Breathing Patterns Case Study Hesi

Meet the client: James Harrison
James Harrison a 9 year old male is brought to the ED by his mother because he is short of breath and unable to sleep, due to coughing
Which is the best technique for the nurse to use to assess Jame’s respirations accurately?
Place a hand on James’ upper abdomen and observe the rise and fall of the chest

Rationale:
This technique allows the nurse to observe and count each ventilatory cycle, even when respirations are shallow

Assessment Skills:

James’ respiratory rate is 36 breaths/min. How should the nurse describe James’ respiratory pattern?

Tachypnea

Rationale: a rapid respiratory rate, which is consistent with Jame’s rate of 36 breaths/min. Normal respiratory rate for a school-aged child is 16-30 breaths/min

Tachypnea
Rate of breathing is regular but abnormally rapid (greater than 20 breaths per minute).
Hyperpnea
Respirations are increased in depth; occurs normally during exercise.

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Hyperventilation
Rate and depth of respirations increase. Hypocarbia, an abnormally low level of carbon dioxide in the blood, may occur.
Hypoventilation
Respiratory rate abnormally low; depth of ventilation may be depressed. Hypercarbia, an abnormally elevated level of carbon dioxide in the blood, may occur
Apnea
Respirations cease for several seconds. Persistent cessation results in respiratory arrest
Cheyne-Stokes respiration
Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses, breathing slows and becomes shallow, climacing in apnea before respiration resumes.
Biot’s respiration
Respirations are abnormally shallow for two to three breaths followed by irregular period of apnea
Because of James’ dyspnea, the nurse is concerned that he may need to receive oxygen. To determine the need for supplemental oxygen, which assessment is most important for the nurse to perform?
Measure oxygen saturation

Rationale: O2 Sat provides imp data about the % of hemoglobin that is saturated with O2–a valuable reflection of the client’s overall oxygenation

In assessing James’ breath sounds, the nurse should ask him to perform which action?
Breath deeply through the mouth

Rationale: James should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds

To measure capillary refill, the nurse must first perform which action?
Compress the nailbed of one finger until it blanches

To measure capillary refill, the nurse should first compress the client’s nailbed, then note how many seconds it takes for the return of normal color to the nailbed

James’ mother states that this is the third time in recent months she has brought him to the ED with a cough and SOB. The nurse asks the mother how many respiratory infections James has had w/ in the past year/. Why does the nurse ask this?
To assess for a possible immune deficiency disorder
Pulse Oximetry

The nurse plans to measure James’ o2 sat with a spring-tension finger clip. While the nurse is explaining this procedure, James asks if it will hurt

Which response is best for the nurse to provide?

The clip feels like squeezing your finger with your other hand.
Which nursing diagnosis is most relevant to James’ current status?
Impaired gas exchange

Rationale:
normal saturation is 95 to 100% James’s oxygen sat is well low

Which assessment finding further supports diagnosis?
Restlessness and fatigue

Rationale:
Restlessness and fatigue are indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed

SIgns of hypoxia
Apprehension, anxiety, behavioral changes

Decreased level of consciousness (LOC),

confusion, drowsiness, altered concentration
Increased pulse rate

Increased rate and depth of respiration or irregular respiratory patterns

Decreased lung sounds, adventitious lung sounds (e.g., crackles, wheezes)

Elevated blood pressure evolving to decreased blood pressure
Dyspnea

Use of accessory muscles of respiration, rib retractions
Cardiac dysrhythmias
Pallor, cyanosis

Increased fatigue
Dizziness
Clubbing of nails due to prolonged, chronic hypoxia

After determining the priority nursing diagnoses, what step should the nurse take next in developing the plan of care?
Establish goals and expected outcomes

Rationale:
After analysis of the data to prioritize nursing diagnoses, the nurse should establish nursing care goals and expected outcomes

Which outcome statement should the nurse use for Jame’s plan of care?
James’ oxygen saturation will be greater than 95% on room air

Rationale:
This client centered outcome statement describes the desired outcome in measurable terms

Characteristics of pulse oximeter sensor probe and sites
REUSABLE PROBE
Digit Probe
Easy to apply, conforms to various sizes.

Earlobe
Clip-on smaller and lighter though more positional than digit probe.
Yields strong correlation with SaO2.
Research suggests greater accuracy at lower saturations (Grap, 2002).
Good when uncontrollable or rhythmic movements (e.g., hand tremors), exercise are present.
Vascular bed least affected by decreased blood flow (Grap, 2002).

DISPOSABLE SENSOR PAD
Can be applied to a variety of sites: earlobe of adult, nose bridge, palm or sole of infant.
Less restrictive for continuous SpO2 monitoring.
Expensive.
Contains latex.
Skin under adhesive may become moist and harbor pathogens.
Available in variety of sizes; pad can be matched to infant weight.

Encourage coughing and deep breathing
Coughing helps to clear mucous from airway which will allow for optimal lung expansion
After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%. Despite the normal reading, James’ mother appears worried and nervous and states, “James has never been sick. I am so scared.”

To encourage the mother to share more about her feelings, how should the nurse respond?

It sounds like this has been a frightening experience for you.

open ended statement acknowledges the situations

James’ mother further states that she is worried her 2 year old daughter at home may also become ill. What is an appropriate and therapeutic response to the mother’s concern about her daughter?
There is a chance she may also become ill. Please call your pediatrician right away is she develops any symptoms
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