Case Study Objective Data: Physical Examination
Physical examination findings of Fred Thompson are as follows: BP 170/90, apical pulse 110, respiratory rate 30, temp 37°C, O2 saturation 87% on room air. Patient siing on edge of bed with arms resting on bedside table. Slight use of accessory muscles in neck and shoulders noted. Chest expansion equal. Respirations regular but slightly laboured with prolonged expiration. Skin colour pale with no cyanosis. No clubbing noted. Trachea midline. Bibasilar crackles, scaered rhonchi, and expiratory wheezing heard on auscultation. Moist, productive cough with yellow-tinged sputum. Throughout this chapter, consider diagnostic studies that may be ordered for Mr. Thompson.
Focused Assessment
Respiratory System Use this checklist to make sure the key assessment steps have been done.
Subjective Ask the patient about any of the following and note the responses:
Objective: Diagnostic Check the following laboratory results for critical values:
Objective: Physical Examination Observe
Inspect
Palpate
Auscultate
Diagnostic Studies of the Respiratory System Blood Studies
Common blood studies used to assess the respiratory system are the determinations of hemoglobin, hematocrit, and ABGs. Table 28-11 lists nursing responsibilities associated with these tests.
Oximetry Oximetry is used to noninvasively monitor SpO2 and SvO2 (see Tables 28-1 and 28-3). Nursing care associated with oximetry is discussed in Table 28- 11. Sputum Studies Sputum samples can be obtained by expectoration, tracheal suction, or bronchoscopy, a technique in which a flexible bronchoscope is inserted into the airways. The specimens may be examined for culture and sensitivity to identify an infecting organism (e.g., Mycobacterium species, Pneumocystis jiroveci) or to confirm a diagnosis (e.g., malignant cells). Nursing responsibilities for specimen collection are described in Table 28- 11. Regardless of whether specimen tests are ordered, it is important to observe the sputum for colour, blood, volume, and viscosity.
Skin Tests Skin tests may be performed to test for allergic reactions or exposure to tubercle bacilli or fungi. Usually, 0.1 mL of purified protein derivative is injected intradermally on the ventral surface of the forearm. Skin tests involve the intradermal injection of an antigen. A positive result indicates that the patient has been exposed to the antigen. It does not indicate that disease is currently present. A negative result indicates that the patient has not been exposed or that cell-mediated immunity is depressed, as occurs in HIV infection. Nursing responsibilities are similar for all skin tests. First, to prevent a false-negative reaction, the nurse should be certain that the injection is intradermal and not subcutaneous. After the injection, the sites should be circled and the patient instructed not to remove the marks. When charting administration of the antigen, the nurse should draw a diagram of the forearm and hand and label the injection sites. The diagram is especially helpful when more than one test is administered.
Tuberculin Skin Testing. When reading test results, the nurse should use a good light. The reading should be performed within 48 to 72 hours after the purified protein derivative is administered. It can take up to 48 hours for induration to become maximal. However, it is difficult to interpret a reaction after 72 hours (Public Health Agency of Canada, The Lung Association, & Canadian Thoracic Society, 2014). If an induration is present, a marking pen should be used to indicate the periphery (on all four sides) of the induration. As the pen touches the raised area, a mark should be made. The nurse then determines the diameter of the induration in millimetres. Reddened, flat areas are not measured. Reactions that indicate a positive and potential negative tuberculin skin test (TST) are described in Tables 28-12 and 28-13. Canadian health care seings use tuberculin purified protein (Tubersol) for skin tests. If any patient has had a previous bacille Calmee-Guérin vaccination, it will affect results. This is significant especially for people from Quebec, Newfoundland, and Indigenous populations, who regularly received this vaccine from 1940 through the 1970s (Public Health Agency of Canada, 2015b).
*The goal of testing for latent tuberculosis is to identify individuals who are at increased
risk for the development of tuberculosis and therefore would benefit from treatment of latent tuberculosis. Only those who would benefit from treatment should be tested; thus a decision to test presupposes a decision to treat if the test result is positive. † In general, this level is considered negative, and no treatment is indicated. HIV, human immunodeficiency virus; TB, tuberculosis. Source: © All rights reserved. Canadian Tuberculosis Standards, 7th Edition. Public Health Agency of Canada and Canadian Thoracic Society, 2014. Adapted and reproduced with permission from the Minister of Health, 2017.