Respiratory Assessment: Importance, Factors, And Findings

Factors Affecting Respiratory Rate

Question:

Discuss about the Nursing Assessment Of Breathing.

The rate and the characteristics of respirations help to provide insight to the general health status of the person. Breathlessness can be a very disturbing symptom for many people and assessment of the breathing patterns help to identify the problem early and intervene with them.

People with lung diseases require their respiratory assessment to be more frequent than the others. People suffering from chest infections, long term lung problems or people who smoke tobacco daily will be benefitted if they have their respirations assessed regularly. There are certain factors that impact the respiratory rate. They are the age, gender, weight, size, exercises pain, anxiety, smoking habits and the effects of some medicines. The normal respiratory rate of a man is about 14 to 18 breaths a minute and for a woman it is about 14 to 18 breaths per minute, hence it is important to assess the respiration in order to measure any changes (Usmani & Barnes 2012, p.146-156). Some of the probable findings of a respiratory assessment can be deep and swallowed breathing that may indicate anxiety. Shallow breathing that can be due to the effect of some medicines (Thim et al. 2012,p. 117). Minimal chest movements are sometimes found in asthma as a differential diagnosis. Person facing respiratory trouble may indicate towards the onset of a lung or heart problems. Pain during breathing may indicate towards a chest infection or cracked rib, chest infection or tumor in the lung (Usmani & Barnes 2012, p.146-156). Breathing through mouth may indicate towards a blocked nose. Irregular breathing can be common in older persons, but may also direct towards heart or brain problems.

While measuring the respirations, the depth, rate, pattern of respiration should be recorded. The depth volume known as the tidal volume should be about 500ml. The breathing rate should've equal with pause between each breath.

Inspection- Inspection is normally done with eyes and it begins with the initial greeting with the patient. A nurse should notice the patient's facial expression in relation to inspiration and expiration (Thim et al. 2012, p. 117).

Palpation- It is done by placing the palm of each hand on the superior portion of the hemithoraces and the hand is then moved inferiorly below the twelfth ribs.

Percussion- Percussion is done for determining the sound if the area under the percussed finger is fluid filled, solid filled and air filled (Thim et al. 2012, p. 117).

A respiratory assessment includes the following:-

Speech:

Normal- No difficulties in speech

Respiratory distress- short sentences, short phrases or may be few words.

Cough:

Productive cough indicates COPD, bronchiectasis or COPD and CF if the patient is younger and dry cough relates to asthma if younger and ILD if older (Csikesz & Gartman 2014).

Inspection of the hands

It is also necessary to inspect the hands. Tar staining on the fingers may indicate towards chain smoking, which increases the chance of COPD and lung cancer. Tenderness and swelling of the joints may indicate towards rheumatological diseases (Thim et al. 2012, p. 117).

Findings in Respiratory Assessment

Respiratory noises:

Normal- no noises or quite

Respiratory distress: Noises on breathing such as crackles or gasps may indicate some clinical conditions. For example wheezing is the characteristic symptom of asthma (Kazaks et al. 2012, p.83-92).

Chest auscultation:

Normal- no wheezes or crackles

Respiratory distress- Wheeze: expiratory; Presence of fine to coarse crackles, inspiratory stridor.  

Auscultation of the lungs is an important part of the respiratory examination and is helpful for diagnosing various respiratory disorders. Auscultation of the lungs includes breath sounds, intensity, vocal resonance and adventitious sounds (Csikesz & Gartman 2014,p.277).

Normal:  Adults: 12-16/ minute, kids: 15-25/ minutes, Babies: 20-40/ minute

Respiratory distress: Tachypnoea- adults >24/min, kids>35/min, babies>50/min.

While measuring the respiratory rate it is essential to assess the color of the lips of the patient. Patient having respiratory problems might have cyanosed lips. Cyanosis can also be seen in the ear lobes, in the tip of the nose, nail beds.

Normal- Minimum effort, small chest/abdo movement

Respiratory distress- Marked movement of the chest and the abdomen, use of the abdominal muscles, sternal retraction, intercostals recession.

Observation of the breathing- to check whether the patient is mouth breathing or pursuing the lips on expiration or using the abdominal muscled or flaring the nostrils. Flaring of nostrils in babies indicates towards acute respiratory problem (Thim et al. 2012, p. 117).

Pulse rate:

Normal- Adults:   60-80 / min

Kids:      80 –120

Babies: 100 –140

Respiratory distress: In case of tachycardia, the signs can be - adults>24/min

Kids>35/ min, babies>50/min.

Skin:

Normal- Pink and normal

Respiratory distress: Sweaty, pale and cyanosis can also occur.

Oximetry:

Normal: 96% _ on room air.

Respiratory distress: 90-95% on room air, <90%= serious hypoxia.

A pulse oximeter is used for measuring the oxygen saturation level of the patient. This will provide a reading of the oxygenation of the red blood cells. If a pulse oximeter is used then the patient may require less arterial blood gases performed (Jubran 2015, p. 272).

Pulsus paradoxus- The pulse wave volume decreases with inspiration then it may indicate with COPD (Thim et al. 2012, p. 117).

Flapping tremor- Indicates retention of the CO₂ and thus type 2 respiratory failure (Csikesz & Gartman 2014,p.277). 

• It is necessary to wash the hands thoroughly between patients to prevent infection.
• Respirations should be recorded full minutes for monitoring the respiration pattern and ensuring the accuracy of the observation (Kazaks et al. 2012 p.83-92).
• If the patient is using the oxygen mask or nasal cannula it should be noted that they were properly placed before the recording. It is also necessary to check that the oxygen flow is as prescribed and is recorded in the chart.

The Roper-Logan-Tierney Model of nursing consists of five components the can be used for describing the individual in relation to prevent the clinical condition, maintaining of the health, self efficacy and coping up with the exacerbations (Alligood 2017). The patient centered nursing according to the R-L-T model, consists of four phases: Assessing, planning, implementing and evaluating (McCrae 2012,p.222-229).

The Roper-Logan-Tierney Model for Nursing  is a nursing framework that is based on the activities of daily living such as breathing (McCrae 2012, 222-229). As per the model it is first important to find out the main clinical priorities (Aldridge et al. 2011,p.52). If a person with COPD is considered then the person should mostly have difficulties with breathing, drinking and swallowing (Jung 2009, p.422-428). At first it is necessary to assess the vital signs of the patient. COPD is chronic illness that is featured by a permanent obstruction in the airways (Elsherif & Noble 2011, p.29-33). This obstruction interferes with the normal breathing. The exacerbation indicates the worsening of the disease.

Techniques Used in a Respiratory Assessment

It is to be mentioned that a person having COPD can have the vital signs McKinney 2012,p.41) – PaO₂: 70 mmHg (↓)

 HCO₃: 19 mmHg (↓)

SpO₂: 88% (↓).

The peak respiratory flow rate is used for assessing the lung function and for determining the progress of the patient to the medications. The modified early warning score helps to measure any changes in the patient and recognizing any improvement or deterioration of the patient (McKinney 2012, p.41).

As mentioned in the previous part of the assignment, assessment of cough is necessary for checking the capability of the patient to expectorate. The color and the consistency of the cough would help the nurse in assessing the clinical condition of the patient (Haruna et al. 2010, p.10).. 

One of the clinical characteristics of COPD is pain while breathing. Post sternal pain can be caused by the infection in the inflammation in the trachea. A visual analog scale was used to assess the pain (Elsherif & Noble 2011, p.29-33).

Some of the problems that can be identified in patients having COPD are changes in the respiratory rate, wheezing, coughing, respiratory pain, and production of abnormal sputum (Haruna et al. 2010, p.10).

The main nursing goal to deal with a patient having COPD is to prevent the potential exacerbation of the problems. Other aims includes, enabling the patient to breathe comfortably (Elsherif & Noble 2011, p.29-33). Maintaining the oxygen saturation rate above 90%, ensure effective coughing; reduce the anxiety in the patient and an infection free respiratory tract. Another goal is to enable the patient to use oxygen and inhale correctly (McCrae 2012,p. 222-229). 

In order to improve the breathing, psychological and the physiological, socio-cultural and the environmental factors should be taken in to account. The patient should be kept in an upright position in order to assist the expansion of the lungs. The vital signs of the patient have to be checked after every 15 minutes (Elsherif & Noble 2011, p.29-33).

After the provision of oxygen, the arterial blood gases should be rechecked for allowing the detection of any augmented concentration of the carbon-dioxide or the falling pH (Jung 2009, p.422-428). As per the NICE guidelines, it is recommended that the patient can be given oxygen by a venturi mask that would help to deliver the accurate oxygen concentration. In order to improve the breathing pattern in the patient, humidification device can be given after discussing with the doctor (Holland 2008, p.265-288). Short-acting beta 2-agonist bronchodilator can be given for relaxing the smooth muscles and improve the breathing. Patients who have frequent episodes of COPD exacerbations, bronchodilators can also be provided by the help of nebulizers. Nurses should encourage the patient for fluid intake as intake fluid helps in thinning of the secretions. The New Borg Scale can be used to assess how the patient feels (Elsherif & Noble 2011, p.29-33).

Self assessment and self management are the important ways to deal with the COPD symptoms.  The patient can be referred to a registered nurse for assessing his/ her inhaler techniques (Elsherif and Noble 2011, p.29-33). Prior to the assessment it is necessary to inform the patient about all the procedures. According to the nursing theories of roper-Logan and Tierney, a multidisciplinary team should be employed to manage with the extreme symptoms of COPD (Jung 2009, p.422-428). The physiotherapist would assess the mobility of the patient and should teach her about the relaxation exercises. Before the discharge of a COPD patient, the respiratory nurses would assess whether the patient is fit for an early discharge (Elsherif & Noble 2011, p.29-33). According to Holland (2008, p.265-288), the aim of the referrals is to reduce the length of the hospital stay of the patient, to reduce the risk of contracting infections and to ensure that the patient easily continues with her activities of living without any interruption. Referrals to proper social support can play a vital role in post- discharge. As they can arrange for home help, respite and day care centers, meals on wheels , which will offer the patient a break from strenuous activities.

It is to be noted that in most of the cases the COPD is mainly caused by the bacterial or viral infections, hence vaccinations can be given to lessen the number of the exacerbation episodes.  Pneumococcal and flu vaccinations can be given. According to Hemming (2010, p. 171), patients with acute respiratory distress can be referred to pulmonary rehabilitation, where a multi-disciplinary approach can be provided, where the patient will be educated about the routined exercises, nutritional advice and other tips (Hemming 2010, p.171). The patient’s weight should be checked for once in every week.  Such a program will be able to improve the patient's breathing, reduced level of anxiety and self management of the clinical condition. It has to be remembered that respiratory distress affects the patient both physically and psychologically as regular episodes of breathlessness can bring about distress in the personal as well as the professional life; this can impact further on her breathing and dyspnoea (Holland 2008, p.265-288). Assistance with dressing, washing and toileting may increase the confidence in the patient (Hemming 2010, p.171). Patients having distressing episodes of respiratory distress may have lost appetite that can affect their body mass index and the nutritional status. The patient should be encouraged to take a balanced diet and enough exercises.

Evaluation of the patient’s condition can be done by asking the patient about any respiratory distress. The visual analog pain assessment scale can be used to determine if the chest pain have subsided. The patient would become more competent to use the bronchodilators or the nebulizers. He/ she will be able to do the exercises properly. The patient would be able to expectorate the cough easily. Correct nursing assessment would help to get beck the vital signs to normal. The SpO₂ would be above 90 percent, which would indicate a low risk of the clinical condition. The patient will show less anxiety. The nutritional assessment of the patient would show a good nutritional status. The patient would say that he was feeling better.

References

Aldridge, J., Eshun, A. & Meurier, C., 2011. Nursing assessment and care 2 planning. Health Assessment, 14, p.52.

Alligood, M.R., 2017. Nursing Theorists and Their Work-E-Book. Elsevier Health Sciences.

Csikesz, N.G. & Gartman, E.J., 2014. New developments in the assessment of COPD: early diagnosis is key. International journal of chronic obstructive pulmonary disease, 9, p.277.

Elsherif, M. & Noble, H., 2011. Management of COPD using the Roper-Logan-Tierney framework. British Journal of Nursing, 20(1), pp.29-33.

Haruna, A., Oga, T., Muro, S., Ohara, T., Sato, S., Marumo, S., Kinose, D., Terada, K., Nishioka, M., Ogawa, E. & Hoshino, Y., 2010. Relationship between peripheral airway function and patient-reported outcomes in COPD: a cross-sectional study. BMC pulmonary medicine, 10(1), p.10.

Hemming, L., 2010. Personal cleansing and dressing. Nursing Care and the Activities of Living, p.171.

Holland, K., 2008. Personal cleansing and dressing. Edinburgh: Churchill Livingstone. 2^nd p.265-288

Jubran, A., 2015. Pulse oximetry. Critical Care, 19(1), p.272.

Jung, K.S., 2009. Management of COPD. Korean Journal of Medicine, 77(4), pp.422-428.

Kazaks, A.G., Uriu-Adams, J.Y., Albertson, T.E., Shenoy, S.F. & Stern, J.S., 2010. Effect of oral magnesium supplementation on measures of airway resistance and subjective assessment of asthma control and quality of life in men and women with mild to moderate asthma: a randomized placebo controlled trial. Journal of Asthma, 47(1), pp.83-92.

Lockey, D.J., Avery, P., Harris, T., Davies, G.E. & Lossius, H.M., 2013. A prospective study of physician pre-hospital anaesthesia in trauma patients: oesophageal intubation, gross airway contamination and the ‘quick look’airway assessment. BMC anesthesiology, 13(1), p.21.

McCrae, N., 2012. Whither Nursing Models? The value of nursing theory in the context of evidence?based practice and multidisciplinary health care. Journal of Advanced Nursing, 68(1), pp.222-229.

McKinney, A., 2012. Acute exacerbation of chronic obstructive pulmonary disease. Nursing The Acutely Ill Adult: Case Book: Case Book, p.41.

Thim, T., Krarup, N.H.V., Grove, E.L., Rohde, C.V. & Løfgren, B., 2012. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine, 5, p.117.

Usmani, O.S. & Barnes, P.J., 2012. Assessing and treating small airways disease in asthma and chronic obstructive pulmonary disease. Annals of medicine, 44(2), pp.146-156.