Angelite Nurses

Health History

1. Presenting problem
1. Nose/nasal sinuses: symptoms may include colds, discharge, epistaxis, sinus problems (swelling, pain)
2. Throat: symptoms may include sore throat, hoarseness, difficulty swallowing, strep throat
3. Lungs: symptoms may include
1. Cough: note duration; frequency; type (dry, hacking, bubbly, barky, hoarse, congested); sputum (productive vs nonproductive); circumstances related to cough (time of day, positions, talking, anxiety); treatment.
2. Dyspnea: note onset, severity, duration, efforts to treat, whether associated with radiation, if accompanied by cough or diaphoresis, time of day when it most likely occurs, interference with ALD, whether precipitated by any specific activities, whether accompanied by cyanosis.
3. Wheezing
4. Chest pain
5. Hemoptysis
2. Life-style: smoking (note type of tobacco, duration, number per day, number of years of smoking, inhalation, related cough, desire to quit); occupation (work conditions that could irritate respiratory system [asbestos, chemical irritants, dry-cleaning fumes] and monitoring or protection of exposure conditions), geographical location (environmental conditions that could irritate respiratory system [chemical plants/industrial pollutants]); type and frequency of exercise/recreation.
3. Nutrition/diet: fluid intake per 24-hour period; intake of vitamins
4. Past medical history: immunizations (yearly immunizations for colds/flu; frequency and results of tuberculin skin testing); allergies (foods, drugs, contact or inhalant allergens, precipitating factors, specific treatment, desensitization)

Physical Examination

1. Inspect for configuration of the chest (kyphosis, scoliosis, barrel chest) and cyanosis.
2. Determine rate and pattern of breathing (normal rate 12-18/minute); note tachypnea, hyperventilation, or labored breathing pattern.
3. Palpate skin, subcutaneous structures, and muscles for texture, temperature, and degree of development.
4. Palpate for tracheal position, respiratory excursion (symmetric or asymmetric movement of the chest), and for fremitus.
1. Fremitus is normally increased in intensity at second intercostal spaces at sternal border and interscapular spaces only.
2. Increased intensity elsewhere may indicate pneumonia, pulmonary fibrosis, or tumor.
3. Decreased intensity may indicate pneumothorax, pleural effusion, COPD.
5. Percuss lung fields (should find resonance over normal lung tissue, note hyperresonance or dullness) and for diaphragmatic excursion (normal distance between levels of dullness on full expiration and full inspiration is 6-12 cm).
6. Auscultate for normal (vesicular, bronchial, bronchovesicular) and adventitious (rales or crackles, rhonchi, pleural friction rub) breath sounds (see Figure 4.11).

FIGURE 4.11 Locations for hearing normal breath sounds


Laboratory/Diagnostic Tests

1. Arterial blood gases (ABGs)
1. Measure base excess/deficit, blood pH, CO₂, total CO₂, O₂ content, O₂ saturation (SaO₂), pCO₂ (partial pressure of carbon dioxide), pO₂ (partial pressure of oxygen)
2. Nursing care
1. If drawn by arterial stick, place a 4X4 bandage over puncture site after withdrawal of needle and maintain pressure with two fingers for at least 2 minutes.
2. Gently rotate sample in test tube to mix heparin with the blood.
3. Place sample in ice-water container until it can be analyzed.
2. Pulmonary function studies
1. Evaluation of lung volume and capacities by spirometry: tidal volume (TV), vital capacity (VC), inspiratory and expiratory reserve volume (IRV and ERV), residual volume (RV), inspiratory capacity (IC), functional residual capacity (FRC)
2. Involves use of a spirometer to diagram movement of air as client performs various respiratory maneuvers; shows restriction or obstruction to air flow, or both.
3. Nursing care
1. Carefully explaining procedure will help allay anxiety and ensure cooperation.
2. Perform tests before meals.
3. Withhold medication that may alter respiratory function unless otherwise ordered.
4. After procedure assess pulse and provide for rest period.
3. Hematologic studies (ESR, Hgb and hct, WBC)
4. Sputum culture and sensitivity
1. Culture: isolation and identification of specific microorganism from a specimen
2. Sensitivity: determination of antibiotic agent effective against organism (sensitive or resistant)
3. Nursing care
1. Explain necessity of effective coughing.
2. If client unable to cough, heated aerosol will assist with obtaining a specimen.
3. Collect specimen in a sterile container that can be capped afterwards.
4. Volume need not exceed 1-3 ml.
5. Deliver specimen to lab rapidly.
5. Tuberculin skin test
1. Intradermal test done to detect tuberculosis infection; does not differentiate active from dormant infections
2. Purified protein derivative (PPD) tuberculin administered to determine any previous sensitization to tubercle bacillus
3. Several methods of administration
1. Mantoux test: 0.1 ml solution containing 0.5 tuberculin units of PPD-tuberculin is injected into the forearm.
2. Tine test: a stainless steel disc with 4 tines impregnated with PPD-tuberculin is pressed into the skin.
4. Results: read within 48-72 hours; inspect skin and circle zone of induration with a pencil; measure diameter in mm
1. Negative: zone diameter less than 5 mm
2. Doubtful or probable: zone diameter 5-10 mm
3. Positive: zone diameter 10 mm or more
6. Thoracentesis
1. Insertion of a needle through the chest wall into the pleural space to obtain a specimen for diagnostic evaluation, removal of pleural fluid accumulation, or to instill medication into the pleural space
2. Nursing care: pretest
1. Confirm that a signed permit has been obtained.
2. Explain procedure; instruct client not to cough or talk during procedure.
3. Position client at side of bed, with upper torso supported on overbed table, feet and legs well supported.
4. Assess vital signs.
3. Nursing care: posttest
1. Observe for signs and symptoms of pneumothorax, shock, leakage at puncture site.
2. Auscultate chest to ascertain breath sounds.
7. Bronchoscopy
1. Insertion of a fiberscope into the bronchi for diagnosis, biopsy, specimen collection, examination of structures/tissues, removal of foreign bodies
2. Nursing care: pretest
1. Confirm that a signed permit has been obtained.
2. Explain procedure, remove dentures, and provide good oral hygiene.
3. Keep client NPO 6-12 hours pretest.
3. Nursing care posttest
1. Position client on side or in semi-Fowler's.
2. Keep NPO until return of gag reflex.
3. Assess for and report frank bleeding.
4. Apply ice bags to throat for comfort; discourage talking, coughing, smoking for a few hours to decrease irritation.