How much do these different nursing fields make annually? (on average?

Respiratory System Assessment (basic nursing, not medical diagnosis viewpoint)

• 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”.

• Answer:

  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.