Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 26: Nursing Assessment: Respiratory System Answer Guidelines 1. A patient who is visibly struggling to breathe requires an immediate emergency respiratory assessment. 2. Possible causes of the onset (it seems sudden but you will need to gather more data) of dyspnea are an allergic reaction, asthma attack, angina, myocardial infarction, and heat stroke. 3. If it does prove to be sudden in onset and related to her respiratory system (allergy, asthma), likely triggers for such a reaction are inhaled allergens, air pollutants, viral infections of the respiratory tract, sinusitis, exercise, stress, drugs, and food additives. 4. Important questions to ask: Did your breathing trouble start suddenly? Has this ever happened to you before? If so, what helped you feel better? Do you have any allergies? Do you have asthma? 5. Components of the emergency respiratory examination should include breath sounds, respiratory rate and character, and (if available) pulse oximetry. 6. While you are speaking with her, count how many words she can say before she has to take a breath. Severe respiratory distress forces a patient to pause for a breath every four or five words. 7. Oxygen supplementation is an obvious first intervention. Medications that may be used include bronchodilators, diphenhydramine or epinephrine (if an allergic response is suspected), and corticosteroids.

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