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.
NURSING HISTORY
The nursing history includes:
1.
History of respiratory function:
This includes presence of:
Cough
· 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 bæatlling:
·
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.
COMMENTS