Chapter 3 – Respiratory System Show
A brief scan (see Figure 3.6) involves inspection of the client’s breathing and includes elements of the primary survey. This assessment helps you quickly recognize cues of clinical deterioration, specifically signs of respiratory distress, and may influence your decision on whether immediate action is required. The steps of a brief scan are prioritized in order of importance. For example, you need to assess whether an airway is patent (i.e., not obstructed) before you assess presence of breathing and respiratory rate. Figure 3.6: A brief scan Guided by the primary survey, steps of the brief scan of the respiratory system include assessing respiratory effort and signs of respiratory distress: 1. Assess airway patency
2. Assess presence of breathing and respiration rate
Table 3.2: Respiratory rate ranges (taken from: https://pressbooks.library.ryerson.ca/vitalsign2nd/chapter/what-is-respiration/)
3. Assess work of breathing and signs of respiratory distress.
4. Assess oxygen saturation.
Contextualizing Inclusivity – Pulse OximetryOxygen saturation measured with pulse oximetry is sometimes overestimated in a client with dark skin: oxygen saturation may appear higher than it really is. If a client indicates that they are short of breath, but this is not reflected on the pulse oximeter, believe the client and assess further. It is always best to assess further when the client’s signs and symptoms do not align with the pulse oximetry. 5. Assess level of consciousness, facial expression, and body position for signs of respiratory distress.
6. Assess colour changes (and fingernails for clubbing and testing capillary refill)
Contextualizing Inclusivity – Assessing Colour ChangeCyanosis: This is best seen in areas with rich vasculature and thin overlying dermis: mucous membranes/lips, conjunctiva, and extremities (fingernails). In people with darker skin, cyanosis can appear as a grey/white shade around the lips and the conjunctiva can appear as a grey/bluish shade while people with yellowish tones to their skin can have a greyish/green shade (Lewis, 2020; Sommers, 2011). In people with lighter skin, cyanosis appears as a dusky bluish/purple shade (Lewis, 2020). Pallor: In people with darker skin, this can appear as a grey shade to the mucous membranes/lips, nail beds, and skin, and a yellowish shade in people with lighter brown skin; it can be helpful to look at the palms of people with dark skin when assessing for pallor as they tend to be paler (Lewis, 2020). In people with lighter skin, pallor can appear as a generalized pale discolouration to the skin, nail beds, and mucous membranes/lips. In people of all skin colours, the conjunctiva is normally a healthy pink due to the vascularity, but with pallor it will appear white or very pale pink (Mukwende et al., n.d.).
Figure 3.7: Clubbing of fingernails on a person’s hands. Taken from Acopaquia.jpg by Desherinka is licensed under CC BY-SA 4.0
7. Note the findings
A client who is in respiratory distress requires immediate intervention, especially if signs indicate an obstructed airway, increased work of breathing, an altered level of consciousness, and an oxygen saturation dropping below 92%. Stay with client and call for help (a senior nurse, physician, or nurse practitioner) if a client is in respiratory distress.
You may need to keep the client in a supine position if you suspect that they are deteriorating quickly and may go into respiratory or cardiac arrest. Notify the or call a code in this case. may be needed if the client is in respiratory arrest. Lower oxygen saturation levels (between 88 to 92%) are acceptable for those with Chronic Obstructive Pulmonary Disease (). In a healthy person without COPD, the strongest stimulus for the normal respiratory drive is hypercapnia (increased carbon dioxide, CO2, in the blood). This means that a person is stimulated to breathe when there are high CO2 levels in their blood. In contrast, a person with COPD has a reduced capacity to exhale carbon dioxide, leading to hypercapnia (increased CO2 in the blood). As a result, there is a shift in the normal respiratory drive: the respiratory drive becomes a hypoxic drive, meaning that low oxygen is the primary stimulus to breathe. This means that low oxygen levels stimulate respirations as opposed to hypercapnia because a person with COPD is a CO2 retainer (i.e., they retain CO2 in their lungs). Therefore, when performing a brief scan, consider oxygen saturation levels in the context of existing conditions and be cautious about applying oxygen when a client’s oxygen saturation is lower than normal, particularly if the client has COPD. Activity: Check Your UnderstandingReferences Lewis, G. (2020). Identifying AEFI in diverse skin colour. https://mvec.mcri.edu.au/references/identifying-aefi-in-diverse-skin-colour/ Mukwende, M., Tamony, P., & Turner, M. (n.d.). Mind the gap: A handbook of clinical signs in black and brown people. (1st edition). https://litfl.com/wp-content/uploads/2020/09/Mind-the-Gap-A-handbook-of-clinical-signs-in-Black-and-Brown-skin.-first-edition-2020.pdf Sommers, M. (2011). Color awareness: A must for patient assessment. American Nurse. https://www.myamericannurse.com/color-awareness-a-must-for-patient-assessment/ Which are the nurse's priority assessments of the breathing component of a primary survey of a client?Assess breath sounds and respiratory effort. The priorities to check for breathing include observation of the chest wall for trauma and assessment of breath sounds and respiratory effort.
What are the components of the breathing assessment?Breathing. Assessment of breathing involves evaluation of the respiratory effort and whether the child is oxygenating and ventilating appropriately. Nasal flaring, chest retractions, and head bobbing are signs of increased respiratory effort.
What assessment finding would be present in a client in respiratory distress?Patients in respiratory distress may have an anxious expression, pursed lips, and/or nasal flaring. Asymmetrical chest expansion may indicate conditions such as pneumothorax, rib fracture, severe pneumonia, or atelectasis. With hypoxemia, cyanosis of the extremities or around the mouth may be noted.
Which 3 things are assessed to Recognise breathing problems?Ask about shortness of breath and watch for signs of labored breathing. Check the patient's pulse and blood pressure. Assess oxygen saturation.
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