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Respiratory assessment for nurses

Photo: Respiratory assessment for nurses
No matter what kind of nurse you are – triage, paediatric, emergency, ICU, mental health, etc. – the skills to perform a good respiratory assessment are essential. It is the first step towards identifying if, and how soon, you need a doctor to review your patient, if you need to make a MET call, and what measures you can take to help your patient in the short term.

MET (Medical Emergency Team) call criteria:

First and foremost is to determine if you need to call a code blue/MET call to summon urgent assistance from fellow nurses and doctors. In terms of respiratory assessment, there are just 4 main criteria:

● A threatened or obstructed airway.
● Respiratory rate <8 breaths/min or >36 breaths/min.
● Pulse oximetry saturation <90% despite oxygen administration.
● If you are seriously concerned about the patient.

If any of the above apply, make a MET call.

Back to Basics

If the patient can’t talk, or if you are waiting for the MET team to arrive, it is time to run through the basic life support algorithm: ABCDE. Here are some measures you can take before the MET team arrives.

Airways – is this patent? Check and clear any blockages in the mouth via suction. Nurse the patient onto their side (unless contraindicated) and help to open the airway with a chin lift or jaw thrust.

Breathing – if the patient has low SpO2, give high flow oxygen through a mask to aim for SpO2 >94%.

Circulation – insert 2 large IV cannulae and take blood. Give a fluid bolus if the patient’s blood pressure is low. Perform a 12-lead ECG if the patient has chest pain.

● Disability – do a finger-prick test to assess blood glucose level.

● Exposure – help expose the patient’s body for examination. Remove unnecessary clothes/layers, but keep a blanket on to maintain body warmth and respect the dignity of the patient.

Whilst doing the above, ideally another nurse on the ward should ensure that both the patient’s inpatient folder and medication/observations folder are by the bedside, ready for easy access by the doctors.

Related CPD training: Advanced Life Support 1 – Developed by LearnEM

Less Urgent Cases

If your patient can talk, begin by taking a background:

● Family history: Atopy, COPD, cancer.
● Occupation: Occupational exposure to asbestos and certain mining/farming areas may predispose patients to certain diseases.
● Sick contacts: Are any of your friends/family members sick? Have you travelled anywhere (especially overseas) recently?
● Smoking: Risk factor for lung cancer and COPD. Quantify smoking by the number of “pack-years” (1 pack-year = 20 cigarettes/day for 1 year).
● Past ICU admissions.
● Patient’s medications (amiodarone, beta-blockers and ACE-inhibitors for example can have respiratory side effects).
● Look up any of your patients’ past discharge summaries to check their past medical history and medications.

Questions to ask your patient about their current symptoms:

● Cough: Duration, character, any sputum production (and colour).
● Are you coughing up any blood/is there any blood mixed with your sputum? Coughing up blood (aka haemoptysis) needs to be brought to a doctor’s attention as it may suggest trauma, bleeding in a lung cavity or pulmonary embolism.
● Dyspnoea and change in exercise tolerance: Particularly important in patients with heart failure and COPD.
● Wheezing (especially in patients with asthma or COPD).
● Night sweats, weight loss: May indicate tuberculosis or cancer.
● Chest pain: May indicate a more serious cause of the patient’s respiratory distress such as a heart attack or pulmonary embolism. Perform an ECG if the patient complains of chest pain or palpitations and have it reviewed by a doctor immediately.

The Paediatric Patient

There are certain crucial things you’ll need to ask parents/guardians when they bring in a sick child/baby.

Red flag signs of a sick child:
● Character of the cough (e.g. barking may indicate croup, whooping may be a sign of whooping cough).
● Stridor/the possibility that the child may have swallowed a foreign body.
● Substernal retraction/nasal flaring/tracheal tug – visual signs that a baby/child is struggling to breathe properly.
● Drowsiness/lethargy.
● Decreased intake of milk/food and decreased number of wet nappies.
● A child that is not up to date with vaccinations.

Things to Look for on Examination

Basic Management
● Give them oxygen if they require it, to meet the saturation range the doctor has recommended (usually above 94%).
● Ensure they have easy access to Ventolin puffers if they have asthma or COPD.
● Give them reassurance – it will help if the patient can try to relax.
● Call a MET call and apply ABCDE in an emergency.

• ARC Advanced Life Support Level 1: Immediate Life Support. Third Edition. Australian Edition. Australian Resuscitation Council 2011.
• Oxford Handbook of Clinical Medicine (9 ed.) by Murray Longmore, Ian Wilkinson, Andrew Baldwin, and Elizabeth Wallin. 


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