Breathing Patterns Essay

599 WordsSep 6, 20143 Pages
Breathing Patterns Jean Flick, RN, MS Meet the client: Josh Haskell, a 9 year-old boy, is brought to the emergency department by his mother because he is short of breath and unable to sleep, due to coughing. What is the best technique for the nurse to use to assess josh’s respirations accurately? -Place a hand on Josh’s chest and count the hand motions His respiratory rate is 36. How should the nurse describe josh’s respiratory pattern -Tachypnea Because of josh’s dyspnea, the nurse is concerned he may need oxygen To determine the need for the nasal cannula, which assessment is most important for the nurse to perform? -Measure Oxygen Saturation In assessing Josh’s breath sounds the nurse should ask him to perform which action? -Breathe deeply through the mouth To measure capillary refill the nurse must perform which action? -Compress Josh’s nailbed The nurse plan’s to measure Josh’s oxygen saturation with a spring-tension finger clip. While the nurse is explaining the procedure Josh asks if it will hurt. Which response is best for the nurse to provide? -The clip feels like squeezing your finger with your other hand The nurse meausres Josh’s oxygen saturation at 88% and capillary refill at 1 second. Breath sounds are absent at the base and coarse bilaterally throughout the rest of the lung fields. The nurse administers a 2 liter nasal cannula. When applying the nasal cannula it is important for the nurse to provide which instructions -Remind the client and family that oxygen is combustible and stay 10 ft away from open flames Which nursing diagnosis is most relevant to josh’s current status? -Impaired gas exchange Which assessment finding further supports the diagnosis? -Restlessness & Fatigue After determining the priority nursing diagnosis. What step should the nurse take in developing a plan of care? -Establish

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