Hi, I’m a 1st year nursing student. Below is an exerpt from an
assignment I’ve done which was a practice Nursing Health Assessment
Interview, just a basic assessment (rather than a diagnosis) was
required. Can someone from a nursing/medical background please have a
look and tell me if the language and descriptions under the
respiratory assesment and key issues headings make sense. I know this
falls into the “homework“ definition, but I was hoping that because
I‘ve actually already done it and am only seeking comments from anyone
experienced in this field, it‘s still ok. Thank you very much.

(Please ignore references within the text, I just cut and pasted this
from my original assignment).

Reason for Seeking Care
Client has experienced episodes of shortness of breath, wheezing and
coughing which worsens at night  “probably all of my life”. This is
triggered by activities such as gardening and mowing, with symptoms
occurring about once a year and lasting up to 3 days from onset.
Client consulted a doctor after last episode (10/10/02) and was
prescribed Seretide Accuhaler 250/50 to be taken twice daily for the
first 3 days, once daily for the following 3 days then once every 2nd
day until symptoms ceased, which they did after 2 weeks of treatment.
A chest x-ray was ordered but client does not wish to pursue further
investigation as he is “not concerned”. Client has no past history or
family history of lung diseases such as emphysema, asthma, TB,
bronchitis or pneumonia, nor does he smoke. Client avoids activities
which precipitate these episodes when possible.

Physical Assessment
Respiratory System Assessment   (Reason: Investigation of shortness of
breath, wheeze and cough)
Assessment made with reference to guidelines from Rathe (2000) and
Jarvis (2000: 461-474)

	Inspection
As noted above, rate and rhythm of respirations are within normal
limits. Respirations are not laboured. Expiratory phase is not
prolonged, as described by Rathe (2000). During inspiration there is
no use of accessory neck muscles, as described by Jarvis (2000: 470),
nor does the anterior-posterior diameter of thoracic cage of the
posterior chest increase, as described by Jarvis (2000: 460).

	Palpation
There is no sign of deformity or tenderness as ribs and sternum are
palpated, as described by Rathe (2000). Expansion of both anterior and
posterior chest is symmetric.

	Percussion
Location and quality of percussion notes over the lung fields, as
described by Rathe (2000) and Jarvis (2000: 462, 472) are normal for
both anterior and posterior chest. Diaphragmatic excursion of
posterior chest, as described by Jarvis (2000: 464) is equal
bilaterally and measures approximately 5 cm.

	Auscultation
Breath sounds from anterior and posterior chest exhibit normal
characteristics, as described in Jarvis (2000: {Table 16-1}466, 474).
There is no presence of adventitious sounds, as per Jarvis (2000:
468).

Evaluation of Key Issues

Shortness of Breath and Wheezing
As client has never been assessed for asthma and his reported symptoms
are characteristic of asthma (NAC: 2002a), it would be advisable to
schedule more precise tests such as respiratory function measurement
by a spirometer as per recommendation of NAC (2002b). Although a chest
x-ray is “ … not routinely required” (NAC 2002c), it may aid in
diagnosing other conditions not explained by asthma. Client should
discuss his reluctance to have a chest x-ray with his doctor. Whilst
these symptoms are minimised by avoidance of activities known to cause
them, it is still important to assess client to get a true picture of
his health status. Although the physical exam revealed no signs of
asthma, it cannot be excluded as client was not experiencing symptoms
when examined and as stated by the NAC (2002d) “the absence of
physical signs [do] not exclude a diagnosis of asthma”.

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Request for Question Clarification by kevinmd-ga on 04 Jan 2003 11:04 PST

Hi lisamcm,
Thanks for asking your question.  I'm an internal medicine physician,
and am just wondering if you were requiring any other information. 
Your current answer makes perfect sense to me - the medical
terminology is fine.  Did you want a more detailed diagnostic
evaluation on wheezing?

Thanks,
Kevin, M.D.

---

Clarification of Question by lisamcm-ga on 04 Jan 2003 16:13 PST

Hello Kevin, bcguide and Surgeon!

Thank you all very much for your comments - I do appreciate it and my
question has been answered.

About the "client" terminology, yes, I agree, it does grate on one's
nerves - depersonalises and objectifies people - another goodie is the
word "stake holders" -haven't worked out what it means in the context
of nursing. Actually I was an EN 10 years ago and gave it away when
the litigation issues started, (requiring one to sit at the desk
writing lengthy reports while the poor patients requiring care had to
wait). You should see some of the nursing theory units I have to do
(the terminology is so alien to a normal person and they write a
million words instead of saying "if a person is sick, they need
nursing care" duh - oh for the days of hospital-based training where
you actually got exposed to the patients.

Now, after my rant (sorry, I just feel so passionate about it), once
again, thank you all, and I can't work out how to pay you (as they
were only comments) - can anyone tell me please?
cheers
Lisa

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Request for Question Clarification by kevinmd-ga on 04 Jan 2003 18:00 PST

Hello Lisa,
Glad to be of help.  If you want, I can just answer your question as
posted with perhaps a little blurb on the workup of the wheezing
patient.

Thanks,
Kevin, M.D.

---

Clarification of Question by lisamcm-ga on 04 Jan 2003 19:01 PST

That would be great Kevin, thank you. 
cheers
Lisa

Hello Lisa,
Thanks for asking your question.  You asked the following:
"Can someone from a nursing/medical background please have a look and
tell me if the language and descriptions under the respiratory
assesment and key issues headings make sense."

I am an internal medicine physician, and your assessment makes perfect
sense to me.  There were no problems with the language and
descriptions.  The key issues were appropriately addressed.  I
especially appreciated you addressing that the "client should discuss
his reluctance to have a chest x-ray with his doctor."

As we discussed above, I'll add some insights in the workup of
wheezing.

The following is taken from UptoDate.

Many different conditions located in a variety of anatomic airway
locations can produce airway obstruction and expiratory or inspiratory
wheezing. Asthma is not the most common cause of wheezing.  The
differential diagnosis can be found here:
http://www.cine-med.com/asthma/IssueOne/Issue_One/1.2/1.2.2/1.2.2.1/body_1.2.2.1.html

In evaluating patients with wheezing, it is important to be aware that
"All that wheezes is not asthma; all that wheezes is obstruction."
Furthermore, there is no characteristic of the wheeze of asthma that
reliably distinguishes it from other conditions. In comparison, the
presence of the classic triad of wheeze, cough, and chronic dyspnea is
highly suggestive of asthma; however, patients often present with only
one element of the triad, and asthma is not the most common cause of
any one of these symptoms.

An approach to evaluating wheeze is to localize the site of the
obstruction to large or small intrathoracic airways or to the
extrathoracic airway. This is done using the history, physical
examination, lung function studies, and knowledge of the spectrum of
differential diagnostic possibilities, especially those that have been
shown to be the most common. Pulmonary function testing can be quite
helpful in confirming a diagnosis once the diagnostic possibilities
have been narrowed by history and physical examination.

Asthma should be considered likely when patients present with episodic
wheezing and other symptoms which respond favorably to conventional
asthma medications (eg, inhaled bronchodilators).  The diagnosis of
wheezing conditions other than asthma should be considered when the
initial evaluation suggests their presence or when wheezing does not
respond to conventional asthma medications. Historical findings
suggestive of nonasthma wheezing include a history of postnasal drip,
sore throat, dyspnea on exertion, gastroesophageal reflux, flushing,
or hemoptysis.

Spirometry and flow-volume loops during helium and air breathing can
be used to localize airway obstruction, since they are influenced by
these phenomena. In addition, spirometry repeated after bronchodilator
or systemic corticosteroids may demonstrate the presence of a
substantial component of reversible airways disease consistent with
asthma. On the other hand, bronchoprovocation challenge testing may be
helpful in patients with normal or nearly normal baseline spirometry,
showing clinically significant bronchial hyperresponsiveness
consistent with asthma.

Summary 

The protocol for evaluation of wheeze places great emphasis on
findings during history and physical examination. The following
stepwise approach is recommended unless the patient appears to be in
imminent danger of respiratory failure:

Potential causes should be identified by distinguishing
characteristics in the history and physical examination.

In the absence of distinguishing characteristics, the presence of the
common causes of wheezing should be considered and evaluated.

Pharmacologic bronchodilator therapy should be given in the absence of
any differentiating features.

Less common causes should be evaluated in a physiologically-oriented
manner when common causes do not explain the symptoms and the symptoms
do not respond to asthma therapy. (1)

Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.   

Thanks,       
Kevin, M.D.       
      
Internet search strategy:       
No internet search engine was used in this research. All sources were
from objective, physician-written, peer reviewed sources.     

Links:
Post-Graduate Medicine
http://www.postgradmed.com/issues/2002/08_02/krieger.htm

Bibliography:
1) Irwin, R. Diagnosis of wheezing illnesses other than asthma. 
UptoDate, 2002.

Spot on for my original question .... and I even got more really
useful info than I was expecting. Thanks

sounds like a good assessment to me: the seasonal quality suggests a
specific allergy rather than asthma, grass or pollen based on the
history. So I suppose an inquiry along those lines would be
considered.

PS: I realize the word client has replaced patient everywhere. Don't
change, but if I may rant , I find it really annoying. It's sort of
like a reaction I heard when a child wanted to call her mom by her
name rather than mom: the mom said, everyone in the world can call me
Judy. You're the only one who can call me mom....Patient is somehow
considered demeaning, I suppose. But everyone is a client (especially
people who see the dreaded lawyers). The healthcare provider-patient
relationship is unique and special, and ought not be seen as one
sided. Client conjures some sort of sterile transaction. Patient, to
me, is a special relationship only to be had between doctor or nurse
and the one who comes to them; I hate to see the word lost, and
replaced by such a sterile one. But that's just me.

Rant on surgeon-ga! If an alternate word needs to be used why not
"participant" - as in scientific studies and clinical trials. At least
that promotes that idea that the "client" is part of the health
delivery system. Client disenfranchises the person seeking treatment
much more than patient ever did.

By the way, lisamcm-ga, the assessment looks fine and you've received
a couple of comments verifying that.

In the evaluation I would add that since the episodes seem to be
triggered by exposure to certain environments ("triggered by
activities such as gardening and mowing") and during certain seasons
("symptoms occurring about once a year"), allergic reaction should be
considered. Sounds like this client is allergic to grass and possibly
some flowers. These symptoms are typical of "rose fever" - the
springtime equivalent of "hay fever." Severe allergic reations can
trigger an asthma attack in an otherwise asymptomatic individual.

Good work!

bcguide-ga

Thanks for the tip!

You're welcome - thanks for the great service!!