There are many skills a nurse can use when assessing an individual’s breathing. Some of these can be measured quantitatively such as respiratory rate, depth and rhythm and pulse oximetry. While others are more qualitative such as the assessment of the patient’s cough, colour and level of pain. These observational skills when used with interview and listening skills assist the nurse in gaining the patient’s history and what is normal for them.
Breathing is the activity of living which involves moving air in to and out of the lungs. The act of breathing is usually subconscious, meaning we are not normally aware of it, and is important for the function of our other activities of living and ...view middle of the document...
The nurse should also observe how the patient is speaking, whether it be in full sentences, which indicates little to no respiratory distress, or in monosyllable answers, which indicates they are experiencing difficulty breathing and if they are using any accessory muscles such as intercostal muscles and muscles in the neck (Crips & Taylor, 2009). For example, during an exacerbation of asthma the patient will present with an increased respiration rate (tachypnoea), a shallow depth, slightly abnormal rhythm with exhalation being longer and an obvious increase in their work of breathing as seen through the use of their intercostal muscles, shoulder heaving and possibly tracheal tug.
As part of the breathing assessment the nurse should listen to the sound of the patient’s respirations. Noises such as wheezing can indicate a narrowing of the airway or snoring sound which can indicate a blockage in the trachea or main bronchi (Crips & Taylor, 2009). A nurse may also assess the patient’s pulse oximetry or oxygen saturation in the blood. This is done using a pulse oximeter which is placed on the patient’s finger (Booker, 2009). An oxygen saturation reading (SaO2) of 95% or over is considered within the therapeutic range, however a reading of eighty-fiver percent 85% or lower indicates respiratory problems. However, the nurse should also be aware of any history that may cause the patient’s saturation to be sitting on 85% even with nursing interventions for example a patient with a history of chronic obstructive pulmonary disorder (COPD) as this may be what is normal for them (Crisp & Taylor, 2009 and Holland et al, 2008).
An assessment of the patient’s skin, lips, mucous membranes and nail beds for any signs of cyanosis, a blueish discolouration, should also be undertaken. Cyanosis indicates low oxygen levels in the blood and tissue perfusion and/or inadequate gas exchange (Marieb & Hoehn, 2010). Quint & Brown (201, pg., 131) state that cyanosis is an indication of poor oxygenation and should be followed up with more reliable tests, such as an arterial blood gas.
If the patient has a productive cough and is bringing up sputum, the nurse should collect a sample and observe the colour, consistency, odour amount and for any signs of blood of the sputum (Crips & Taylor, 2009).
When assessing a patient’s breathing it is important to keep in mind all the variables that can influence results such as history of smoking, disease and medications. This includes what is normal for the patient. For example, Crisp and Taylor (2009 pg. 567) suggest that a patient who is a chronic smoker may have an increased respiration rate at rest. Crisp and Taylor (2009 pg. 567) go on to say that analgesics or pain relief can lower respiration rate and depth while amphetamines can increase it. This data can be gained by past medical records and interviewing the patient and family.
A 10-year-old child presenting to the Emergency department...