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466 PHYSICAL EXAMINATION

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HEALTH EDUCATION

UNIT 2

Risk factors for pneumonia

The following are risk factors for consumers who are susceptible to developing pneumonia and should be considered when gathering health assessment data:

> Smoking – including passive smoking exposure

> Age – very young and very old

> Underlying lung disease

> Chronic diseases (e.g. renal failure, heart failure)

> Malnutrition

> Alcohol and drug use

> Mechanical ventilation

> Consumer in intensive care

> Decreased mobility

> Postoperative status

> Immunosuppressed status (chemotherapy, HIV, chronic diseases)

> Decreased cough reex

> Sedated or decreased consciousness

> Swallowing disorders (stroke, Parkinson’s disease, traumatic brain injury)

> Oxygen therapy

> Infectious diseases that cause SARS.

CLINICAL REASONING

Arterial blood gas assessment

Arterial blood gas (ABG) assessment is undertaken to identify the consumer’s acid–base balance and oxygenation status. Often results of this test will be a denitive aspect of the assessment and will direct interventions for the consumer’s respiratory support. The ability to undertake arterial ABG will be inuenced by your scope of practice. For some people this will be considered advanced practice. It is important that you have some basic understanding about ABG assessment. You should be aware of the normal range of values in your clinical setting and understand common abnormalities and how to interpret and action these (Table 13.5).

TABLE 13.5 Arterial blood gas assessment

ABG NORMAL VALUES

PARAMETER ARTERIAL VALUE

pH 7.35–7.45

PaO

PaCO

HCO

–

80–100mmHg

35–45mmHg

22–26 (28)mmol/L

Base excess ±2 (normal is 0, + indicates alkalosis/base excess, – indicates acidosis/base

decit)

SaO

>95%

CLINICAL ABNORMALITIES

Respiratory acidosis Characterised by a decrease in pH to <7.35 and an increase in PaCO

of >45mmHg

Respiratory alkalosis Characterised by an increase in pH to >7.45 and a decrease in PaCO

of <35mmHg

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TABLE 13.5 continued>>

CLINICAL ABNORMALITIES

Metabolic acidosis Characterised by a decrease in pH to <7.35 and a decrease in HCO

<22mmol/L

Metabolic alkalosis Characterised by an increase in pH to >7.45 and an increase in HCO

>26mmol/L

–

Steps for ABG assessment

1. Check the value of each number (i.e. pH, PaCO2 and HCO

• Does it represent acidity or alkalinity?

Check the pH:

• If >7.45 – alkalaemia.

• If <7.35 – acidaemia.

• If 7.40 – normal.

Find the value that matches the acid–base status of the pH:

• If PaCO

• If HCO

matches, the problem is respiratory.

– matches, the problem is metabolic.

4. Determine the extent of compensation:

• Absent – The value that doesn’t match the acid–base status of the pH is normal.

• Partial – Both the value that doesn’t match the acid–base status of the pH and the pH

itself are above or below normal.

• Complete – The value that doesn’t match the acid–base status of the pH is above or

below normal but the pH is normal.

–

(Berman et al., 2 018; Wotton, 2017)

Assessing consumers with respiratory supportive equipment

Supportive equipment may be necessary to support respiratory structure and function. The need for such devices automatically indicates an underlying respiratory disorder. For each type of supportive equipment, determine the reason for its use.

CHAPTER 13

Oxygen

> Mode of delivery (e.g. nasal cannula/prongs [HFNO – high-ow nasal oxygen],

face mask [non-rebreather mask; NIV – non-invasive ventilation])

> Non-invasive ventilation (continuous positive airway pressure [CPAP]; bilevel

positive pressure support [BiPAP])

> Percentage of oxygen that is being delivered (e.g. 25%, 40%) > Flow rate of the oxygen (e.g. 2L/min, 4L/min) > Humidication provided and oxygen warmed

Pulse oximeter (Figure 13.23A)

> Determine the monitor’s settings. > The monitor’s alarms are on. The appropriate limits are set. > If using the probe on a nail, the consumer’s nail polish has been removed. > If using the probe on the ear, the skin is intact and earrings are not interfering.

Incentive spirometer

> Frequency of use > Volume achieved (e.g. 1000mL, 1500mL) > Number of times consumer reaches goal with each use

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UNIT 2

Endotracheal tube

> Size of endotracheal tube > Nasal or oral insertion > Tube secured to the consumer > Length of the endotracheal tube as it exits the nose or the mouth (e.g. 24cm at

the lips or 27cm at the tip of the left nare)

> Cuff inated or deated

A. Pulse oximeter

SHUTTERSTOCK .COM/NEW AFRICA

ISTOCK.COM/ABALCAZARMEDICAL IMAGES/GARO/PHA NIE

B. Peak ow meter

C. Consumer using another type of peak ow meter

FIGURE 13.23 Respiratory

supportive equipment

Peak ow meter (Figure 13.23B)

> Consumer is seated while performing the manoeuvre. > Indicator line is lowered to the baseline level. > Consumer exhales as deeply as possible while maintaining a rm seal with the

lips around the mouthpiece (

> Consumer does not obstruct the exhalation outlet.

Figure 13.23C).

Tracheostomy tube

> Size of tracheostomy tube > Cuff present; if yes, cuff inated or deated > Tracheostomy ties secure the tube

Mechanical ventilation

> Type of ventilator (e.g. Servo, Bear, Emerson) > Fraction of inspired oxygen (FiO2) setting > Mode used (e.g. assist, intermittent mandatory ventilation) > Amount of positive end-expiratory pressure (PEEP) or continuous positive airway

pressure (CPAP)

> Rate and tidal volume > Peak inspiratory pressure > Temperature of the humidication > Alarms set

EVALUATION OF HEALTH ASSESSMENT AND PHYSICAL EXAMINATION FINDINGS

In the evaluation phase of a health assessment, the focus is on ensuring the data gathered is complete, accurate and documented appropriately (see case study as an example of the focused assessment; see Chapter 22 for a comprehensive health assessment). In evaluating the data you should:

> draw on your critical thinking and problem-solving skills to make sound

clinical decisions

> act on abnormal data (include communicating ndings to other

health professionals)

> ensure documentation reects the outcomes of the clinical decisions/actions

taken (refer to Chapter 3 which discusses in detail why documentation is so

important and how this may be undertaken in different health settings).

The case study that follows steps you through this process.

Advanced Assessment

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THE CONSUMER WITH COVID-19 (MODERATE DISEASE WITH DETERIORATION)

This case study illustrates the application and objective documentation of the respiratory assessment.

Aarav Maharjan is a 77-year-old male who is transported to the medical ward from a local aged care facility.

HEALTH HISTORY

CONSUMER PROFILE 77-year-old Indian male

CHIEF COMPLAINT ‘I have a headache, I have a sore throat and cough, shortness of breath.’

HISTORY OF THE PRESENT ILLNESS

PAST HEALTH HISTORY MEDICAL HISTORY

Mr Maharjan was in reasonable health until 4 days ago, when he became lethargic, lost his appetite, and began to cough. He reports clear rhinorrhoea and anosmia (loss of smell). Mr Maharjan feels increasing shortness of breath (SOB); however, breathing is slightly easier when the bed is elevated. In the aged care facility Mr Maharjan has been displaying restless, unsettled behaviour.

> Hypertension > Cardiovascular disease > Bilateral hearing decit > Osteoarthritis

SURGICAL HISTORY Coronary artery stenting (left anterior descending coronary artery)

ALLERGIES Nil known

MEDICATIONS Lisinopril 5mg daily

Acetaminophen PRN

COMMUNICABLE DISEASES Nil known

INJURIES AND ACCIDENTS Crush injury left foot >30 years ago

Severed middle nger at the distal interphalangeal joint >40 years ago

CHAPTER 13

CASE STUDY

SPECIAL NEEDS Nil noted

BLOOD TRANSFUSIONS Nil noted

CHILDHOOD ILLNESSES Chickenpox age 3

Mumps age 7 Rubella age 16

IMMUNISATIONS Last tetanus 10 years ago

Inuenza vaccination current COVID vaccination three doses

FAMILY HEALTH HISTORY Denies family history of asthma or TB

SOCIAL HISTORY ALCOHOL USE 1–2 stubbies of beer 3–4 times per week

TOBACCO USE Nil

DRUG USE Nil noted

DOMESTIC AND INTIMATE PARTNER VIOLENCE

SEXUAL PRACTICE Monogamous relationship with his wife of 57 years

TRAVEL HISTORY Limited travel for the last 5 years

WORK ENVIRONMENT Retired

Denies

Previous biennial trips to India

Small business owner (builder) for >50 years

HOME ENVIRONMENT Has lived in an aged care facility for the last seven years

HOBBIES AND LEISURE ACTIVITIES

Member of chess club; plays bowls regularly at the facility, likes to paint, potter in the facility garden

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HEALTH HISTORY

UNIT 2

STRESS Nil noted

EDUCATION Building apprenticeship trade certication

ECONOMIC STATUS Middle class

RELIGION Hindu

CULTURAL BACKGROUND Indian

ROLES AND RELATIONSHIPS Married to his wife Vamika for 57 years

Four children and 10 grandchildren

HEALTH MAINTENANCE ACTIVITIES

CHARACTERISTIC PATTERNS OF DAILY LIVING

SLEEP Sleeps for four hours per night

DIET Vegetarian

EXERCISE Bowls, walks around the facility gardens

STRESS MANAGEMENT Playing chess

USE OF SAFETY DEVICES Walking stick occasionally

HEALTH CHECK-UPS As required by the residential aged care facility’s visiting general

Routine

practitioner

PHYSICAL EXAMINATION

INSPECTION SHAPE OF THORAX AP diameter/transverse diameter = 5:7; kyphosis

SYMMETRY OF CHEST WALL Shoulder and scapula height equal; no masses present

PRESENCE OF SUPERFICIAL VEINS

COSTAL ANGLE Less than 90°

ANGLE OF THE RIBS 45° with sternum

INTERCOSTAL SPACES No bulging/retractions noted

MUSCLES OF RESPIRATION Minimal use of sternocleidomastoid muscles

Nil noted

PALPATION GENERAL PALPATION > Pulsations: Nil noted

RESPIRATIONS > Rate: 32/min

> Pattern: regular > Depth: exaggerated, some effort required > Symmetry: paradoxical movement > Audibility: heard upon entering room > Consumer position: sitting upright > Mode of breathing: predominantly nose, occasional mouth

SPUTUM Nil

> Masses: Nil noted > Thoracic tenderness: Nil reported > Crepitus: Nil noted

THORACIC EXPANSION Unilateral expansion:

Right <2cm, Left 5cm

TACTILE FREMITUS Increased tactile fremitus

Tussive fremitus

TRACHEAL POSITION Right side

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HEALTH HISTORY

PERCUSSION GENERAL PERCUSSION Dull

DIAPHRAGMATIC EXCURSION Reduced

AUSCULTATION BREATH AUSCULTATION Bronchial and vesicular

ADVENTITIOUS SOUNDS Fine and coarse crackles in RLL, posterior thorax

VOICE SOUNDS Increased voice sounds

Asymmetric bronchophony

SUPPORTIVE EQUIPMENT

EVALUATION AND CLINICAL REASONING FOR CASE STUDY

The assessment and clinical decisions you make should reect your scope of practice. For example, advanced practice health professionals, such as nurse practitioners and remote area nurses with endorsement, may be able to make diagnostic decisions and prescribe medications without referring to a medical practitioner.

Fundamentally, all health professionals collect, assess, synthesise, evaluate and act on person-centred health information. Person-centred health information may include referral to, or collaboration with, other healthcare team members. Nurses interpret responses to interventions and determine escalation to the broader healthcare team, based on changes in a person’s condition. The clinical reasoning cycle provides health professionals with a framework to consider all this information in a meaningful way for planning person-centred care. These phases are reected below and draw on the health history and physical examination information presented. We will work through the clinical reasoning cycle components that are relevant to this case study (clinical reasoning cycle components are bolded).

For Aarav Maharjan, the 77-year-old man who has been admitted to the medical ward from a residential aged care facility, and subsequently diagnosed with COVID-19, the signicant data that needs to be considered includes the following.

Collecting Cues/Information

Recall and Review: In the rst instance you will need to reect

on what you know about COVID-19. COVID-19 is an acute respiratory syndrome that leads to various respiratory and systematic conditions. Airway inammation leads to recurrent episodes of coughing, and breathlessness. Symptoms may require conservative management or intensive invasive treatment. You will also need to consider infection control and prevention measures to ensure that Mr Maharjan does not spread COVID-19 to visitors, staff, or healthcare professionals. Additional information required to determine treatment will include blood test (full blood count, creatinine, electrolytes, liver function test, c-reactive protein), chest X-ray, blood gas, consider ECG, coagulation screening (d-dimer, ferritin) and blood cultures.

> Pulse oximetry: SpO > Ventilation: non-invasive ventilation (continuous positive airway

pressure [CPAP]) (or HNFO if CPAP is unavailable)

> Oxygen: via CPAP

Chief complaint and history of present illness

> Headache, sore throat and cough and breathlessness > Reports clear rhinorrhoea, and anosmia > Reports feeling shortness of breath with mild exertion,

requiring elevated bed and pillows to support upright positioning

Processing information

Interpret: These symptoms and details outline the scope of the

issue for this consumer and how it will now affect his present deviation from normal health.

Health maintenance activities

> Unable to manage activities of daily living > Feels very fatigued

Physical assessment

> Respiration rate 32 breaths/minute > Temperature 38.7°C > Respirations audible upon entering room; Mr Maharjan

positioned upright and breathing predominantly through nose and occasionally mouth

> Adventitious breath sounds, crackles RLL, posterior thorax > Pulse oximetry: 92–94% room air, requiring oxygen to maintain

adequate O

Interpret, Discriminate, Infer and Predict: The signicance of these ndings indicates that Mr Maharjan is experiencing an acute episode of respiratory distress caused by COVID-19. According to the current guidelines, Mr Maharjan’s ndings put him in the moderate disease with deterioration category. Close observation will be required to determine transfer to critical care services.

Putting it all together – synthesise information

The role of the nurse in this case is to ensure Mr Maharjan is managed appropriately in the ward so that he is seen promptly by the interprofessional healthcare team. This will ensure that intervention is undertaken before any further deterioration in respiratory status occurs and to limit the possibility of invasive intervention. While the medical ofcer will review and prescribe medical treatment for Mr Maharjan, the nursing team will manage

92–94%

level

CHAPTER 13

472 PHYSICAL EXAMINATION

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holistic care for the consumer and his family/whànau. Treatment focuses on relieving respiratory distress, positioning, medications, monitoring deterioration. Relief from symptoms should usually occur following supportive treatment, and medication

UNIT 2

administration. Close monitoring for deterioration for 5 to 10 days following onset of symptoms is vital.

Actions based on assessment ndings

Other areas that need to be considered include:

1 Monitor the continued use of infection prevention and control

strategies. Consider communication with Mr Maharjan and how he might manage his hearing impairment while staff and healthcare professionals are wearing personal protective equipment (PPE).

2 Ongoing assessment, pulse oximetry and respiratory

assessments (pulmonary embolism) will be vital to detect potential deterioration.

3 Consider periods of prone positioning if tolerated until

Mr Maharjan is no longer deteriorating (i.e. maintain oxygen levels above 93%).

4 Assessment for deterioration of cardiovascular

(thromboembolism, arrhythmias, cardiac impairment), neurological (delirium) and renal (acute kidney injury) systems, sepsis, shock, and multi-organ dysfunction is imperative.

5 Medication management currently suggests intravenous or oral

corticosteroids (dexamethasone) for up to 10 days. Baricitinib (selective immunosuppressant), low molecular weight heparin (e.g. enoxaparin 40mg daily), and possible antibiotic therapy.

6 Close monitoring of consumer deterioration particularly 5 to

10 days after onset of symptoms.

7 Communication and holistic care: clear communication

regarding symptoms and management to consumer, family/ whànau or carers. The nurse should give Mr Maharjan the opportunity to communicate concerns about his condition to his family/whànau while he is in hospital. Remember that Mr Maharjan has a hearing impairment, therefore the nurse will need to implement additional strategies to facilitate effective communication.

8 Support communication between Mr Maharjan and his wife

Vamika, who remains alone in the residential aged care facility while he is in hospital.

9 Liaise with pastoral care, counselling and other social support

services considering his cultural beliefs and needs while he is in hospital.

10 Discharge planning: consider specialist clinic follow-up,

investigations, and support. Discharge planning usually begins prior to discharge.

11 Education about post COVID infection management is critical

for Mr Maharjan.

12 Post COVID infection signs and symptoms include cough,

SOB, neurological symptoms, hair loss, skin conditions, renal disease, thromboembolism, psychological symptoms, cardiac and musculoskeletal symptoms, fever, reduced activity and function, altered nutrition and weight loss.

The nal step in the process is accurate documentation. The nurse must document ndings, referrals, interventions, and advice and education given. The consumer would then be reassessed following denitive diagnosis, and long-term management and follow-up would be facilitated.

Austr alian Nation al COVID-19 Clini cal Eviden ce Taskforc e

(202 2); Ministr y of Health /Manat ù Hauora (20 22)

Evaluate outcomes

Mr Maharjan was admitted to your ward with moderate COVID-19 disease, and he was deteriorating. Was the treatment and care enough to manage Mr Maharjan in the ward, or did he deteriorate and require transfer to critical care services? Were you the nurses that detected a slight change in his condition, communicated this with the team, and instigated nursing care that minimised the possibility of his transfer for invasive treatment?

Reections

Consider Mr Maharjan’s clinical presentation, and management underpinned by current and evolving evidence, and how Mr Maharjan recovered. What did you learn about the management of a person with COVID-19? What would you do the same or differently in the future? Are there additional opportunities for learning about the management of people with COVID-19?

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CHAPTER RESOURCES

REVIEW QUESTIONS

For answers to these questions, see Answer section at the end of the book.

1. The nurse observes that the consumer is having difculty

breathing. Which muscles are used in a state of increased oxygen demand? Select all that apply.

a. Diaphragm b. External intercostal muscles c. Sternocleidomastoid muscles d. Abdominal rectus muscles e. Internal intercostal muscles f. Trapezius muscles

2. A consumer reports that he was climbing Mount Cook and

noted an increase in the depth of his respirations. This physical assessment nding is called:

a. Biot’s respirations b. Apneustic respirations c. Hyperpnoea d. Air trapping

3. Kussmaul respirations are respirations that: a. Have an increased depth and slow rate b. Are the body’s attempt to raise its PaCO c. Are regularly irregular d. Are tachypnoeic and hyperpnoeic

4. The nurse suctions the consumer’s endotracheal tube and

notes that the secretions are pink coloured. What is a possible aetiology of this consumer’s pathology?

a. Asthma b. Pulmonary oedema c. Viral infection d. Pneumococcal pneumonia

5. When performing diaphragmatic excursion, you measure a

distance of 2cm. This nding suggests:

a. A normal distance b. Hypoventilation c. Pneumonectomy d. High diaphragm level

6. During inspection of a consumer’s thorax, you note that

the consumer’s ribs attach to the sternum at a 45° angle. This consumer has:

a. A normal nding b. Pleural effusion c. Cystic brosis d. Chronic bronchitis

level

7. You auscultate abnormal breath sounds on the consumer’s

right chest at the 5th rib in the midclavicular line. In which lobe of the lung are you auscultating this sound?

a. Right upper lobe b. Right middle lobe c. Right lower lobe d. Right oblique ssure

8. Which of the following consumers has the highest risk of

contracting COVID-19?

a. A 78-year-old male with chest pain and diarrhoea b. A 55-year-old sheep farmer who presents with a cough c. A 17-year-old female who has cystic brosis, and spends

a lot of time with her grandmother in a residential aged care facility

d. A 27-year-old person with a history of drug and alcohol

abuse who recently moved to Darwin, Northern Territory,Australia

9. In which condition might you expect to see a rib angle of

45°, decreased thoracic expansion, tracheal deviation, dull percussion, tachypnoea, and increased tactile fremitus?

a. Pneumothorax b. Emphysema c. Pneumonia d. Atelectasis

10. The nurse auscultates the consumer’s lungs and hears ne

and coarse bronchial crackles, and increased voice sounds. These sounds are heard during inspiration. What condition does the nurse suspect that the consumer is experiencing?

a. Pneumonia b. Bronchitis c. Croup d. Pleurisy

CLINICAL SKILLS

The following Clinical Skills are relevant to this chapter and can be found in Tollefson & Hillman, Clinical Psychomotor Skills, 8th edition:

> 19 Focused respiratory health history assessment and

physical assessment

> 27 Healthcare teaching.

CHAPTER 13

474 PHYSICAL EXAMINATION

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FURTHER RESOURCES

> Asthma + Respiratory Foundation NZ: https://www.

UNIT 2

asthmafoundation.org.nz/health-professionals

> Asthma New Zealand: https://www.asthma.org.nz/ > Auscultation Assistant: http://www.wilkes.med.ucla.edu/ > Australian Asthma Handbook: https://www.nationalasthma.

org.au/health-professionals/australian-asthma-handbook

> Australian Government Cancer Australia. Cancer Learning:

Our Lungs, Our Mob Community Education Resource: http:// cancerlearning.gov.au/resources/links/our-lungs-our-mobcommunity-education-resource

> Australian Government Department of Health: The Australian

immunisation handbook (10th ed.). Australian Technical

Advisory Group on Immunisation (ATAGI): https://immunisationhandbook.health.gov.au/

> Australian Government Department of Health: The Strategic

Plan for Control of Tuberculosis in Australia, 2016–2020: Towards Disease Elimination: https://www1.health.gov.au/internet/main/ publishing.nsf/Content/ohp-ntac-tb-strat-plan.htm

> Better Health Channel Victoria State Government: https://

www.betterhealth.vic.gov.au/

> Cancer Society New Zealand: http://www.cancernz.org.nz/ > Centers for Disease Control and Prevention: http://www.cdc.gov

REFERENCES

> Health Direct: https://www.healthdirect.gov.au/ > Health Navigator New Zealand: http://www.healthnavigator.

org.nz

> Health Navigator New Zealand – COPD/Mate ia tuku: https://

www.healthnavigator.org.nz/health-a-z/c/copd/

> Immunisation Advisory Centre: https://www.inuenza.org.nz/ > Inuenza Specialist Group: http://www.isg.org.au/index.php/

vaccination/

> Lung Foundation Australia: https://lungfoundation.com.au/

health-professionals/

> Mayo Clinic: http://www.mayoclinic.com > Ministry of Health/Manatù Hauora: http://www.health.govt.nz/ > National Asthma Council Australia: https://www.

nationalasthma.org.au/health-professionals

> National Immunisation Program Schedule: https://beta.health.

gov.au/topics/immunisation/immunisation-throughout-life/ national-immunisation-program-schedule

> R.A.L.E. Repository: http://www.rale.ca > The Thoracic Society of Australia & New Zealand:

http://www.thoracic.org.au

Alkhodari, M., & Khandoker, A. H. (2022). Detection of COVID-19 in

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Australian Government Department of Health. (2021). Australian COVID-19

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Australian Institute for Health and Wellbeing (AIHW). (2020). Chronic

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Australian Institute for Health and Wellbeing (AIHW). (2022a). Chronic

respiratory conditions. Retrieved 12 December 2022 from: https://www. aihw.gov.au/reports/australias-health/chronic-respiratory-conditions

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tobacco & other drugs in Australia. Retrieved 12 December 2022 from: https://www.aihw.gov.au/reports/phe/221/alcohol-tobacco-otherdrugs-australia/contents/population-groups-of-interest/young-people

Australian Technical Advisory Group on Immunisation (ATAGI). (2018).

Australian immunisation handbook. Australian Government Department of Health, Canberra. Retrieved 7 June 2022 from: https://www.immunisationhandbook.health.gov.au.

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Australian Technical Advisory Group on Immunisation (ATAGI). (2022,

May). Australian Technical Advisory Group on Immunisation (ATAGI) recommended COVID-19 vaccines and doses. Retrieved 22 May 2022 from: https://www.health.gov.au/

Berman, A., Snyder, S., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N.,

… & Stanley, D. (2018). Kozier and Erb’s fundamentals of nursing: Concepts, process and practice, 4th Australian edition. Frenchs Forest, NSW: Pearson Education Australia.

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