Patient Assessment - Respiratory Distress

[gwenith, BSN, RN]

I have long had some disagreements with the way assessment is traditionally taught. I don't believe that it is automatic that if you know the normal you can recognise the abnormal. Sometimes assessment, particularly in the hospital setting is about evaluation of an evolving abnormality.

So here is the game I will post a scenario about a patient and ask everyone to try to picture this patient from their point of view. The next step will be up to you - over the next 12-24 hours what will we expect to see. How can we assess if the patient is getting better or worse?

So there is no real "Wrong" in this game only some answers that are more right than others so no blame and no shame! You might post an answer about the improvements you might expect and you would be equally as correct as the person who posts about a rare and life-threatening complication. As I said as there will be many "Right" answers no one will be flamed for not getting it right.

Feel free to post even if you are unsure or ask a question at any time.

Paul Monery is a 46 year old man who has just been admitted following a single vehicle accident involving a high speed collision. He was wearing a seat belt and has sustained 2 rib fractures. He has a significant amount of pain from the rib fractures. The medical staff tell you that they are concerned that he might develop some pulmonary contusion. Since he has been a heavy smoker for more than 30 years there is some concern about underlying lung function. He has a pca but because he is only a small man you are concerned that the dosage might be set a bit high.

As you can see a lot of factors impacting on the respiratory system for this patient so what would you assess for. Assume that on admission all vital signs are within normal limits for this patient and that his sao2 is 97% on 2 lpm via nasal prongs.

[Cheyenne RN,BSHS]

This "game" sounds interesting.

First, I would think that if the man is still having a lot of pain as the paragraph stated, then perhaps the PCA dose is not too high.

Continually monitoring of vital signs, including pulse ox, LOC, lung sounds, and amount of pain will help with assessment and the interventions accordingly. Turn, cough, and deep breath with incentive spirometer are also indicative.

I would also include asking the MD for a nicotine patch to decrease the patients cravings, and possibly even a prn ant-anxiety medication so that the patients anxiety and addictive issues would less likely mask any actual physiological changes. Anti-anxiety meds will also help with the effectiveness of the pain medication.

At least these would be my starting point.

[gwenith, BSN, RN]

Good reply - but what would we assess?

Lets take this 30 year history of smoking - remember that is all you know we don't know what or how - was he a pipe smoker or did he smoke "rollies" Tobacco or MJ?

We have to look for those signs he may have an underlying chronic lung disease.

What verbal history are we going to ask?

what might we see about his chest?

Does his body build have anything to do with lung disease?

Should we look at his hands?

[altomga, ADN, BSN, MSN, DNP, RN, APRN]

Other than the normal resp assessment. Auscultation, inspection, depth and rate of inspiration, vital signs etc...I would want to know what his x-rays, verbal collaboration with pt, etc showed. Does he have underlying process such as COPD, restrictive lung disease, emphysema, etc from long term cigarette use? Is he barrell/flail chested, pale nail beds/clubbing. Is he poorly nurioushed? Any diaphramatic injury?

Inspect for any new, larging bruising on his chest, poor lung expansion.

Ask to possibly decrease the PCA amount as to not mask any new findings that the pt might not be able to verbalize under the effects of pain med.

continually monitor o2 sats, O2 requirements, pt's color, resp rate for possible resp decompensation.

Assess lung sounds frequently to assess for a pneumo secondary to rib fractures possible internal bleeding from seat belt injury.

Listen to the pt and how he is feeling. Pt's that say they simply "feel funny" are the ones to overly, overly, assess and get new films, CT's, etc. on. They usually have something happening.

continuous monitor, vital signs of course. They all give clues to possible blood loss from internal injury, resp distress, pain. All which will effect breathing.

[gwenith, BSN, RN]

Thank - you are very good - this is what I was after but imagine you are out at Thargamindah Hospital waaaaay out in the remote areas and you HAVE no diagnostic equipment except an O2 monitor an ancient cardiac monitor and ECG, a peak flow meter someone left behind and a portable x-ray - it is just you and your assessment skills and a whole lot of worry.

[altomga, ADN, BSN, MSN, DNP, RN, APRN]

Sorry, but I do work at a level one trauma center (thankfully)..If I was in a small remote hospital I would totally depend on my knowledge and critical thinking skills!! The equipment available would give you enough basis to diagnose some of the most potential life threatening problems. The pt would still need a higher level of care, but a good nurse and doctor could prevail in the meantime! Tests are ways to confirm what you pretty much already know...so you would have to roll with that...otherwise I would be calling a lifeflight copter to come get 'em!!

[altomga, ADN, BSN, MSN, DNP, RN, APRN]

BTW-----good question......never hurts to keep your thinking up!:)

[Gator,SN]

I have only a few things to add to the last post......

I would also start looking at the pts back for bruising.

Also palpation/ auscultation of the abdomen is important to check for internal bleeding or hematoma.

Definitely keep the o2 level as low as possible while still maintaining high sat rates....if the pt does have copd, any higher rates may knock out his hypoxic drive.

What medication is in the PCA???? Morphine may decrease the respiratory rate.

I would also start the pt on I&O to make sure that he is profusing well and that the kidneys are functioning properly. (metabolic acidosis/alkalosis risk) ABG's may be indicated if any changes are noted.

Is the pt able to answer questions without becoming SOB? Coughing? any cyanosis? Is the pt restless, calm, anxious?

Also, I would do frequesnt neuro checks for the first few hours just because he was in a MVC at high speed.

Assess pain level. location, and character of the pain frequently.

I would also position the pt in semi-fowlers and hold all food and fluids.

I would check his stool and unrine for occult blood.

(I know that I need a drs order for some of this stuff)

Gator

[gwenith, BSN, RN]

Great posts and just what I was looking for. One of the things I would also be checking is the colour of his fingers for nicotine staining. This is especially important as a lot of people under report the amount they smoke and it is difficult to judge if they do smoke "rollies".

Now let us step it along a bit. Pulmonary contusion develops over time so a patient who is coping well on admission may start to deteriorate within the first 24 hours as consolidation within the lungs increases.

Think about what this guy is going to look like as his distress increases and imagine explaining that over the phone to the flying doctor!

(PS I love making these scenarios rural/remote area as it really emphasises our skills!!)

[cab631]

I have BEEN in BFE with this kind of patient. Four/five nurses in the whole hospital, and me...a traveler! Talk about nursing by the seat of your pants! I would monitor quality of resps, ABGs if possible, o2 sats, heart rate and quality of rhythm and watch for changes. No patches for the first night. I'd probably hold on the anti-anxiety med till I felt comfortable with his reaction to the PCA. Look for changes in skin color, monitor I&O, frequent abd. assessment/neuro checks, then thank the LORD that he is your only patient in a 4 bed ICU!

[gwenith, BSN, RN]

Too right!

BTW - I forgot to tell you that the "flying doctors" are not some sort of angelic medico. The Royal Flying Doctor Serice provides medical cover to remote areas where there is no medical officer. Yes It is seat - of - the - pants nursing but in setting it here we get ot the fundamentals of assement - what we are picking up with our senses.

This thread isn't about me teaching you it is about us learning form each other. Which is why there is no "wrong" answer.

I could quite happily write a scenario describing poor old Mr Monery as he became increasingly breathless and arrested and be just as correct as the person who describes how by using pillow support they managed to increase the effectiveness of his cough and not only keep him alive until evac but improve his condition!

[nowplayingEDRN]

If I were in BFE with this sort of patient, I would be looking to evacuate to the nearest trauma center ASAP because of the the mechanism of injury and his Hx of smoking, he is at high risk to deteriorate and rapidly. In the mean time, I would abstain from the antianxiety medication, apply O2 at 4LPM as per ACLS protocol, place them on what ever monitoring equipment I had available, closely monitoring pulse and SPo2. I would have drawn complete chemestries and blood counts as well as coagulation studies and a type and screen and obtained a base line abg on RA. Then I would start the PCA and monitor the pt closely for his reaction to it (our facility requires we monitor LOC, VS and quality and quantity of pain) I would also be watching this pt's LOC and pupilary reflexes. I would also obtain x-rays, CT of the cest of it were available, and titraite the PCA according to the patient's reaction. i would have suction and intubation equipment at the bedside just in case as well as have 2 large bore IV caths placed, 1 I would heplock and the other I would have NSS0.9% running at about 100-150cc/hr. Don't want to overload in this case because if there is a contusion going on and compromised cardiopulmonary status, I don't want a pulmonary edema happening. I would monitor the VS at least q30-60 minutes and more often as the situation merited.

Then I would place a foley to have good control over I&Os and start my secondary assessment of this man. looking for lacs and bruises. A high speed crash with a seat belt, if it broke, not only do you have a high potential for pulmonary contusion but a hemo/pneumothorax, as well as a tear to the aorta........