Putting it All Together: A Clinical Case Study for a Pulmonary Patient:

Christopher W. Blackwell, ARNP, MSN, PhD(c)

A 55- year old African American male client presents to the Emergency Department (ED). When determining the chief complaint, the client informs the nurse that “I have shortness of breath that started about an hour ago.” The patient informs the nurse that he has a history of asthma and that during today’s attack, his Proventil^® inhaler “didn’t seem to help.”

1. What information would be most helpful for the nurse to obtain regarding this patient’s health history and history of present illness?

It would be essential for the nurse to determine the existence of other illnesses, past surgeries, medications the client is currently taking, how long the patient has had asthma and, what he has done in the past to manage his symptoms. Because the patient is SOB, it is also important for the nurse to obtain only vital information as meeting the patient’s oxygen demands must take priority. This means condensing the health history to obtain only vital information and completing the remainder of the history after the patient has been stabilized and is able to meet oxygenation demands.

2. What are some general assessment findings that indicate the patient is experiencing respiratory distress?

General assessment findings that would indicate this client is in respiratory distress includes the use of accessory muscles, using the tripod position to facilitate easier breathing, and an increased respiratory rate (tachypnea). Although cyanosis is indicative of hypoxia, it is considered a late finding; thus the nurse should be aware that a patient with cyanosis is in severe distress, hypoxemia, and hypoxia.

3. How should the nurse proceed with the physical examination of this patient? What is the priority of the physical exam?

After the general survey of the patient, the nurse uses the ABCs and would first assess the patient’s airway, breathing pattern, and overall respiratory system. Examination of other systems would be secondary to examination of the respiratory system.

4. What are adventitious sounds? Would the nurse expect to find adventitious sounds in this client? If so, which ones would most likely be present?

Adventitious sounds include wheezes, crackles, and rhonchi. Wheezes are high-pitched musical notes that result from airway constriction (for example, bronchial constriction). Crackles are popping sounds typically resulting from fluid in the lungs or from re-opening of atelectic alveoli. Rhonchi result from fluid and inflammation of the airways and sounds like a low-pitched growling sound. To differentiate between crackles and rhonchi, the nurse asks the patient to take a deep breath and cough. If the sounds clear with coughing, the patient has rhonchi. If the sounds remain, crackles are more likely. This patient would probably present with wheezes. With asthma, the bronchi and bronchioles constrict as a result of an irritant and spasm, constricting airflow and creating wheezes.

5. What notes/tones would the nurse expect to find with percussion of the thorax in this client?

Percussion of this patient’s thorax would probably result in Hyperresonance. Normally, a resonant sound predominates the lung fields. With asthma, air becomes trapped within the lungs and as a result, hyperressonant sounds are percussed.

6. What other systems are affected by the respiratory system? How might the nurse assess these systems and what findings would the nurse expect to find?

The respiratory system is the most important system of the human body. Without respiratory function, tissues cannot receive oxygen, resulting in death. ALL body systems are affected by the respiratory system. The nurse would want to assess the client’s cardiovascular system (listen to heart sounds, note heart rate, etc.), neurological system (note for signs of cerebral hypoxia), GI system (note for bowel sounds or pain), Musculoskeletal system along with the hair, skin, and nails. While it is essential to complete a head-to-toe assessment on this patient, concentration on the pulmonary system must take top priority for the nurse.