Shortness of Breath Assessment

• Professional nurses promote health, prevent illness, treat responses to health issues, and advocate for individuals, families, communities.
• Assessment includes health history (subjective) and physical assessment (objective).

Clinical Judgment Model

• Nursing assessments can be: emergency, comprehensive, or focused.
• Emergency assessment involves ABCDE (Airway, Breathing, Circulation, Disability, Exposure).
• Emergency assessments require simultaneous assessment and intervention.
• Comprehensive assessment includes complete health history and physical assessment of all body systems, head-to-toe.
• Focused assessment occurs in all settings, concentrates on one or two body systems, and is more in-depth than a comprehensive assessment.

Subjective Cues

• Subjective cues are client experiences and perceptions.
• The client is the primary source.
• The client describes feelings, sensations, and expectations.
• Subjective data includes health history and interview process.

Objective Cues

• Objective cues involve physical assessment.
• Objective cues are observations and measurable data.
• Observe and document client's general appearance, vital signs, auscultation of heart, lungs, and abdomen, and assess peripheral circulation and skin.

Principles for Prioritization

• Systemic before local problems.
• Acute before chronic problems.
• Actual before potential problems.
• Medication timing.
• Unexpected vs expected findings.

The Communication Process

• Therapeutic communication focuses on the patient and their concerns.
• Therapeutic communication involves caring and empathy.
• Requires nonverbal/verbal communication skills.
• Avoid nontherapeutic responses.
• Culturally competent communication is essential.
• Consider patients with limited English skills and work with an interpreter if necessary.
• Be aware of gender bias.

Components of the Health History

• Subjective data includes: Demographic data, Reason for seeking care, History of Present Illness (HPI), Past health history, Medications/Allergies, Family history, Functional health assessment/Growth and development, Review of systems.
• Objective data includes: Physical Assessment.
• Other considerations: Psychosocial and Lifestyle factors, Cultural considerations, Mental health assessment, Abuse and violence, Sexual history, and Lifespan considerations.

Assessment Techniques

• Assessment techniques include: Inspection, Palpation, Percussion, Auscultation.

Inspection:

• Inspection is the first technique used.
• Goal is to gain an overall impression, observe for cues, expose body parts, and ensure adequate lighting.
• Remove devices or clothing as necessary.
• Label and document findings.
• Ensure findings match the subjective report.

Palpation:

• Palpation assesses: Texture, Temperature, Moisture, Size, Shape, Location, Position, Vibration, Crepitus, Pain, Edema.

Percussion

• Percussion produces sound or elicits tenderness.
• Dense tissue produces flat or quiet tones.
• Air produces louder tones (tympany).
• Direct percussion is performed directly on the skin.
• Indirect percussion uses your hand as a barrier.
• Percussion is being phased out due to imaging.

Auscultation

• Auscultation involves listening with a stethoscope to transport normally unheard sounds.
• The diaphragm (larger side) is used for most sounds.
• The bell (smaller side) is used for murmurs, small clients.
• Use proper technique.

Documentation

• The purpose of a medical record is to ensure: Confidentiality, Accuracy and completeness, Organization, Timeliness, Conciseness.
• Communicate clearly with other health care professionals.