Nursing History: Oxygen Needs, Fatigue, and Dyspnea

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Questions and Answers

What is the best way to assess a client's fatigue?

Ask the patient to rate fatigue from 1 to 10 (correct)

Measure the client's oxygen saturation levels

Observe the client's skin color

Check the client's blood pressure

Which statement best describes pathological dyspnea?

It is a clinical sign of hypoxia

It is shortness of breath related to exercise or excitement

It involves the inability to catch a breath without relation to activity (correct)

It is an abnormal condition requiring multiple pillows for breathing

What is orthopnea characterized by?

A persistent dry cough

Difficulty swallowing

Abnormal swelling in the legs

The need to sit with elevated arms to breathe comfortably (correct)

What is the purpose of cough in the respiratory system?

To expel air forcibly from the lungs Signup and view all the answers

Which condition is associated with coughing primarily in the morning?

Chronic sinusitis Signup and view all the answers

What is physiological dyspnea typically associated with?

Shortness of breath during exercise or excitement Signup and view all the answers

What is the purpose of performing palpation during a physical examination?

To elicit areas of tenderness, abnormal masses, and tactile fremitus Signup and view all the answers

What is the significance of longer capillary refill time (CRT) in a patient?

Peripheral vasoconstriction Signup and view all the answers

Which observation during inspection might indicate chronic hypoxemia in a client?

Clubbing of fingers Signup and view all the answers

During inspection, what does cyanotic mucous membranes indicate?

Decreased oxygenation (hypoxia) Signup and view all the answers

What is the purpose of percussion during a physical examination of the lungs?

Detecting abnormal fluid or air in the lungs Signup and view all the answers

Why is the detection of asymmetry important during chest wall inspection?

Possible chest wall injury Signup and view all the answers

What is the normal range for partial pressure of oxygen (paO2) in arterial blood?

75-100mmHg Signup and view all the answers

What does oxygen saturation measured by oximetry represent?

Percentage of hemoglobin saturated with oxygen Signup and view all the answers

What is the main purpose of bronchoscopy?

To obtain biopsy and sputum samples Signup and view all the answers

How is a throat culture sample obtained?

By swabbing the oropharynx and tonsillar regions Signup and view all the answers

What is the purpose of sputum culture and sensitivity (C&S)?

To identify the type of organism and its drug resistance/sensitivities Signup and view all the answers

When is Sputum Acid-Fast Bacillus (AFB) obtained?

On 3 consecutive days in the early morning Signup and view all the answers

What should be inspected for in a patient presenting with hemoptysis?

Color, consistency, odor, and amount Signup and view all the answers

What is a characteristic feature of wheezing?

High-pitched musical sound Signup and view all the answers

How is pleuritic chest pain typically described?

Stabbing or knifelike Signup and view all the answers

What environmental/geographical exposures are mentioned in the text?

Cigarette smoking and asbestos exposure Signup and view all the answers

What should be assessed in terms of respiratory infections in a client?

Frequency and duration of colds per year Signup and view all the answers

Which risk factor should be inquired about in the nursing assessment?

Family history of lung cancer Signup and view all the answers

What is the purpose of thoracentesis?

To perform surgical perforation of the chest wall Signup and view all the answers

Which technique is used during thoracentesis?

Aseptic technique Signup and view all the answers

Who should not receive the Influenza vaccine?

People with known hypersensitivity to eggs Signup and view all the answers

How long does it take for antibody development after receiving the Influenza vaccine?

1-2 weeks Signup and view all the answers

Who is recommended to receive the Pneumococcal vaccine?

People living in nursing homes Signup and view all the answers

Why is revaccination with the Pneumococcal vaccine recommended after 5-10 years?

Due to declining antibody levels Signup and view all the answers

Study Notes

Physical Examination

Inspect the client from head to toe to observe skin and mucous membrane color, general appearance, level of consciousness, adequacy of systemic circulation, breathing patterns, and chest wall movement.
Observe for clubbing of fingers, indicating chronic hypoxemia.
Note flaring nares, indicating air hunger and dyspnea.
Observe conjunctivae for pallor, indicating anemia.
Observe for cyanotic mucous membranes, indicating decreased oxygenation (hypoxia).
Note chest retractions, indicating increased work of breathing and dyspnea.

Palpation

Perform palpation to elicit tenderness, abnormal masses or lumps, and tactile fremitus.
Check for capillary refill time (CRT), which is normally 1-2 seconds.
A longer CRT (>2 seconds) indicates poor perfusion, peripheral vasoconstriction, low circulating blood volume, and reduced oxygen delivery to vital tissues.

Percussion

Perform percussion to detect abnormal fluid or air in the lungs.

Auscultation

Perform auscultation to identify normal and abnormal heart and lung sounds.

Nursing Process

Assessment

Obtain a nursing history focusing on the client's ability to meet oxygen needs.
Perform a physical examination, including inspecting, palpating, percussing, and auscultating the client.

Risk Factors

Ask about environmental/geographical exposures, such as cigarette smoking, asbestos, coal, cotton fibers, fumes, or chemical irritants.
Ask about a family history of lung cancer or cardiovascular disease.

Respiratory Infections

Ask about the frequency and duration of respiratory tract infections, with an average of 4 colds per year.

Fatigue

Assess fatigue, a subjective sensation of loss of endurance, and ask the client to rate it on a scale of 1-10.

Dyspnea

Assess dyspnea, a clinical sign of hypoxia, which manifests as breathlessness or an uncomfortable sensation of breathing.

Cough

Assess cough, a sudden, audible expulsion of air from the lungs, which is a protective reflex to clear the trachea, bronchi, and lungs of irritants and secretions.

Diagnostics

Oximetry

Use oximetry, a non-invasive and readily available method, to measure capillary oxygen saturation (percentage of hemoglobin saturated with oxygen).

Chest X-ray Examination

Perform a chest X-ray examination to observe the lung fields for abnormal findings.

Bronchoscopy

Perform bronchoscopy, a visual examination of the tracheobronchial tree, to obtain biopsy and fluid or sputum samples and to remove mucus plugs or foreign bodies.

Throat Cultures

Obtain a throat culture by swabbing the oropharynx and tonsillar regions with a sterile swab.

Sputum Specimen

Obtain a sputum specimen to identify the type of organism growing in the sputum.

Thoracentesis

Perform thoracentesis, a surgical perforation of the chest wall and pleural space with a needle, to aspirate fluid for diagnostic or therapeutic purposes.

Planning

Client maintains a patent airway.
The client achieves and maintains adequate gas exchange and ventilation.
The client mobilizes pulmonary secretions.

Health Promotion

Maintain the client's optimal level of health to reduce the number and/or severity of respiratory symptoms.
Prevent respiratory infections through health promotion strategies, such as vaccination.

Vaccination

Influenza Vaccine

Annual vaccination is recommended for older clients and clients with chronic illnesses.
Influenza vaccine is 70-90% effective in healthy young adults.
It takes about 1-2 weeks after vaccination for antibody development.
Persons with a known hypersensitivity to eggs or other components of the vaccine should not be vaccinated.

Pneumococcal Vaccine

Recommended for clients at increased risk of developing pneumonia, those with chronic illnesses or immunosuppression, those living in nursing homes, and clients over the age of 65.
Revaccination has been recommended after 5-10 years due to declining antibody levels as well as for clients vaccinated before 1983.

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Description

Test your knowledge on nursing history focusing on the client's ability to meet oxygen needs, subjective sensation of fatigue, and clinical signs of dyspnea. Explore concepts such as assessing fatigue levels and understanding different types of dyspnea.