Assessing Patients with Chronic Obstructive Pulmonary Disease (COPD)

Nursing Elective 2 By: Cris R. Quimora, BSN4a

Health History
y y Has the patient been exposed to risk factors (type, intensity, duration) ? Does the patient have a past medical history of respiratory dieseases/problems, including asthma, allergy, sinusistis, nasal polys, or respiratory infections? Does the patient have a family history of COPD or other chronic respiratory diseases? How long has the patient had respiratory difficulty? What is the pattern of symptom development? Does exertion increase the dyspnea? What type of exertion? What are the limits of the patient s tolerance for exercise? At what times during the day does the patient complain most of fatigue and shortness of breath? Which eating and sleeping habits have been affec ted? What is the impact of respiratory distress on quality of life? What does the patient know about the disease and his or her condition? What is the patient s smoking history (primary and secondary)? Is there occupational exposure to smoke or other pollutants? What are the triggering events (eg, exertion, strong odors, dust, exposure to animals)? Does the patient have a history of exacerbations or previous hospitalizations for respiratory problems? Are comorbidities present? How appropriate are current medical treatments? Does the patient have available social and family support? What is the potential for reducing risk factor (eg, smoking cessation)?

Physical Assessment
y y y y y y y y y y y y y y What position thus the patient assume during the interview? What are the pulse and the respiratory rates? What is the character of respirations? Even and without effort? Other? Can the patient complete a sentence without having to take a breath? Does the patient contract the abdominal muscles during inspiration? Does the patient use accessory muscles of the shoulders and neck when breathing? Does the patient take a long time to exhale (prolonged expiration)? Is central cyanosis evident? Are the patient s neck engorged? Does the patient have peripheral edema? Is the patient counghing? What are the color, amount, and consistency of the sputum? Is clubbing of the fingers present? What types of breath sounds (ie, clear, diminshed or distant, crackles, wheezes) are heard? Described and document findings and locations. What is the status of the patient s sensorium? Is there short-term or long-term memory impairment? Is there increasing stupor? Is the patient apprehensive?

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Reference:

Brunner&Suddarth s MEDICAL-SURGICAL NURSING, 12th edition,Vol.1, Page 606/chart24-2