What is the best reason for the nurse to instruct a male patient to take slow deep breaths during insertion of an indwelling?
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With an understanding of the basic structures and primary functions of the respiratory system, the nurse collects subjective and objective data to perform a focused respiratory assessment. Subjective AssessmentCollect data using interview questions, paying particular attention to what the patient is reporting. The interview should include questions regarding any current and past history of respiratory health conditions or illnesses, medications, and reported symptoms. Consider the patient’s age, gender, family history, race, culture, environmental factors, and current health practices when gathering subjective data. The information discovered during the interview process guides the physical exam and subsequent patient education. See Table 10.3a for sample interview questions to use during a focused respiratory assessment.[1] Table 10.3a Interview Questions for Subjective Assessment of the Respiratory System
Life Span ConsiderationsDepending on the age and capability of the child, subjective data may also need to be retrieved from a parent and/or legal guardian. Pediatric
Older Adult
Objective AssessmentA focused respiratory objective assessment includes interpretation of vital signs; inspection of the patient’s breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds using a stethoscope. For more information regarding interpreting vital signs, see the “General Survey” chapter. The nurse must have an understanding of what is expected for the patient’s age, gender, development, race, culture, environmental factors, and current health condition to determine the meaning of the data that is being collected. Evaluate Vital SignsThe vital signs may be taken by the nurse or delegated to unlicensed assistive personnel such as a nursing assistant or medical assistant. Evaluate the respiratory rate and pulse oximetry readings to verify the patient is stable before proceeding with the physical exam. The normal range of a respiratory rate for an adult is 12-20 breaths per minute at rest, and the normal range for oxygen saturation of the blood is 94–98% (SpO₂)[3] is less than 12 breaths per minute, and is greater than 20 breaths per minute. As a general rule of thumb, respiratory rates outside the normal range or oxygen saturation levels less than 95% indicate respiration or ventilation is compromised and requires follow-up. There are disease processes, such as chronic obstructive pulmonary disease (COPD), where patients consistently exhibit below normal oxygen saturations; therefore, trends and deviations from the patient’s baseline normal values should be identified. A change in respiratory rate is an early sign of deterioration in a patient, and failing to recognize such a change can result in poor outcomes. For more information on obtaining and interpreting vital signs, see the “General Survey” chapter.InspectionInspection during a focused respiratory assessment includes observation of level of consciousness, breathing rate, pattern and effort, skin color, chest configuration, and symmetry of expansion.
Palpation
AuscultationUsing the diaphragm of the stethoscope, listen to the movement of air through the airways during inspiration and expiration. Instruct the patient to take deep breaths through their mouth. Listen through the entire respiratory cycle because different sounds may be heard on inspiration and expiration. As you move across the different lung fields, the sounds produced by airflow vary depending on the area you are auscultating because the size of the airways change. Listen to normal breath sounds on inspiration and expiration. Correct placement of the stethoscope during auscultation of lung sounds is important to obtain a quality assessment. The stethoscope should not be performed over clothes or hair because these may create inaccurate sounds from friction. The best position to listen to lung sounds is with the patient sitting upright; however, if the patient is acutely ill or unable to sit upright, turn them side to side in a lying position. Avoid listening over bones, such as the scapulae or clavicles or over the female breasts to ensure you are hearing adequate sound transmission. Listen to sounds from side to side rather than down one side and then down the other side. This side-to-side pattern allows you to compare sounds in symmetrical lung fields. See Figures 10.5[7] and 10.6[8] for landmarks of stethoscope placement over the anterior and posterior chest wall. Figure 10.5 Anterior Auscultation AreasFigure 10.6 Posterior Auscultation AreasWhen assessing patients who are experiencing shortness of breath (or fatigue easily), it may be helpful to begin auscultation in the bases and progress upward to other lung fields as tolerated by the patient. This ensures that assessment of the vulnerable lower lobes is achieved prior to patient fatigue. Expected Breath SoundsIt is important upon auscultation to have awareness of expected breath sounds in various anatomical locations.
Adventitious Lung SoundsAdventitious lung sounds are sounds heard in addition to normal breath sounds. They most often indicate an airway problem or disease, such as accumulation of mucus or fluids in the airways, obstruction, inflammation, or infection. These sounds include rales/crackles, rhonchi/wheezes, stridor, and pleural rub:
Life Span ConsiderationsChildrenThere are various respiratory assessment considerations that should be noted with assessment of children.
Older AdultsAs the adult person ages, the cartilage and muscle support of the thorax becomes weakened and less flexible, resulting in a decrease in chest expansion. Older adults may also have weakened respiratory muscles, and breathing may become more shallow. The anteroposterior-transverse ratio may be 1:1 if there is significant curvature of the spine (kyphosis). PercussionPercussion is an advanced respiratory assessment technique that is used by advanced practice nurses and other health care providers to gather additional data in the underlying lung tissue. By striking the fingers of one hand over the fingers of the other hand, a sound is produced over the lung fields that helps determine if fluid is present. Dull sounds are heard with high-density areas, such as pneumonia or , whereas clear, low-pitched, hollow sounds are heard in normal lung tissue.
Expected Versus Unexpected FindingsSee Table 10.3b for a comparison of expected versus unexpected findings when assessing the respiratory system.[12] Table 10.3b Expected Versus Unexpected Respiratory Assessment Findings
What is a critical step when inserting an indwelling catheter into a male patient?Male patient: Hold penis perpendicular to body and pull up slightly on shaft. Ask patient to bear down gently (as if to void) and slowly insert catheter through urethral meatus. Advance catheter 17 to 22.5 cm or until urine flows from catheter.
What is the most common indication for male indwelling urethral catheterisation?The most common indication for male urethral catheterisation is to relieve urinary retention but it may also be used for investigations such as urodynamic studies and for instilling intravesical medication.
Why must short catheter not be used on a male?Length. It is important to use the correct catheter length for each patient. Inflating a short female catheter in the male urethra can cause severe pain and lead to serious complications such as haematuria, penile swelling, urinary retention and renal failure.
How many inches should an indwelling catheter be lubricated before inserting in a male patient?Lubricate 6 to 7 inches (15 to 17.5 cm) of the catheter tip. With your nondominant hand, gently grasp the shaft of your patient's penis, just below the glans. Keep your hand in place, as it's now contaminated.
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