Introduction
This essay is focused on the signification of health assessment throughout the nursing process of a scenario of patient (Mr Lee) who diagnosed with acute exacerbation of COPD and express how health assessment and emergency assessment help to plan a suitable nursing care for Mr Lee.
Background
Firstly, let’s describe of Mr. Lee’s health status.
Mr. Lee, aged 70, graduated from high school, retired. He have a son and living with wife and son. He had smoking habit (2 packs / day), but had been quit recently. He also has drinking habit (2 beers per week). He has allergic history of drug – Sulfonamides.
For the past history, Mr. Lee had myocardial, hypertension, left-sided heart failure and fractured ankle. He also previously diagnosed with emphysema.
Mr. Lee admitted hospital with wheelchair at 23:30 hour on 23 Jan 2014 by complaint of increased cough and laboured breathing at home for past 24 hours. Pain rated 4/10 (10 is being the worst) with cough and mucus sputum. Dyspnoeic breathing, breath sounds heard on the bilateral lung field.
Vital signs checked: temperature 37.3 ℃, pulse 90/ min, respiration 22 /min, blood pressure 130/84 mmHg, SpO2: 95% on room air. Urine test results normal.
General condition fair and conscious, emotion stable but showed anxious and claim had insomnia. Mr. Lee is obese: BW 84kg, Height 1.6m (BMI 32.8), he also has oedematous on both ankles (size ++). His vision and hearing are normal.
Mr. Lee speaks Cantonese with clear communication. Appetite normal with denture which kept by patient, special diet: low sodium 4g should be given to patient. Elimination is normal, bowel pattern usual habit once per day. For the mobility part, Mr. Lee ambulates independently with fairly steady gait. He did not have disability but need to assist the self-care ability.
Medical orders
At 01:30 of 24 Jan 2014 MO (Dr Chow) went to see Mr. Lee and prescribed some medical orders as below:
Prednisolone (steroid, 80mg po daily) improve respiratory function and oxygenation by reduce inflammation. However sever adverse effect may occur by taking oral steroids, such as hypertension, fluid retention, GI upset, anxious etc. Nurse need to assess and close monitor BP, in/out put, emotion and give low sodium diet for patient.
Due to Mr. Lee have MI history, Aspirin (Salicylate, 80mg po daily) prescribe for inhibit platelet aggregation avoid MI relapse. Nurse need to assess coagulation function and liver function.
Prescription of two bronchodilators: Atrovent (2 puffs t.i.d.) and Ventolin (2 puffs q6hr prn) are for COPD treatment by make bronchial smooth muscle relaxation. Nurse need to assess the technique of inhalation and difficulty breathing.
Furosemide (diuretic, 40mg po daily) prescribe for removes the stimulus of sodium, chloride absorption because of Mr. Lee has oedematous on both ankles. This drug causing a profound increase in urine output, Nurse need to assess the in/output balance and electrolyte level.
Metoprolol (Beta-blocker, 50mg po daily) causing vasodilation to treat hypertension and prevent heart attack. Nurse need to assess the BP and heart rate before given.
Mr. Lee has left-sided heart failure history, MO prescribes Digoxin (cardiac glycoside, 0.125mg po daily) which help maintain normal heart rhythm and improve blood circulation. Nurse need to assess the apical rate make sure >60/min before given.
To make sure the above drugs are safety administer to Me. Lee, not only notice the special precautions of each drug state as above and apply three check five right
in giving medication
, nurse also should give assessment for patients’ health history especially allergy history; general survey such as vital signs q4hr and p.r.n., I/O chart; physical assessment e.g. breathing pattern and follow laboratory results (CXR, CBP, R/LFT, ABG, Urinalysis), assess and detect any abnormal finding before drug given, assess the drug efficacy and side effect after receive drugs.
Oxygen therapy
Except oral drug, Dr Chow also prescribes oxygen to Mr. Lee with maximum 4L/min to keep pulse oximetry≧90%. During administering oxygen, hanging notice near Mr. Lee, let everyone know he is on oxygen therapy and the flow rate. Nurse should be awareness that COPD patients can cause respiratory depression or acidosis (pH<7.35) when receive wrong level of oxygen. Nurse must determine the medical prescription is safe and appropriate.
Nurse should ensure the setting of oxygen delivery is smooth, on the right type i.e. low-flow devices; and method i.e. nasal cannula or simple mask.
Assess and monitor pulse oximetry level and respiratory rate closely. Keep vision observation of presentation of Mr. Lee such as SOB. Follow the medical review and the ABG result which may affect the need and level adjustment of oxygen.
Assessment of SOB
Base on the chief complain of laboured breathing for Mr. Lee, nurse need to pay more attention on his clinical presentation. If patient suffering short of breath (lack of oxygen and/or excess carbon dioxide in the blood) symptoms include: breathing rate become faster and shallow, tachycardia, unable to speak long sentences,
cyanosis
, use
accessory muscles of respiration
. Patient also may have
chest pain
or getting confused
.
Besides, nurse can apply assessment tool ‘COLDSPA’ asking the symptoms of SOB as below:
Character: Ask Mr. Lee to describe the difficulty breathing. Onset: Ask whether the onset of difficulty breathing is sudden or gradual. Location: Ask have chest pain or not and the manifestation and stationary or moves. Duration: Ask how long the SOB lasts, does it appear when walk or doing activities. Severity: Ask how much it bothers Mr. Lee. Pattern: Ask what cause SOB being better or worse. Associated factors: Ask is there any symptoms occur with it and does it affect patient.
Physical assessment also can use to assess SOB includes four parts:
Inspection to give observation of skin (shin skin, cyanosis), body weight (fat, oedema), breathing pattern (faster respiratory rate, using accessory muscles), chest wall (barrel chest).
Palpation mainly focus on the degree of expansion of chest, COPD patient may symmetrically reduced lung expansion.
Percussion which to tap the lung and produced sounds. Different types of sound mean the chest filled with air, fluid or solid. Mr. Lee with SOB may have full of air in the lung, the tapping sound will be hyper resonant.
Auscultation is use stethoscope to listen the sound of breathing. Mr. Lee with SOB, the breath sound would be wheeze and crackles.
Nursing action on N shift
Base on the assessment, the nurse should keep close observation of Mr. Lee clinical presentation, pulse Oximetry and vital sign monitoring. Give Ventolin puff if patient SOB. Set NS block for used. Chart I/O for the fluid balance. Pend investigations such as CXR and blood taking as quick as possible.
Important information hand over to A shift nurse
The information of Mr. Lees’ health history, general survey and physical assessment and the nurse action done at night shift should be hand over to A shift nurse. Also told the nurse that Mr. Lee dyspnea at night, advise chasing lab results, suggest doctor order sputum test and Peak flow rate checking.
Important health problem identification
To identify the main problem of Mr. Lee, nurse need to compare the objective and subjective data of the below groups.
Oxygen: (subjective data) Mr. Lee complaint dyspnoeic gradually, increase cough with mucus sputum, labored breathing at home 24hours. History of smoking 2 packs/day, quite recently. (Objective data) Mr. Lee diagnosed acute exacerbation of COPD, GC fair, dyspnea at night shift, pulse Oximetry from 95% reduce to 88%, Heart Rate from90/min increase to 110/min and Respirations are difficulty at 30/min with right lower lobe crackles and wheezing bilaterally.
Fluid (subjective data) Mr. Lee have denture kept by himself, drink 2beers/week. No complaint of eating and drinking, (Objective data) He is obesity with BMI 32.8 abnormal level , there also oedematous on both ankles. At night Mo prescribe Furosemide (40mg Po QD) and offer special diet (low sodium 4g). His I/O is positive balance, NS block setup and voiding per urinal.
Safety of physical and psychological (subjective data) Mr. Lees’ vision and hearing are normal, non disability but pain rated 4/10 (10 is being the worst) with cough. He also claims insomnia. (Objective data) Mr. Lee doesn’t tolerate get up to restroom need to use voiding per urinal. For mobility, he ambulates independently with fairly steady gait but self-care ability need assisted. He has hypertension history BP 130/84, Metoprolol (50mg po daily) prescribed for him. His mental stable but emotion shows anxious. He suffers dyspnea at night with Pulse Oximetry 88%, Fast Heart Rate 110/min and RR 30/min.
Comparison with three groups’ data, the most important health problem for Mr. Lee is Gas Exchange, Impaired related to altered oxygen supply and the evidence already showed above. Although Mr. Lee also has excess body fluid and risk of safety problems, but the problem priority should be meet the physical needs of the patient, and then consider other levels of need. Problem of oxygen supply is immediate threat to life may cause dysnea or brain hypoxia etc, and need to take immediate action to solve it. Besides fluid retention is a symptom of acute exacerbations of COPD and anxious is related to the dyspnoeic, so if the Gas Exchange, Impaired solve, the other problems may improve.
To improve Mr. Lee’s condition, A shift nurse need to have some essential assessment and measures perform for him.
Give general assessment including: monitor vital sign and notice any abnormal reading which directly reflect metabolism, oxygenation and circulatory functions; Monitor O
2
saturation where Mr. Lee at risk for desaturation; Assess skin colour and perfusion for development of cyanosis; Communication such as any changes in orientation and behavior.
Use IPPA to check lung condition i.e. use accessory muscles, lung sound, expansion of chest, noting any signs and symptoms of SOB or airway resistance, also pay attention to breathing pattern, respiration rhythm and dept can reflex lung function such as decrease lung volume and ventilation. Nurse also can use peak expiratory flow rate to measure airflow obstruction,
Follow the lab report of CXR, ABGs etc and note changes. Assess the positioning of Mr. Lee to notice any physical effort on oxygenation. Also assess patient’s ability to cough effectively to clear airway secretions. Note the quantity, color, and consistency of sputum.
After assessments, nurse need to compare with the normal standards, noted any abnormal finding which help to give suitable measures.
The measures includes keep continues assessment and monitor which state on above. Positioning of patient, eating and drinking assist avoid dehydration. Medication should be given as prescription and assess any side effect appear. Also use anxiety scale to check the emotion then give psychological care to reduce the anxiety level.
The expected outcome in the A shift for Mr. Lee is free of difficulty breathing by showed as maintains pulse oximetry≧90%, normal ABGs result and alert responsive, reduce anxious level. However there may occur undesirable situation such as patient’s condition remain unchanged even become worse. In that way, nurse need to refresh the data and reassessment patient’s health condition to modify the aim and intervention to meet the need of patient.
Important information hand over to B shift nurse
A shift nurse should hand over the information of Mr. Lees’ health history, general survey and physical assessment, Mr. Lees’ condition in A shift and the nurse action done at A shift.
In conclude nursing assessment is a process with planning, purposeful and systematic and run through hold nursing process of Mr. Lee. It helps nurses collect information to master health condition of patient. The assessment provides evidences to nurse analysis, judgment and give proper nursing care, which increase the accuracy of nursing diagnosis and the management, fit the health needs of the patient more specifically.
