Assessment of a Patient with Breathing Difficulty and Chest Pain

This assessment focuses on a patient with breathing difficulty, chest pain, and other symptoms. It includes a detailed examination of the patient's vital signs, airway, breathing, circulation, disability, exposure, ABG analysis, chest x-ray result, and nursing goals and interventions. The assessment concludes with an evaluation of the implemented interventions.

Running head: ASSESSMENT
Assessment
Name of the student:
Name of the University:
Author’s note

1ASSESSMENT
Introduction:
Mr. John is a 55 year old man, who was admitted to the emergency hospital last night
because of increase in breathlessness issues and worsening cough with productive sputum. Prior
to the hospital admission, he has been struggling with persistent cough and shortness of breath
from the past 4 days. However, last night his breathing difficult increases and it made him
difficult to even sit up. He became very anxious. For this reason, he was rushed to the hospital
immediately. Other symptoms found in patient during assessment include fatigue, fever and
sweating. The patient also complained that he is developing slight pain in his chest.
The review of his medical history suggests that he has been treated for bronchitis two
years ago. He is also a diabetic patient and takes medicine for hypertension. He is also a heavy
smoker taking 1 pack of cigarettes per day for the past 30 years. He lives with his family
members in a two bed room apartment. He has one son and one daughter who live in other town.
The vital sign assessment of Mr. John shows a blood pressure of 150/90 mmHg. Breathing rate is
17 breaths per minute (bpm) and heart rate is 110 bpm. The assessment of oxygen saturation
level shows oxygen saturation rate of 84% on room air and 98% on 4L nasal cannula.
A-E assessment:
Airway:
Airway assessment is important for patient to check whether patient is responsive or not
and there is any signs of respiratory obstruction or not. According to A-E assessment guideline
framed by Resuscitation Council UK (2014), conducting ‘Look, listen and feel’ test along with
assessment of signs of airway obstruction is important. The patient was alert and responsive,
however some changes in his voice was seen. Voice of patient and assessment of breath sound is

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a vital part of airway assessment. While questioning Mr. John, it has been found that he is
speaking with difficulty and cannot complete full sentences. This indicates signs of airway
obstruction. Miller and Miller (2016) support that change in voice and increased breathing effort
is sign of partially obstructed airways. The assessment of breath sound of patient shows coarse
breath sounds and wheeziness.
Breathing:
Breathing assessment involves assessing the patient for signs of respiratory distress by
looking for signs of sweating, central cyanosis, use of accessory muscles and efforts taken during
breathing. It also involves assessment of pulse oximetry results, chest wall movements and lung
auscultation (Resuscitation Council UK 2014). The physical assessment of patient by ‘look,
listen and feel’ revealed sign of sweating and fatigue. His breathing rate was 17 breaths per
minute which is below the normal value and it is indicative of dyspnoea. The assessment of skin
revealed normal skin colour and no signs of cyanosis. His abdomen was slightly distended. On
lung auscultation, late inspiratory crackles and bilateral diminished breath sound was heard. The
pulse-oximetry reading revealed an oxygen saturation level of 84% on room air. The normal
oxygen saturation level is 95 to 100% and the oxygen saturation level lower than this is
indicative of need for supplemental oxygen for Mr. John
Circulation:
The basic responsibilities during circulation assessment involve assessment of capillary
refill time, pulse rate, heart auscultation and blood pressure. It also involves checking skin colour
and checking skin temperature (Thim et al. 2012). No changes in skin colour of Mr. John found.
However, his body temperature is 101 degree Fahrenheit, which is greater than the normal value.

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His pulse rate is 110 breaths per minute which is greater than normal value. Research shows that
high body temperature, crackling sound in lung, high pulse rate and low oxygen saturation level
is common in patients with pneumonia (Fouzas, Anthracopoulos and Bohadana 2018).
Percussion and auscultation of the lungs reveal no abnormal signs of abnormality. His blood
pressure value is 150/90 mmHg, which needs to be managed and monitored. Based on the
assessment done so far, prioritizing breathing difficulty, airway obstruction and blood pressure is
important to promote optimal health of patient.
Disability:
Disability assessment for Mr. John was done by assessment of level of consciousness,
papillary light reflexes and blood glucose in patient. AVPU (alert, voice responsive, pain
responsive or unresponsive) was done to assess level of consciousness. Mr. John was alert and
responsive. His pupils were reactive to light and his blood glucose value was 140 mg/DL
indicating he is a diabetes patient. His medication chart review shows he is taking medications
for diabetes and hypertension.
Exposure:
Full body exposure assessment was done for Mr. John by maintaining his privacy and
pulling the curtains. Adequate information was given to patient regarding this procedure and
permission was taken before conducting the assessment (Thim et al. 2012).No signs of infection
or other issues were found.
ABG analysis:
PH: 7.4

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PCO2: 35 mm Hg
PO2: 65 mm Hg
HCO3: 24
ABG result shows decrease in PO2 values and abnormal pH range. It may be caused by
breathlessness and decrease in airway ventilation due to airway obstruction
Chest x-ray result:
Following admission to the hospital, chest x-ray was done for patient to examine the
signs of any changes in the anatomy of chest. Focal consolidations were found in the right lower
lobe indicative of pneumonia. Blood test result revealed the following values:
WBC: 17, 000/mm
Neutrophils: 70%
Hemoglobin: 10.8
Hematocrit: 36.2
Platelets: 115
Lymphocytes: 15%
The WBC value is high indicating signs of inflammation and stress. Hemoglobin level is slightly
below the normal range. Hematocrit value is also in normal range.
His blood sugar result was 7.5% indicating he is diabetic.

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ECG result: No abnormalities found in ECG result. All the wave patterns are normal.
Nursing goals:
Based on the assessments results, the following nursing goals are important for recovery
of Mr. John:
 To promote airway clearance and improve ineffective breathing pattern
 To address high blood pressure and promote activity tolerance
 To reduce pain and risk for deficient fluid volume.
Nursing interventions:
 Assesses the patient for changes in rate and depth of respiration, use of accessory muscles
and changes in breath sounds. This was necessary because of wheezing and inspiratory
crackles which indicate decreased airflow in areas with consolidated fluid (Ochoa et al.
2018).
 Patient’s head of bed was elevated and change in position was done to promote chest
expansion and expectoration of secretions.
 To reduce discomfort due to breathing difficulty, Mr. John was assisted with deep-
breathing exercise and method of effective coughing. Deep breathing exercise facilitates
lung expansion and improves productivity of cough. In case of increase in hypoxemia,
suction was also done occasionally to address airway obstruction and mechanically clear
airway of patient.
 Drug therapy with the use of analgesic and bronchodilator treatment initiated to promote
respiration and control the progression of the disease (Yamauchi et al. 2016).

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 Supplemental oxygen provided post admission to provide relief from breathing difficulty
and treat hypoxemia. Oxygen therapy is a common treatment for patient with lung
disease. It can reduce risk of death and shorten length of hospital stay (Marti and
Esperatti 2016).
 Made changes in room temperature in response to fever and signs of sweating. This was
necessary to regulate temperature of the patient
 Antipyretic medication was given to treat fever and hypertensive medications were
reviewed with physicians to identify need for changing the medication
 Made changes in diet to reduce blood pressure
Evaluation:
The A-E assessment was useful in identifying impairment in vital signs. The abnormal
parameters that were observed in Mr. John included increased pulse rate, low oxygen saturation
level, high blood pressure and increased heart rate. Chest x-ray further confirmed that Mr. John
is suffering from pneumonia. After the implementation of the nursing interventions, patient was
found to breathe normally and difficulty during breathing was minimized. Symptoms of fever
and slight chest pain were relieved. Airway obstruction was minimized by suction and deep
breathing exercise. It became easier for patient to extract out sputum. Activity tolerance
increases as patient was able to sit up and do normal activities. Any risk of clinical deterioration
was managed by initiation of pharmacological treatment for pneumonia and blood pressure.

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References:
Fouzas, S., Anthracopoulos, M.B. and Bohadana, A., 2018. Clinical Usefulness of Breath
Sounds. In Breath Sounds (pp. 33-52). Springer, Cham.
Hoffmann, F., Schmalhofer, M., Lehner, M., Zimatschek, S., Grote, V. and Reiter, K., 2016.
Comparison of the AVPU Scale and the Pediatric GCS in Prehospital Setting. Prehospital
emergency care, 20(4), pp.493-498.
Marti, A.T. and Esperatti, E.M., 2016. Community-acquired pneumonia. In Respiratory
infections (pp. 110-128). CRC Press.
Miller, R.A. and Miller, T.N., 2016. Pneumonia, Aspiration. Encyclopedia of Pathology, pp.1-3.
Ochoa, A., Ji, W., Smith, C., Rhee, C. and Klompas, M., 2018, November. 722. Normal Clinical
Signs and Duration of Antibiotics in Hospitalized Patients with Pneumonia. In Open Forum
Infectious Diseases (Vol. 5, No. Suppl 1, p. S259). Oxford University Press.
Resuscitation Council UK. 2014. The ABCDE approach. Retrieved from:
https://www.resus.org.uk/resuscitation-guidelines/abcde-approach/
Thim, T., Krarup, N.H.V., Grove, E.L., Rohde, C.V. and Løfgren, B., 2012. Initial assessment
and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE)
approach. International journal of general medicine, 5, p.117.
Yamauchi, Y., Yasunaga, H., Hasegawa, W., Takeshima, H., Sakamoto, Y., Jo, T., Matsui, H.
and Nagase, T., 2016. Out-patient combination therapy with inhaled corticosteroids and

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bronchodilators is associated with lower in-hospital mortality in pneumonia in patient with
COPD.