Assessment of breathing

13
Assessment of breathing

Diagram shows factors for consideration in a respiratory assessment as patient history, look, listen, feel, investigate, and measure. It also shows normal and clubbed of fingernails, signs of hypercapnia as mild, moderate and severe, palpation of chest expansion, et cetera.


Assessment of breathing is the second step of the ABCDE approach. In order to obtain an accurate assessment and interpret clinical findings, the nurse needs to be familiar with basic respiratory physiology, understanding oxygenation with concepts of gaseous exchange and ventilation (Chapters 11 and 12). Respiratory disease comprises a significant percentage of hospital admissions and acute respiratory problems may develop as a secondary problem whilst in hospital. A knowledge of pre-existing conditions that place the individual at risk of respiratory problems is helpful for early identification. It is important to be familiar with the patient history (Figure 13.1), as knowledge of underlying chronic respiratory problems will inform the assessment and subsequent action taken. The respiratory system is responsive to problems in cardiac, neurological and renal status, and even subtle changes can be an early indicator of deterioration. A systematic approach to data collection, using the ‘look, listen, feel, measure, investigate’ approach, contributes to a comprehensive assessment and has been summarised in Figure 13.1.


Breathing assessment: look

Apr 8, 2019 | Posted by in NURSING | Comments Off on Assessment of breathing
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