Respiratory Assessment Activity
– Complete the Respiratory Assignment for Tina Jones, including the Sounds Lab, before completing this assignment. Base your discussion/findings for this assignment upon the findings in the Shadow Health assessments. I have already done this and attached you will find “Tina Jones Respiratory assessment”findings
· After your respiratory assessment of Tina, differentiate the expected (normal) findings to the findings of Tina Jones’ breathing pattern-discuss this in your assignment. (Wheezing is the only abnormal finding)
· Discuss a care plan for Tina based on your assessment findings to include a NANDA nursing diagnosis with three NIC’s and three NOC’s
· Read Chapters 4, 19 & 32 In Jarvis, C. (2018). Physical examination and health assessment (8th ed.). St. Louis, MO: Saunders.
Rubric
– Fully discusses the differentiation of expected normal findings to the findings of the respiratory
assessment
– Completes at least 3 fully developed SMART goals including each component; specific., measurable,
attainable, relevant, and timely
– Fully discusses a care plan that contains one NANDA DX with three NICs and three NOCs related to
assessment findings
– Ensure conclusion paragraph.
– No errors in APA, Spelling, and Punctuation.
– Provides two or more references.
Introduction
Respiratory assessment is crucial in identifying any respiratory dysfunction in patients. In this assignment, we will discuss the respiratory assessment findings of Tina Jones and differentiate between expected normal findings and abnormal findings, which in this case is wheezing. We will also develop a care plan for Tina based on our assessment findings, including a NANDA nursing diagnosis with three NICs and three NOCs.
Differentiation of Expected Normal Findings to Findings of Tina Jones’ Respiratory Assessment
During the respiratory assessment of Tina Jones, we observed the following normal findings:
Normal respiratory rate of 16 breaths per minute
Equal chest expansion during inspiration and expiration
Clear lung sounds except for wheezing in the left lower lobe
Regular respiratory pattern
Adequate oxygen saturation of 98%
The abnormal finding was wheezing, which indicates narrowing of the airways, obstruction, or inflammation. Wheezing is a high-pitched musical sound that can be heard during inspiration, expiration or both, and it indicates lower airway obstruction. Based on this finding, we can infer that Tina is experiencing an obstructive respiratory disease, and further investigation is needed to identify the underlying cause of wheezing.
Care Plan for Tina Based on Assessment Findings
NANDA Nursing Diagnosis: Impaired Gas Exchange related to lower airway obstruction as evidenced by wheezing and decreased oxygen saturation.
NICs:
Administer oxygen therapy as prescribed to improve oxygen saturation levels.
Help the patient with deep breathing exercises to improve lung function and prevent atelectasis.
Administer bronchodilators as prescribed to relieve airway obstruction and improve lung function.
NOCs:
Improved oxygen saturation levels within 24 hours of therapy initiation.
Improved lung function as evidenced by decreased wheezing and improved breath sounds.
Improved knowledge of the patient regarding management of respiratory symptoms.
SMART Goals:
By the end of the first shift, Tina’s oxygen saturation will improve from 92% to 96%.
By the end of the second shift, Tina’s wheezing will decrease by 50%.
By the end of the third shift, Tina will demonstrate proper technique for deep breathing exercises.
Conclusion
In conclusion, respiratory assessment is vital in identifying any respiratory dysfunction in patients. In Tina’s case, wheezing was identified as an abnormal finding. Based on our assessment findings, a care plan was developed with a NANDA nursing diagnosis of Impaired Gas Exchange related to lower airway obstruction as evidenced by wheezing and decreased oxygen saturation. The care plan included three NICs and three NOCs with specific and measurable SMART goals to improve Tina’s respiratory status. It is crucial to provide proper respiratory care to prevent complications and improve the patient’s quality of life.
References
Jarvis, C. (2018). Physical examination and health assessment (8th ed.). St. Louis, MO: Saunders.
Nursing care plan for impaired gas exchange. (n.d.). Retrieved March 26, 2023, from https://nurseslabs.com/nursing-care-plan-for-impaired-gas-exchange/
