1. HISTORY TAKING
1.1. SUBJECTIVE DATA
1.1.1. Biographic
1.1.1.1. Mr. Chan, a 65-year-old first-generation Chinese man
1.1.1.2. Mandarin is his first language; however, he speaks English with only a slight accent and has a well-developed vocabulary and fluent pacing.
1.1.2. Chief Complaints
1.1.2.1. Has come to the clinic today reporting increasing shortness of breath and fatigue
1.1.2.2. The patient states, "I'm still not feeling very well. When I came in last time, they said that I had bronchitis, but it feels like it was getting worse. Last time I felt wheezy: this time, I'm coughing more."
1.1.2.3. Denies chest pain, complains of increasing fatigue and shortness of breath
1.1.2.4. Coughing up approximately 240 ml thick yellow sputum daily.
1.1.3. Patterns
1.1.3.1. He has smoked two packs of cigarettes a day for 49 years
1.1.4. Medication
1.1.4.1. He states that he has been using his inhalers as prescribed, but for the last few days, his breathing has gotten worse
1.1.5. Medical History
1.1.5.1. Chronic obstructive pulmonary disease (COPD)
1.1.5.2. Congestive heart failure (CHF)
1.1.5.3. High blood pressure (BP)
1.2. OBJECTIVE DATA
1.2.1. Temperature 38°C (100.4°F) oral
1.2.2. Pulse rate 102 beats/min
1.2.3. Respiration rate 24 breaths/min
1.2.4. Blood Pressure 156/78 mm Hg, Sa02 90%
1.2.5. Oxygen Saturation (Sa02) 90%
2. INSPECTION
2.1. Patient is alert and oriented.
2.2. The patient was sitting in a tripod position in a chair with increased respiratory effort.
2.3. Pursed lip breathing noted.
2.4. Patient needs to pause for breath while talking in brief sentences.
2.5. Skin color pale, using neck muscles to breathe, no intercostal retractions recorded.
2.6. Clubbing is present in fingers bilaterally.
2.7. Coughing up moderate amounts of thick yellow sputum.
2.8. No intercostal or sunray clavicular retractions were noted.
3. TEST & EXAMINATION
3.1. PALPATION
3.1.1. Chest wall nontender to palpation.
3.1.2. Using sternomastoid and scalene muscles to assist breathing.
3.1.3. Tactile fremitus increased in the suitable base.
3.1.4. Bronchophony, egophony, and whispered pectoriloquy are present over the suitable base.
3.2. PERCUSSION
3.3. AUSCULTATION
3.3.1. Breath sounds decreased in the base of the right lung: a few scattered expiratory wheezes in all lung fields.
3.3.2. Decreased breath sounds were noted in the suitable base.
4. NURSING DIAGNOSIS
4.1. Impaired gas exchange related to fluid in alveoli as evidenced by Sa02 90%, decreased breath sounds suitable base.
4.2. Activity intolerance related to an imbalance between oxygen supply and demand as evidenced by increased respirations of 24-32 breaths/min after walking 20 ft.
4.3. Pallor ??
4.4. Complaints of dyspnea ??
4.5. Fatigue ??
5. NURSING INTERVENTION
5.1. Contact the primary care provider (PCP) with assessment findings, discuss the need for sputum culture and chest x-ray, and obtain medication orders.
5.2. Assess the effect of dyspnea on the patient's sleep pattern and ability to perform ADL5.
5.3. Teach correct techniques for coughing and deep breathing; teach energy-conserving measures.
5.4. Consult with the respiratory therapy team about the need for nebulizer treatments and then contact POP for orders if indicated.
5.5. Discuss concerns with the patient and his wife.
6. TOOLS
6.1. Obtaining Sputum Specimen
6.1.1. Suction setup (container, liner with lid, suction tubing and catheter)
6.1.2. Specimen suction trap
6.1.3. Epistick or tongue blade
6.1.4. Sterile gauze pad
6.1.5. Sterile saline for clearing tube
6.2. Obtaining Vital Signs
6.2.1. Oral thermometer
6.2.2. Pulse Oximeter
6.2.3. Spirometer
6.2.4. Stethoscope
6.2.5. Sphygmomanometer