Assessing an individuals ability to breathe

Assessing an individuals ability to breathe - Remember that assessment of breathing is only part of a holistic nursing assessment and should not be undertaken in isolation without reference to or consideration of the client’s other activities of living.

The specific points to be considered when assessing an individual’s breathing include:

• Physical
Respiratory rate
depth
sounds
pattern/rhythm
Presence of cough
productive
unproductive
Sputum
colour
consistency
amount
smell

Degree of effort, use of accessory muscles (e.g. shoulders/neck) Nasal flaring, which is usually a sign of increased effort, particularly in infants Sternal recession, the sinking in of sternum during inspiration, particularly in infants Tracheal tug, the sinking in of the soft tissues above the sternum and between the clavicles during inspiration, particularly in infants Intercostal recession, the sinking in of the soft tissues between the ribs during inspiration

Facial expressions
Colour of skin/mucous membranes – mottling, pallor, cyanosis
Presence of scars
Shape of thorax, symmetry of movement
Evidence of external/internal injury
Position adopted by client and influence of body position on breathing
Pain related to inspiration/expiration/movement
Breathes through mouth and/or nose
Clubbing of finger ends

Head bobbing, that is, forward movement of head on inspiration in a sleeping or exhausted infant is a sign of breathing difficulty Status of hypoxic drive, that is, is the client retaining carbon dioxide?

• Psychological
Stress
Anxiety
Depression
Hysteria
Irritability
Confusion

• Sociocultural
Level of support from family/external agencies
Smoking
Health beliefs/values
Hobbies/pastimes
Level of family support

• Environmental
Pollution, such as dust mites and pollen
Cold, damp or foggy weather
Type of accommodation
Stairs to climb
Work related

• Politico-economic
Limited finances
Employed/unemployed
Poor heating
Poor diet

• Past history
Past illnesses related/unrelated
Recent holiday abroad
Family difficulties
Powers of recovery
Knowledge of condition