Assessment Rationales

Using an appropriate quantitative scoring scale,

1 to 10 for example, can aid the patient to
formulate the amount of weakness experienced.
Further scoring scales can be developed by
Evaluate the patient’s description of weakness:
using pictures or descriptive language. This
severity, changes in severity over time,
system allows the nurse to weigh against
aggregating factors or alleviating factors.
changes in the patient’s weakness level over
time. It is important to conclude if the patient’s
level of weakness is constant or if it varies over
time.

Determine possible causes of weakness, such

as:
 
 Last physical illness
 Pain
 Emotional stress Identifying the related factors with weakness
 Depression can benefit in recognizing potential causes and
 Side effects of medication building a collaborative plan of care.
 Anemia
 Sleep disorders
 Imbalanced nutritional intake
 Extended responsibilities and demands
at home or work

Weakness can restrict the patient’s ability to

Assess the patient’s ability to perform ADLs,
participate in self-care and do his or her role
instrumental activities of daily living (IADLs),
responsibilities in the family and society, such
and demands of daily living (DDLs).
as working outside the home.

Assess the patient’s nutritional ingestion for Fatigue may be a symptom of protein-calorie
adequate energy sources and metabolic malnutrition, vitamin deficiencies, or iron
demands.
Evaluate the patient’s outlook for fatigue relief,
eagerness to participate in strategies to reduce
fatigue, and level of family and social support.
Review results of laboratory or diagnostic test:
 Blood glucose
 Hemoglobin/hematocrit
 BUN
 Oxygen saturation, resting and with
activity
Observe physiological reaction to activities
such as any alterations in BP, respiratory rate,
or heart rate.
Assess the patient’s typical level of exercise
and physical movement.
Assess the patient’s sleep patterns for quality,
quantity, time taken to fall asleep and feeling
upon awakening and observe alteration in
thought processes or behaviours.
Assess the patient’s routine recommendation
and over-the-counter drugs.
deficiencies.
These will promote active participation
in planning, implementing, and evaluating
therapeutic management to alleviate fatigue.
Social support will be essential to assist the
patient put into practice changes to decrease
fatigue.
Changes in these physiological measures may
be associated with other measurement data to
recognize possible sources of the patient’s
fatigue.
Tolerance varies significantly, depending on the
phase of the disease
progression, nutrition condition, fluid balance,
and quantity or sort of opportunistic diseases
that patient has been subjected to.
Increased physical exertion and inadequate
levels of exercise can add to weakness.
Changes in the patient’s sleep pattern may be a
contributing factor in the development of
fatigue. Numerous factors can exacerbate
fatigue, together with sleep deprivation,
emotional distress, side effects of drugs, and
progressing CNS disease.
Fatigue may be a medication side effect or an
indication of a drug interaction. The nurse must
 perform particular notice to the patient’s
utilization of beta-blockers, calcium channel
blockers, tranquilizers,
alcohol, muscle relaxants, and sedatives.

The common emotional responses associated

Assess the patient’s emotional reaction to with fatigue are anxiety and depression. These
fatigue. emotional conditions can increase the person’s
fatigue level and produces a vicious cycle

Patient History
A respiratory assessment must begin with a detailed patient history. Ask about previous
respiratory illnesses, chronic respiratory conditions, and cardiovascular health. If the patient
has an infection or is in respiratory distress, get as many details as possible about the event
preceding the emergency. Ask about the patient’s vaccine history, as well.
 
This is also an ideal chance to determine whether the patient has special needs that might
affect the assessment. Preterm infants, for example, have weaker respiratory muscles than
children and adults, while infants and young children have a more rapid rate of respiration.
Ensure you know what’s normal for the patient population you serve, as well as the specific
patient you are treating.
 
Observation
Observe the patient for important respiratory clues:
 Check the rate of respiration.
 Look for abnormalities in the shape of the patient’s chest.
 Ask about shortness of breath and watch for signs of laboured breathing.
 Check the patient’s pulse and blood pressure.
 Assess oxygen saturation. If it is below 90 percent, the patient likely needs oxygen.
  
Auscultation
Hearing the sounds of the patient breathing provides vital information about the patient’s
overall health. Auscultate the chest, back, and sides with a focus on signs of loud or laboured
breathing. Signs of abnormal breathing include:
  Crackling, popping, or bubbling sounds, which may indicate pneumonia or pulmonary
oedema.
 Wheezing, which can signal pulmonary disease, asthma, allergies, or an infection.
 Pleural friction. This grating sound occurs when the pleural surfaces rub together and
suggests pneumonia.
 
Physical Examination
A hands-on exam is critical for detecting abnormalities that simple observation and
auscultation cannot. To examine the patient:
1. Palpate the back at the tenth rib, positioning a thumb on each rib as the patient
breathes deeply. Patients with decreased lung expansion may have a tumor or
pneumonia on one side. Poor lung expansion could also indicate pneumothorax.
2. Evaluate the thorax by positioning the palms over the thorax and feeling for bulging,
tenderness, and retractions while breathing. Feel the ribs for lumps, scars, and
swelling.
3. Have the patient fold their arms across their chest. Then position both palms on either
side of the back, touching the patient’s back with your fingers while the patient says a
sentence.
4. You should feel buzzing as the patient speaks. If there is fluid in the lungs or a lower
respiratory obstruction, the vibrating will be intense because of the ability of fluid to
more effectively transmit sound.
 
Percussion
Percussion can provide additional information about respiratory status. Use the middle or
index finger of your dominant hand to tap the areas between each rib through the chest or
back. Avoid touching the skin with your other fingers, since this can cause vibrations that
compromise the assessment.
 
Sounds to monitor for include:
 A short and high-pitched or very dull sound over muscle or bone. This suggests
respiratory consolidation.
 A loud, long, low-pitched and hollow sound over the lungs or stomach that may
suggest bronchitis.
  A dull, thudding sound over large organs such as the liver. This may also be a sign of
consolidation.
 A loud, low-pitched sound over the stomach that can indicate pneumothorax or
emphysema.
 A high-pitched drum sound is heard when the chest is expanded. This suggests excess
air, often due to a collapsed lung.

Cough is caused by stimulation of irritant receptors in the central airways and/or stretch
receptors in the distal airways or the lung interstitium. It is a normal protective mechanism,
which may be lost with local or general anaesthesia, other causes of decreased level of
consciousness, or neuromuscular problems (especially bulbar). Cough is abnormal if it is
persistent, painful or productive.

History and examination If a patient presents with a cough, the following features should be
clarified on history:
• duration – days, weeks, months or years
• course – constant, worsening, intermittent, diurnal variation
• triggers – allergens, irritants, swallowing, position
• dry or productive (nature and volume of sputum) – clear/ white/grey (mucoid), yellow/green
(purulent) or bloody (haemoptysis)
• other – shortness of breath, chest pain, wheeze/tightness, loss of weight, fever, sweating. On
examination, one should listen to the type of cough and look for signs, particularly the
following:
• general – distress, fever, sweating, loss of weight, cyanosis, clubbing
• respiratory – respiratory rate, hyperinflation, dullness, crackles, wheeze, bronchial
breathing, pleural rub. Investigations will depend on the most likely cause determined
clinically

Common causes/types of cough Description and associated features

Chronic bronchitis (‘smokers’ cough’) Cough productive of sputum for most days
for at least 3 months of a year for at least 2
years, usually mucoid, but may be purulent
during infective exacerbations
Acute bronchitis/tracheitis Dry or purulent, with central burning chest
pain; short duration

Pneumonia Purulent or rusty, often with associated

pleuritic chest pain, shortness of breath and
fever; short duration

Bronchiectasis Usually large volumes of purulent sputum,

sometimes offensive, often associated with
clubbing and coarse crackles transmitted to
the mouth; long duration

Lung abscess Usually large volumes of purulent sputum,

sometimes offensive, often associated with
fever, clubbing and amphoric breathing;
usually long duration

Tuberculosis (TB) Dry, purulent or bloody, often associated

with fever, night sweats, loss of weight
(LOW); long duration

Lung cancer Dry, purulent or bloody, occasionally

‘bovine’ (vocal cord palsy) or ‘brassy’
(central airway compression), often
associated with LOW

Interstitial lung disease (ILD) Usually dry, often associated with fine
crackles; long duration

Pulmonary oedema Dry or productive (pink froth or blood),

often associated with orthopnoea and
paroxysmal nocturnal dyspnoea
Assessment on chest pain

Subjective history

You’ll need to know the most common causes of chest pain as well as the distinguishing
symptoms of both cardiac and noncardiac causes of chest pain. Take a quick, but thorough
subjective history. Most important, you and the patient must understand each other. Each
patient brings his or her own past experiences of pain to the visit, as well as level of
education, socioeconomic status, ethnicity, and individual pain threshold, which plays a role
in how the patient will present and describe the current pain experience.

Using follow-up questions, such as asking the patient to point to the area of pain, and
repeating what the patient said can be very helpful in making sure the patient is understood.
Explore the characteristics of the chest pain first. These include quality, location, duration,
intensity, accompanying symptoms, aggravating and alleviating factors, as well as the
relationship between any type of exertion and pain experienced. Additionally, to help rule out
an ischemic cause of chest pain, ask about any history (self or family) of angina or MI; the
patient’s age (coronary artery disease is more common with age); and additional risk factors,
such as smoking, hypertension, hyperlipidaemia, or diabetes. Gender also plays a role in
chest pain complaints, as MIs are more common in men over the age of 40 and in women
over the age of 50. Remember that chest pain in women may vary significantly from men.
Women often have symptoms of fatigue, tiredness, or sleep disturbances as prodromal
symptoms before a cardiac event.

Physical assessment

You can ask the subjective questions above while performing a quick but thorough physical
assessment. Although some physical findings are common for the various causes of chest
pain, a patient with chest pain may not have all of these signs, and some patients may not
have any signs at all (see Chest pain physical assessment clues). Determining the cause of
chest pain depends on the patient’s history and objective data from the physical exam and
diagnostic tests.10 The most important diagnostic tool when evaluating chest pain is the
ECG. The ECG may provide the most valuable clue to whether a patient is having an
ischemic event; however, it should be noted that the ECG is limited with regard to its ability
to fully evaluate the left ventricle’s posterior, lateral, and apical walls.

Exposure History
Analyzing a patient's extensive exposure history is a crucial first step in determining whether
they are at risk of contracting an asbestos-related disease. The risk of an asbestos-related
disease generally rises with cumulative dose. But because asbestos builds up in the body,
even small amounts of exposure from decades past could be a factor in illnesses like
mesothelioma. The exposure history should include:

 Work history, including occupations in which the patient may have been exposed
directly or indirectly.
 Source, intensity, frequency and duration of exposure.
 Time elapsed since first exposure.
 If extant, workplace dust measurements or cumulative fibre dose (or exposure
scenario, if levels cannot be determined).
 Use of personal protective equipment.
 Other sources of exposure, including Para occupational exposures from family
members and other household contacts.
 Sources of environmental exposure, including residence near an area with naturally
occurring asbestos deposits or hobbies or recreational activities that involve materials
that contain asbestos).
 Smoking history and sources of other environmental contaminants such as
environmental tobacco smoke.

Most people with cancer-related relatives won't have inherited a bad gene. Most cases of
cancer affect older adults. It is a widespread illness. In the UK, one in two (50%) individuals
born after 1960 may receive a cancer diagnosis at some point in their lifetime. Therefore, at
least one cancer patient will be present in the majority of families. A cancer gene flaw does
not necessarily run in the family just because a few relatives have been diagnosed with the
disease.
In families with an inherited faulty gene, there is usually a pattern of specific types of cancer
running in the family. The strength of your family history depends on:
 who in your family has had cancer
 the types of cancer they have had
 how old they were at diagnosis
 how closely related the relatives with cancer are to each other

The more relatives who have had the same or related types of cancer, and the younger they
were at diagnosis, the stronger someone’s family history is. This means that it is more likely
that the cancers are being caused by an inherited faulty gene.