Pneumonia Q 12

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Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply.

  

     A. Auscultation of breath sounds.

     B. Auscultation of bowel sounds.

     C. Presence of chest pain.

     D. Presence of peripheral edema.

     E. Color of nail beds.

    

Correct Answers: A, C, E.

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A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.

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Option A: The movement of air generates normal breath sounds through the large and small airways. Normal breath sounds have a frequency of approximately 100 Hz. The absence of breath sounds should prompt the health care provider to consider shallow breath, abnormal anatomy or pathologic entities such as airway obstruction, bulla, hyperinflation, pneumothorax, pleural effusion or thickening, and obesity.

Option B: When bowel sounds are not present, one should listen for a full 3 minutes before determining that bowel sounds are, in fact, absent. Auscultation for abdominal bruits is the next phase of abdominal examination. Bruits are “swishing” sounds heard over major arteries during systole or, less commonly, systole and diastole. The area over the aorta, both renal arteries. and the iliac arteries should be examined carefully for bruits.

Option C: In the face of a history of chest discomfort, ask the patient to point to the area(s) of greatest discomfort. Palpate the area with increasing firmness in an attempt to elicit tenderness and to assess if this maneuver reproduces the patient’s symptoms. Pay particular attention to the costochondral junctions in patients reporting anterior chest pain to evaluate the possibility of costochondritis.

Option D: The detailed physical exam can help immensely to differentiate systemic causes such as CHF (common findings are jugular venous distension, dyspnea, bilateral crackles, history of heart disease), liver disease (jaundice, ascites, history of hepatitis, and alcohol use disorder), renal disease (proteinuria, oliguria, history of uncontrolled diabetes and hypertension), thyroid disease (fatigue, anemia, weight gain).

Option E: Active observation skills are used to search for the use of pursed lips during expiration, the activity and development of the sternocleidomastoid muscles, the use of other accessory muscles of ventilation, the presence of shoulder girdle fixation in relation to the use of these accessory muscles, the flaring of the nasal alae, the presence of jugular venous distention, the degree of comfort, and, as discussed in previous chapters, the presence of cyanosis and clubbing.

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