UNIT FOUR
560
Clinical Skills and Care
Speak in a normal tone of voice, without sounding excited or upset. Tell the patient what you need them to do. Help them slow down breathing by repeating “Breath in, breath out” at the tempo at which you want the patient to breathe. It is important that you reassure the patient that help is present. Do not leave the patient in acute respiratory distress alone, even if you think that the patient is “just anxious.” Assessing Respiratory Status As you perform a respiratory assessment, you will inspect, palpate, and auscultate the patient. As you enter the room and interact with the patient, note the following: • Color of skin and mucous membranes • Respiratory effort • Cough COLOR OF SKIN AND MUCOUS MEMBRANES. When oxygen levels in the tissues decrease, the lips take on a bluish color, called cyanosis . This color change may also be observed on the tip of the nose, on the tops of the ears, and in the nailbeds. When the patient has dark skin, the color may appear more ashen than cyanotic, and you will depend more on the color of the mucous membranes. Check the palms of the hands and soles of the feet for color changes as well. Safety: Cyano- sis is a late sign of hypoxia. Take action immediately and notify the health-care provider immediately. RESPIRATORY EFFORT. When the patient is having dif fi - culty moving air in and out of the lungs, it is referred to as dyspnea. Notice if the patient is having dif fi culty breathing while at rest and also if they become short of breath when ambulating a short distance, such as to the bathroom and back. If the patient has to stop to rest or catch their breath when ambulating a brief distance, then the patient is short of breath, known as exertional dyspnea. Patients with impaired oxygenation often assume a position of sitting upright and leaning slightly forward with the arms and head over a table. This is the orthopneic position. It increases the intrathoracic area, allowing the patient to inhale more air. Watch for gasp- ing respirations, or “air hunger,” and expressions of grimac- ing or fear on the patient’s face. • Chest appearance • Oxygenation status • Oxygen saturation COUGH. If the patient is bringing up sputum , or mucus, from the lungs when coughing, it is referred to as a productive cough. If the cough is dry, it is referred to as a nonproduc- tive cough. It is important to notice the color, consistency, and amount of any sputum the patient produces. Sputum that is clear or white may indicate a viral infection; if it is yellow or green, it may indicate a bacterial infection. Rust-colored sputum indicates the presence of blood and may be seen in some pneumonia infections and tuberculosis. When sputum is gray or black, it usually indicates that the patient has inhaled smoke or soot. Pink and frothy, or bub- bly, sputum indicates fl uid and blood mixed together and is seen in a life-threatening condition called pulmonary edema.
In addition to the color of sputum, the consistency of the sputum is an important observation. Thick, tenacious, sticky mucus is dif fi cult to cough out. It tends to remain in the lungs and provides a good medium for bacteria growth. If you observe this in your patient, encourage them to drink more fl uids to help thin the mucus and make it easier to cough out. CHEST ASSESSMENT. Inspection. Look for muscular retrac- tions between the ribs, substernally, and around the neck, evidenced by muscles and skin pulling inward as the patient inhales. Safety: This is also a late sign of hypoxia and hypox- emia. Notify the health-care provider immediately. Observe the patient for use of the accessory muscles in the neck and shoulders while breathing, indicating excessive muscular effort to breathe (Fig. 28.1). Palpation. To begin palpating the chest, place your hands on either side of the chest. As the patient inhales and exhales, determine whether each side of the chest is moving equally, called excursion. Differences in chest wall movement, along with shortness of breath, can indicate a serious problem, such as airway obstruction, pneumothorax, or pleural effu- sion ( fl uid in the chest cavity). A pneumothorax occurs when a hole allows air to enter the pleural space, also termed the pleural cavity, where there is supposed to be negative pressure. A life-threatening type of pneumothorax is a ten- sion pneumothorax. When this occurs, air is trapped in the pleural cavity surrounding the lungs, which not only com- presses and collapses the lungs but also causes pressure on the heart and major blood vessels, causing them to shift within the thorax. Safety: Tension pneumothorax is a medical emergency. Notify the health-care provider immediately. Feel for crepitus, or air in the subcutaneous tissues, in the chest wall, face, and neck. When you gently press your fi ngertips on the patient’s skin, you will feel a crackling sensation, much like the feeling of crispy rice cereal being crushed, beneath the patient’s skin. Crepitus is usually felt beneath an area of edema. Safety: Air in the subcutaneous tis- sues, also called subcutaneous emphysema, indicates that air that should be in the lungs is in the tissues. Notify the physician immediately. Auscultation. Now use your stethoscope to auscultate the lungs, as you learned in Chapter 21. As you listen to respi- rations, both with and without the stethoscope, observe the rate, character, and quality of respirations. Note if the rate is outside the normal range of 12 to 20 breaths per minute. As you assess quality, determine whether the respirations are shallow or deep or if the patient is struggling to breathe. Determine the pattern of respirations. (Refer to Table 21.3
• WORD • BUILDING • cyanosis: cyan – blue + osis – condition
orthopneic: ortho – straight + pneic – breathing pleural effusion: pleural – pleural membrane; effusion – pouring out pneumothorax: pneumo – air + thorax – chest
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