While conducting the assessment, nurses must be able to recognise and assess symptoms of respiratory dysfunction to provide early, effective and appropriate interventions, thus improving client outcomes. In this essay will discuss the skills nurses must possess during a respiratory assessment and the nursing actions that assist clients in breathing. It is vital that nurses have knowledge of the anatomy and physiological process of a healthy functioning pulmonary system, in order to carry out a respiratory assessment (Cox & McGrath 1999, p. 226).
Breathing is the effort required to expand and contract the lungs. ‘Most individuals breathe unaided and independently from birth throughout their life span until the moment of death… It is the cessation of breathing that signifies death (Holland et al. 2008, p. 138).
Breathing is usually the first vital sign to alter in a deteriorating client. This is why a respiratory assessment should be carried out by a nurse with a complete understanding of the system so they can diagnose and manage respiratory conditions in clients. Holland et al. (2008, p. 57) states that there are three phases involved in a respiratory assessment which include the collection of data, interpretation of the data, and identifying the clients actual and potential problems. According to Hunter (2008, p. 41) before proceeding with a physical respiratory assessment, it is important that nurses obtain information that may be relevant to the client’s respiratory status such as medications, their medical history, occupation, and smoking history. A client should be able to answer questions without any breathing difficulties.
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However, if the client is unable to communicate, information can be gathered from other sources such as family members or past records. A nurse must demonstrate active listening skills when collecting client history to ensure effective communication. The appropriate use of eye contact is one of the most significant and prevailing techniques for indicating true concern about a client. Eye contact should be established often enough and long enough to be encouraging and not make the client feel uncomfortable (Higgs et al. 2008, p. 106).
Nurses must also ask for clarification on certain points, take brief notes, and allow time for silence during the collection of information to demonstrate active listening. When a client’s history is correctly recorded nurses are provided with an organised, unbiased, detailed and chronologic report of the development of symptoms that has caused the client to seek health care (Hunter 2008, p. 42).
However, history taking maybe limited depending on the severity of the breathing condition and therefore observation skills may need to be used (Moore 2007, p. 51).
Kennedy (2007, p. 3) claims that ‘the physical examination only serves to reinforce the information derived from the history’.
Using observation skills such as reading body language and facial expression is important because ‘if non-verbal messages conflict with verbal messages, we are more likely to believe the nonverbal’ (Higgs et al. 2008, p. 16).
When collecting data about a clients breathing condition, nurses should assess the client’s vital signs such as respiratory rate, depth of breathing, rhythm of breathing, changes in breathing habit, coughing, production of abnormal secretions, and pain, as well as general appearance (Holland et al. 008, p. 159).
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Holland et al. (2008, p. 159), affirms that it is ‘relatively easy for a nurse to assess breathing by observing the rate, depth and rhythm of respiration’ to determine baseline data of the client’s breathing function. A client with a respiratory condition should be observed on admission, preoperatively and postoperatively to be monitored efficiently (Holland et al. 2008, p. 159).
A client’s respiratory rate should be counted for one minute. ‘A breath is an inspiration followed by expiration which can be observed by watching the movement of the chest wall’ (Hunter 2008, p. 2).
This is known as the depth of breathing which can be described as normal, shallow or deep. Chest movements should be symmetrical. At times, nurses are unable to observe the depth, therefore they must place their hands either side of the chest to feel and determine the depth and quality of movement during inspiration and expiration (Simpson 2006, p. 485).
Nurses further demonstrate their observational skills when they take clients body position and general appearance into consideration.
A client’s posture can indicate the level of breathing difficulty that they are experiencing because they may position themselves in an unusual position in order to make breathing easier. Clients that require an increased effort to breathe are usually inclined to sit as straight as possible with pursed lips, where as a client with impaired breathing usually sits in a tripod position, with their arms resting on their knee’s or a table (Kennedy 2007, p. 44).
During the assessment, nurses must also pay attention to the colour and condition of a client’s skin and extremities, including nail beds, as it can indicate respiratory failure.
Cyanosis is a dusky or bluish tinge to the skin, lips or tongue which means there is an inadequate level of oxygen reaching the client’s extremities (Simpson 2006, p. 484).
Normal breathing is effortless and quiet. Hence, nurses must use observational skills to distinguish the effort clients are using to breathe. When a client is using their accessory muscles, they are experiencing dyspnoea. Dyspnoea may be the result of airflow obstruction or infection and is very distressing for clients because the body is attempting to compensate by conveying more oxygen to the tissues (Holland et al. 008, p. 161).
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Nurses must also be competent in listening to noises as they can reveal specific alterations in the respiratory cycle, and restrictions in the volume and movement of air in and out of the lungs. According to Kennedy (2007, p. 45) adventitious breath sounds are breath sounds that are abnormal due to limitations, obstruction, or accumulated fluid, thus blocking the airway. Wheezing is caused by restricted air flow through narrowed airways which are usually more pronounced on expiration. The pitch of a wheeze indicates the degree of narrowing.
Hence high pitched wheezing indicates near obstruction (Simpson 2006, p. 487).
According to Holland et al. (2008, p. 160) wheezing is common in people with asthma and chronic bronchitis and may also occur in response to exercise or inhalation of toxic substances. Stridor is another abnormal, high-pitched breathing sound that occurs on inspiration which is caused by an obstruction in the larynx (Hunter 2008, p. 43).
Auscultation involves listening to breath sounds with a stethoscope and is a main factor when conducting a respiratory assessment.
It allows the nurse to listen beyond normal breath sounds for noises such as crackling (Kennedy 2007, p. 45).
Many clients with respiratory problems experience coughing. ‘Nurses must take note of the presence frequency, depth, nature, and sound of a cough’ (Holland et al. 2008, p. 161).
A cough may be accompanied by sputum which should be expectorated to prevent it accumulating in the lungs. A dry cough has minimal sputum as opposed to a loose cough which is associated with the production of sputum (Holland et al. 2008, p. 161).
Sputum specimens can be collected and can aid the diagnosis of respiratory problems. The colour must be noted as it may indicate an infection if it is either green, yellow and grey, or it may be blood stained, which is known as haemoptysis and can be life threatening (Simpson 2006, p. 488).
Chest pain is often provoked by a cough. Hence, a respiratory assessment should involve a pain assessment including the nature, type, duration and severity (Kennedy 2007, p. 43).
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When a client is experiencing pain in any part of their body, changes will occur in their breathing (Holland et al. 2008, p. 161).
Once nurses have collected all necessary data and interpreted what they found, they must identify actual and potential problems, identify priorities, establish short and/or long goals, determine nursing actions and interventions required, and document the plan in order to assist a client to breathe with ease. To ensure that a client’s care plan is planned appropriately, it is vital that nurses review the individual’s actual and potential problems, and level of breathing. According to Holland et al. (2008, p. 162), actual problems are specific to the health problem such as those identified above.
However, potential problems may relate to the clients breathing condition specific to the factors that affect the client. Nurses are then required to determine which problem is more important. Holland et al. (2008, p. 165) illustrates the grade of client priorities which may change each day, shift, hour or minute. Therefore, nurses must continually assess their clients to ensure that they are aware of possible changes. The grade is as follows: life threatening (totally dependent), urgent (mainly dependent but some ability to be independent), semi-urgent (some dependency, mainly independent), and non-urgent (totally dependent) (Holland et al. 008, p. 165).
The level of dependency or independency is linked with the lifespan which are underpinned by factors affecting breathing (Holland et al. 2008, p. 165).
Factors influencing the activity of living of breathing include physical, psychological, sociological, environmental, and politico economic. Dependency care can be accomplished through supplementary oxygen by the use of oxygen therapy, administration of prescribed medications and/or nebulisers, localised airway passage obstruction and/or postural drainage, artificial airway maintenance and cardiopulmonary resuscitation (Holland et al. 2008, p. 166).
