Respiratory Assessment

Respiratory Assessment

Respiratory assessment is crucial to any patient evaluation, as the respiratory
system plays a vital role in the body's overall functioning. It involves evaluating the patient's
respiratory rate, breath sounds, oxygen saturation levels, and ability to speak and breathe
comfortably. The assessment helps healthcare providers identify any abnormalities or issues with
the respiratory system, such as asthma, COPD, or pneumonia, and can help guide treatment plans
and interventions. It is important to thoroughly assess the respiratory system to ensure the patient
receives adequate oxygenation and ventilation and to identify any potential issues early on to
prevent further complications. The respiratory assessment of Tina Jones the presence of
abnormalities suggesting that care plan with interventions such as oxygen therapy,
bronchodilator and corticosteroid administration, and further testing and evaluation to enhance
the plan.

Findings

During the respiratory assessment of Tina Jones, several abnormal findings were
identified. One of the most prominent abnormal findings was the presence of tachypnea or rapid
breathing. In addition, Tina's respiratory rate was measured at 22 breaths per minute,
significantly higher than the expected normal range of 12-20 breaths per minute. Tina's breath
sounds were also characterized by rales or abnormal crackling sounds, typically indicative of
fluid accumulation in the lungs.
The other abnormal findings during the respiratory assessment included decreased breath
sounds in the left lower lobe and wheezing and stridor (Aviles-Solis et al., 2019). Tina also
reported experiencing shortness of breath, especially with activity. It is another deviation from
the expected normal finding, as most individuals do not experience shortness of breath with

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normal daily activities. These findings suggest the presence of airway obstruction, which could
be caused by various factors, including asthma, bronchitis, or even a foreign body in the airway
(Jarvis, 2018). In contrast to these abnormal findings, Tina's oxygen saturation levels were
within the normal range, indicating that her body could adequately oxygenate her blood (Fraiwan
et al., 2021). Tina also had no difficulty speaking or completing the deep breathing exercise,
which suggests that her respiratory muscles were functioning normally.
NICs and NOCs or Tina’s Respiratory Problems

Identifying and addressing the underlying cause of Tina's abnormal breathing pattern and
shortness of breath is also important. It may involve further testing and treatment for asthma,
COPD, or pneumonia (Fraiwan et al., 2021). Based on these findings, a care plan for Tina could
include the following NANDA nursing diagnosis: impaired gas exchange, with the following
NICs (Nursing Interventions Classification) and NOCs (Nursing Outcomes Classification)
identified:
NIC 1: Oxygenation Enhancement
 Interventions: Administer oxygen therapy as prescribed, monitor oxygen saturation levels
regularly, and encourage deep breathing and coughing exercises (Fraiwan et al., 2021)
 Outcomes: Improved oxygen saturation levels, increased ability to speak and complete
activities of daily living
NIC 2: Airway Management
 Interventions: Administer bronchodilators and corticosteroids as prescribed, encourage
the use of inhalers or nebulizers, assess for the presence of foreign bodies in the airway

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 Outcomes: Improved airflow, decreased frequency and severity of wheezing and stridor,
increased ability to speak and complete activities of daily living (Aviles-Solis et al.,
2019)
NIC 3: Fluid Management
 Interventions: Administer diuretics and chest physical therapy as prescribed, encourage
increased fluid intake, monitor for signs of fluid accumulation
 Outcomes: Decreased crackling sounds in the lungs, improved ability to breathe,
decreased shortness of breath (Jarvis, 2018)
Conclusion

It is important to note that the care plan for Tina may need to be adjusted based on the
underlying cause of her respiratory difficulties. In addition, further testing and evaluation may be
necessary to determine the specific diagnosis and the most appropriate treatment plan. However,
the above interventions and outcomes provide a starting point for addressing Tina's respiratory
issues and improving her overall respiratory function.

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References

Aviles-Solis, J. C., Jacome, C., Davidsen, A., Einarsen, R., Vanbelle, S., Pasterkamp, H., &