, or the gastrointestinal tract (hematemesis).
 5.     Description of sputum:
  • ·        When is the sputum produced?
  • ·        What is the amount, color, thickness and odor?
  • ·        Is it ever tinged with blood?

6.     Dyspnoea-Difficult or uncomfoftable b├Žatlling:
·        It is a clinical sign of hypoxia
·        It is associated with many disease conditions E:g. pulmonary disease
·        It occurs in the pregnant woman in the final months of pregnancy.
·        Environmental factors such as pollution, cold air ans smoking also cause or worsen dyspnoea.
·        Ask when it occurs (such as with exertion, stress or respiratory tract infections)
·        Determine whether the patient's dyspnea affects the ability to lie on flat.
·     Orthopnoea- is the inability to breathe except   in an upright or standing  position.
7.     Wheezing:
·        High pitched musical sound caused by high velocity movement of air through a narrowed airway.
·        Determine if there are any precipitating factors such as respiratory infection, allergens, exercise or stress.
8.     Pain
·        Chest pain requires an immediate thorough evaluation, including location, duration and frequency.
·        Pericardial pain- inflammation of the pericardial sac occurs on inspiration and does not usually radiate.
·        Pleuritic chest pain (typically sharp and 'stabbing' in a part of the chest). The pain is usually made worse when breathe in or cough. It is peripheral and radiates to the scapular regions.
·        Musculoskeletal pain is often present following exercise, rib trauma and prolonged coughing episodes.
9.     Presence of chest pain:
·        How does going outside in the heat or the cold affect you?  
·        Do you experience any pain with breathing or activity?
·        Where is the pain located?
·        Describe the pain. How does it feel?
·        Does it occur when you breathe in or out?
·        How long does it last, and how does it affect your breathing?
·        Do you experience any other symptoms when the pain occurs (e.g., nausea, shortness of breath, light-headedness, and palpitations)?
·        What activities precede your pain?
·        What do you do to relieve the pain?
10. Environmental or geographical exposures:
·        The most common environmental exposures in the home are cigarette smoke, CO and radon.
11. Smoking:
·        It is important to determine patients direct and secondary exposure to tobacco.
·        Ask about any history of smoking; including the number of years smoked and the number of packages smoked per day.
12. Lifestyle:
·        Do you smoke? If so, how much?
·        If not. Did you smoke previously and when did you stop?
·        Does any member of-your family smoke?
·        Is there cigarette smoke or other pollutants in your workplace?
·        Do you use alcohol? If so, how many drinks (mixed drinks, glasses of wine or beers).
·        Do you usually have per day or per week?
·        Describe your exercise patterns.
·        How often do you exercise and for how long?
13. Respiratory infections:
·        Obtain information about the patient's frequency and duration of respiratory tract infections.
·        Ask about any known exposure to tuberculosis and the date and results of the last tuberculin skin test.
·        Determine the patients risk for HIV infection (IV drug use, multiple unprotected sexual partners).
·        Patients display the symptoms of pneumonia (mycoplasma, pneumocystis carinii).
14. Current respiratory problems:
·        Have you noticed any changes in your breathing pattern?
·        If so, which of your activities might cause these symptom(s) to occur?
·        How many pillows do you use to sleep at night?

15. History of respiratory disease:
·        Have you had colds, allergies, asthma, tuberculosis, bronchitis, pneumonia or emphysema?
·        How frequently have these occurred?
·        How long did they last?
·        How were they treated?
·        Have you been exposed to any pollutants?
16. Allergies:
·        Inquire about patient's exposure to airborne allergens.
·        The allergic response is often watery eyes, sneezing, runny nose or respiratory symptoms such as cough or wheezing.
·        Obtain information about the type of allergens, response to these allergens, successful and unsuccessful relief measures.
17. Health risks
·        Determine familial risk factors such as family history of lung cancer or cardiovascular disease.
·        Document about the blood relatives who had the disease and their present level of health or age at the time of death.
18. Presence of risk factors:
·        Do you have a family history of lung cancer, cardiovascular disease?
·        The nurse should also note the. client's weight, activity pattern and dietary assessment.
·        Risk factors include obesity, sedentary lifestyle and diet high in saturated fats.
19. Medications:
·        Collect the history about the medications that the patient is using.
·        Prescribed medications, over-the-counter medicine, folk medicine, herbal medicines, alternative therapies, illicit drugs and substances.
·        Have you taken or do you take any over-the-counter or prescription medications for breathing (e.g., bronchodilator, inhalant, narcotic)?
·        If so, which ones? In addition, what are the dosages, times taken and results, including side effects?
20. Fatigue:
·        It is a subjective sensation in which the patient reports a loss of endurance.



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item Notes Nursing assessment
Notes Nursing assessment
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