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NRS 310: HEALTH ASSESSMENT Lecture 5 Fall 2013 Karrie Hendrickson PhD, RN 1.

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Presentation on theme: "NRS 310: HEALTH ASSESSMENT Lecture 5 Fall 2013 Karrie Hendrickson PhD, RN 1."— Presentation transcript:

1 NRS 310: HEALTH ASSESSMENT Lecture 5 Fall 2013 Karrie Hendrickson PhD, RN 1

2 CHAPTER 11 Lungs and Respiratory System Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

3 Concept Overview: Oxygenation Processes that facilitate and impair oxygenation. Adequate perfusion is necessary to deliver oxygenated blood to tissues and remove metabolic waste. Intracranial regulation supports oxygenation. Adequate oxygenation needed to support intracranial function. Interrelationship necessary. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 3 Oxygenation Motion Tissue Integrity Nutrition Sleep Perfusion Intracranial Regulation Metabolism

4 Anatomy and Physiology Respiratory system supplies oxygen to cells and removes carbon dioxide using processes of ventilation and diffusion: Ventilation is the process of moving gases in and out of lungs by inspiration and expiration. Diffusion is the process by which oxygen and carbon dioxide move from areas of high concentration to areas of lower concentration. After inspiration, concentration of oxygen is higher in alveoli than in pulmonary capillaries, causing oxygen to diffuse across alveolar-capillary membrane, then carried by erythrocytes to cells. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 4

5 A&P At cellular level, oxygen diffuses into cells, and carbon dioxide diffuses from cells into capillaries, where it is carried by erythrocytes to alveoli. Carbon dioxide diffuses from pulmonary capillaries to alveoli and is exhaled. Cardiovascular system provides transportation of oxygen and carbon dioxide between alveoli and cells. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 5

6 Structures in the Thorax: Mediastinum Three main structures within thorax or chest: Mediastinum and right and left pleural cavities. Mediastinum positioned in middle of chest. Within it are: Heart Arch of aorta Superior vena cava Lower esophagus Lower part of trachea Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 6

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9 Structures in the Thorax: Pleural Cavities  Pleural cavities contain lungs.  These cavities lined with two types of serous membranes:  Parietal pleura  Visceral pleura  Chest wall and diaphragm are protected by parietal pleura, and lungs are protected by visceral pleura.  Small amount of fluid lubricates space between pleurae to reduce friction as lungs move during inspiration and expiration. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 9

10 Structures in the Thorax: The Lungs Right lung has three lobes and left has two. Each lobe has a major, oblique fissure dividing upper and lower portions. However, right lung has a lesser horizontal fissure dividing upper lung into upper and middle lobes. Each lung extends anteriorly about 1.5 inches above first rib into base of neck in adults. Posteriorly, lungs’ apices rise to level of T1 (first thoracic vertebrae); lower borders expand down to T12 and, on expiration, rise to T9. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 10

11 External Thorax Thoracic cage protects most of respiratory system and consists of: 12 thoracic vertebrae 12 pair of ribs Sternum Ribs connect to thoracic vertebrae posteriorly: First seven ribs also connected to sternum by costal cartilages. Costal cartilages of eighth to tenth ribs are connected immediately superior to ribs. Eleventh and twelfth ribs are unattached anteriorly, thus the name “floating ribs.” 11

12 External Thorax  Sternum is about 7 inches long and has three components:  Manubrium  Body  Xiphoid process  Manubrium and body articulate with first seven ribs; manubrium also supports clavicle.  Intercostal) is the area between ribs. space (ICS  ICS named according to rib immediately above it; thus, first ICS is located between first and second ribs. 12

13 Mechanics of Breathing  Diaphragm and intercostal muscles are primary muscles of inspiration.  During inspiration, diaphragm contracts and pushes abdominal contents down, while intercostal muscles push chest wall outward.  Combined efforts decrease intrathoracic pressure, creating negative pressure within lungs.  During expiration, muscles relax, expelling air as intrathoracic pressure rises. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 13

14 Mechanics of Breathing Accessory muscles contributing to respiratory effort include:  Anterior: Sternocleidomastoid Scalenus Pectoralis minor Serratus anterior Rectus abdominus  Posterior: Serratus posterior superior Transverse thoracic Serratus posterior inferior Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 14

15 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 15

16 Mechanics of Breathing  During inspiration, air is drawn through mouth or nose and passes through pharynx and larynx to reach trachea.  Nose, pharynx, larynx, and intrathoracic trachea make up upper airway.  Three functions of upper airway:  Conducts air to lower airway.  Protects lower airway from foreign matter.  Warms, filters, and humidifies inspired air. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 16

17 Upper Airway Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 17

18 Mechanics of Breathing Lower airway consists of: Trachea Right and left main stem bronchi Segmental and subsegmental bronchi Terminal bronchioles Bronchi are further subdivided into increasingly smaller bronchioles. Bronchioles open into alveolar ducts and terminate in multiple alveoli, where gas exchanges occur. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 18

19 Lower Airway Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 19

20 Topographic Markers: Anterior Chest Wall Nipples Suprasternal notch: Depression at ventral aspect of neck, just above manubrium. Manubriosternal junction (angle of Louis): Junction between manubrium and sternum; useful for rib identification. Midsternal line: Imaginary vertical line through middle of sternum. Costal angle: Intersection of costal margins, usually no more than 90 degrees. Clavicles: Bones extending out both sides of manubrium to shoulder; they cover first ribs. Midclavicular lines: MCL Imaginary vertical lines on right and left sides of chest that are “drawn” through clavicle midpoints, parallel to midsternal line Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 20

21 Topographic Markers: Lateral Chest Wall Anterior axillary lines: Imaginary vertical lines on right and left sides of chest “drawn” from anterior axillary folds through anterolateral chest, parallel to midsternal line. Posterior axillary lines: Imaginary vertical lines on right and left sides of chest “drawn” from posterior axillary folds along posterolateral thoracic wall with abducted lateral arm. Midaxillary lines: Imaginary vertical lines on right and left sides of chest “drawn” from axillary apices; midway between and parallel to anterior and posterior axillary lines. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 21

22 Topographic Markers: Posterior Chest Wall Vertebra prominens: Spinous process of C7; visible and palpable with head bent forward. Vertebral line: Imaginary vertical line “drawn” along posterior vertebral spinous processes. Scapular lines: Imaginary vertical lines on right and left sides of chest “drawn” parallel to midspinal line; pass through inferior angles of scapulae in upright patient with arms at sides. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 22

23 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 23

24 ASSESSMENT QUESTIONS Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 24

25 General Health History: Present Health Status Do you have any chronic illnesses? Do you have allergies? Do you have difficulty breathing during daily activities? Do you have difficulty breathing when you sleep? In what position do you sleep? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 25

26 General Health History: Present Health Status Are you currently taking any oral medications for a respiratory disorder? If so, what are you taking, and how effective have they been? Do you use an inhaler? What medication is in inhaler? What is the purpose? How often? Do you use oxygen at home? Does oxygen relieve symptoms? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 26

27 General Health History: Past Medical History  Have you ever had problems with your lungs?  Have you been diagnosed with respiratory diseases such as the following:  Asthma  Bronchitis  Bronchiectasis  Emphysema  Lung cancer  Tuberculosis  Pneumonia  Have you ever had an injury to your chest? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 27

28 General Health History: Personal and Psychosocial History Do you smoke? Have you smoked in the past? How often do (did) you smoke? Have you ever tried to quit? Why do you think you were unsuccessful? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 28

29 General Health History: Family History Is there a family history of lung disease? Tuberculosis Cancer Cystic fibrosis Emphysema Asthma Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 29

30 General Health History: Home Environment Are there environmental conditions that may affect your breathing at home? Air pollution Possible allergens in home, such as pets. Type of heating or air conditioning, including air filtering system. Hobbies: woodworking, plants, metal work. Exposure to smoking of others in home. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 30

31 General Health History: Occupational Environment Where do you work? Factory Outdoors In heavy traffic Are you frequently exposed to any allergens? If you are exposed to irritants, do you wear a mask or respirator mask? Does work area have special ventilation to clear pollutants? Do you wear monitor to evaluate exposure? Do you have periodic health examinations, pulmonary tests, or radiographic examinations? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 31

32 General Health History: Travel Have you recently traveled to foreign countries or areas of the United States where you may have been exposed to uncommon respiratory diseases? Examples: Histoplasmosis in Southeast and Midwest US Schistosomiasis or severe acute respiratory syndrome [SARS] in Southwest Asia, Caribbean, and Asia? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 32

33 Problem-Based History Commonly reported problems related to lungs are cough, shortness of breath, and chest pain with breathing. A symptom analysis is completed, which includes: Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 33

34 Problem-Based History: Cough When did you first notice cough? Is cough constant, or does it come and go? Has cough changed since you first noticed it? Describe your cough. Is it dry? Productive? Hacking? Hoarse? How often are you coughing up sputum (all of the time or just periodically)? What is color of sputum? Consistency of sputum (thick, thin, frothy)? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 34

35 Problem-Based History: Cough  Have you noticed if sputum has an odor?  Have you noticed other symptoms:  Shortness of breath?  Chest pain or tightness with breathing?  Hoarseness?  Gagging?  Does coughing tire you out?  Keep you awake at night?  Have you done anything to treat cough such as medications, fluids, or vaporizer? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 35

36 Problem-Based History: Shortness of Breath  How long have you had shortness of breath?  Short of breath all the time, or does it come and go?  Describe your shortness of breath:  Harder to inhale or exhale or difficulty with both?  Do symptoms interfere with your activities?  Does anything seem to trigger episodes or make shortness of breath worse?  If it occurs at night, in what position do you sleep?  How many pillows do you use?  Does changing your position affect problem?  Have you noticed any other problems when you are short of breath?  What do you do to relieve symptoms? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 36

37 Problem-Based History: Chest Pain with Breathing How long have you had pain in chest with breathing? When did this start? Does pain radiate to other areas such as neck or arms? What does pain feel like (viselike, tight, sharp, burning)? When it started, was pain associated with injury to ribs or respiratory infection? Pain worse with deep inspiration? Does pain interfere with getting enough air? Pain Scale: 0-10 Is there anything that makes pain worse, such as movement or coughing? Have you done anything to treat pain, such as heat, splinting, or pain medication? Have any measures been effective? Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 37

38 Physical Examination 38

39 Physical Exam: Respiratory System INSPECT General appearance, posture, breathing effort Observe respirations Nails, skin, lips Anterior and posterior thorax AUSCULTATE Anterior, Posterior, and Lateral thorax Sometimes vocal resonance PALPATE Trachea, thoracic muscles, expansion of thoracic wall Tactile fremitus PERCUSS For tone and diaphragmatic excursion Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 39

40 INSPECT General appearance, posture, breathing effort Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 40

41 INSPECT Observe respirations Rate, breathing pattern, and chest expansion Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 41

42 INSPECT Nails, skin, and lips for color. 42

43 Examination: Posterior Thorax Inspect posterior thorax for shape and symmetry, and muscle development. Auscultate posterior and lateral thorax for breath sounds. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 43

44 Examination: Anterior Thorax Inspect anterior thorax for shape and symmetry, muscle development, anteroposterior diameter to lateral diameter, and costal angle. Auscultate anterior thorax for breath sounds. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 44

45 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 45

46 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 46

47 Adventitious Breath Sounds Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 47

48 Examination: Advanced Practice and Special Circumstances Posterior thorax: Palpate posterior thoracic muscles for tenderness, bulges, and symmetry. Palpate posterior chest wall for thoracic expansion. Palpate posterior thorax wall for vocal (tactile) fremitus. Percuss posterior and lateral thorax for tone. Percuss thorax for diaphragmatic (respiratory) excursion. Auscultate thorax for vocal sounds (vocal resonance). Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 48

49 Examination: Advanced Practice and Special Circumstances Anterior thorax: Palpate trachea for position. Palpate anterior thoracic muscles for tenderness, bulges, and symmetry. Palpate anterior chest wall for thoracic expansion. Palpate the anterior thorax wall for vocal (tactile) fremitus. Percuss anterior thorax for tone. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 49

50 Age-Related Variations: Infants, Children, and Adolescents Assessing respiratory status of infants, children, or adolescents follows sequence as for adult—there are differences worth noting: Infants must be undressed to diaper for exam. Keep infant covered when not examining to prevent exposure and cooling. Conduct exam while infant is calm; exam of a crying infant is difficult. By ages of 2 or 3 years, child is usually cooperative. Prior to that age, you need to develop a relationship with child to improve cooperation. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 50

51 Age-Related Variations: Older Adults Assessing respiratory status of older adults usually follows same procedures as other adults, although there are may be structural and functional differences noted: Posterior thoracic stooping or bending or kyphosis may alter thorax wall configuration and make thoracic expansion more difficult. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 51

52 Common Problems and Conditions: Infections and Inflammatory Conditions – Acute Bronchitis Acute bronchitis is inflammation of mucous membranes of bronchial tree caused by viruses or bacteria. Clinical findings: Cough initially nonproductive but may become productive after few days. Patients may complain of substernal chest pain aggravated by coughing. Other clinical manifestations include fever, malaise, and tachypnea. Rhonchi and crackles frequently heard on auscultation, with wheezing heard after coughing. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 52

53 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 53

54 Common Problems and Conditions: Infections and Inflammatory Conditions – Pneumonia Pneumonia is inflammation of terminal bronchioles and alveoli; may be caused by bacteria, fungi, viruses, mycoplasma, or aspiration of gastric secretions. Clinical findings: Viral pneumonia tends to produce a nonproductive cough or clear sputum. Bacterial pneumonia, however, causes productive cough that may produce white, yellow, or green sputum. Other clinical findings associated with pneumonia include fever, tachypnea, and dyspnea. Crackles and wheezes may be heard on auscultation of the lungs. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 54

55 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 55

56 Common Problems and Conditions: Infections and Inflammatory Conditions – Tuberculosis Tuberculosis is a contagious, bacterial infection caused by Mycobacterium tuberculosis. Primarily in lungs, but kidney, bone, lymph node, and meninges can also be involved. Clinical findings: Patient usually asymptomatic in early stages of disease; initial clinical manifestations consist of fatigue, anorexia, weight loss, fever. Characteristic finding later in disease is cough that becomes increasingly frequent, producing a mucopurulent sputum. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 56

57 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 57

58 Common Problems and Conditions: Infections and Inflammatory Conditions – Pleural Effusion Pleural effusion is accumulation of serous fluid in pleural space between visceral and parietal pleurae. Clinical findings: Degree of manifestation depends on amount of fluid accumulation and position of patient. If effusion occurs rapidly and if it is large, there may be dyspnea, intercostal bulging, or decreased chest wall movement. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 58

59 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 59

60 Common Problems and Conditions: Asthma  Asthma is hyperreactive airway disease characterized by:  Bronchoconstriction  Airway obstruction  Inflammation.  Asthma occurs in response to:  Allergens or pollutants  Infection  Cold air  Vigorous exercise  Emotional stress Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 60

61 Common Problems and Conditions: Asthma  Clinical findings signs include:  Increased respiratory rate with prolonged expiration  Audible wheeze  Dyspnea  Tachycardia  Anxious appearance  Possible use of accessory muscles  Cough  Prolonged expiration, expiratory and occasionally inspiratory wheeze, and diminished breath sounds are common findings with auscultation. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 61

62 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 62

63 Common Problems and Conditions: Chronic Pulmonary Disease – COPD & Emphysema Emphysema is destruction of alveolar walls that causes permanent abnormal enlargement of air spaces. Clinical findings: Classic appearance of a patient with advanced emphysema is underweight with barrel chest and short of breath with minimal exertion. Other findings reveal diminished breath and voice sounds, possible wheezing or crackles on auscultation, and decreased diaphragmatic excursion on percussion. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 63

64 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 64

65 Common Problems and Conditions: Chronic Pulmonary Disease – Chronic Bronchitis Chronic bronchitis characterized by hypersecretion of mucus by goblet cells of trachea and bronchi resulting in productive cough for 3 months in each of 2 successive years. Caused by irritants such as cigarette smoke and air pollution or by infection. Clinical findings: Chronic bronchitis Symptoms are productive cough, increased mucus production, and dyspnea. Findings on auscultation are rhonchi, sometimes cleared by coughing. When sufficient mucus occludes alveoli, crackles may be heard. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 65

66 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 66

67 Common Problems and Conditions: Acute or Traumatic Conditions – Pneumothorax Pneumothorax results from air in pleural spaces. Three types of pneumothorax: Closed: May be spontaneous, traumatic, or iatrogenic. Open: Occurs following penetration of chest by either injury or surgical procedure. Tension: Develops when air leaks into pleura and cannot escape. Clinical findings: Pneumothorax Signs vary, depending on amount of lung collapse. With minor collapse, patient may be slightly short of breath, anxious, and have chest pain. With large amount of lung collapse, patient may be in severe respiratory distress, including dyspnea, tachypnea, and cyanosis. Decreased chest wall movement on affected side; may also have paradoxic chest wall movement. If severe, may be tracheal displacement toward unaffected side with a mediastinal shift. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 67

68 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 68

69 Common Problems and Conditions: Acute or Traumatic Conditions – Hemothorax Hemothorax results from blood in pleural space caused by injury to the chest but also may be complication of thoracic surgery. Clinical findings: Signs are similar to those described for pneumothorax, although it is common to note distant muffled breath sounds and dullness with percussion over affected area. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 69

70 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 70

71 Common Problems and Conditions: Other Pulmonary Conditions – Atelectasis Atelectasis refers to collapsed alveoli caused by external pressure from tumor, fluid, or air in pleural space (compression atelectasis) or by removal of air from hypoventilation or obstruction by secretions (absorption atelectasis). Clinical findings: Affected lobe has diminished or absent breath sounds. Oxygen saturation may decrease to less than 90%. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 71

72 Common Problems and Conditions: Other Pulmonary Conditions – Lung Cancer Lung cancer is uncontrolled growth of anaplastic cells in lung. Agents such as tobacco smoke, asbestos, ionizing radiation, and other noxious inhalants can be causative agents. Clinical findings: Most common initial symptom reported is a persistent cough. Weight loss, congestion, wheezing, hemoptysis, labored breathing, or dyspnea are other manifestations that occur with advanced disease. Lung sounds may be normal or diminished over affected area; if there is a partial obstruction of airways from tumor, wheezes may be heard. Percussion tones may be normal or may be dull over tumor, particularly if cancer is large or patient has associated atelectasis. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 72

73 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 73

74 Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 74

75 Question 1 Before caring for the patient, the nurse reviews the test results. A chest radiographic report shows that there is atelectasis in the right base. During lung auscultation, what would the nurse expect to find? A. Increased fremitus in the right base. B. Diminished breath sounds. C. Wheezing throughout. D. Symmetrical chest expansion. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 75

76 Question 2 The nurse is caring for a patient who is suffering from chronic obstructive pulmonary disease. He coughs frequently and produces a thick white sputum. During auscultation, the stethoscope should be placed: A. Over the scapula to enhance adventitious lung sounds. B. So that it is barely touching the skin to avoid auditory artifact. C. Over the left lung fields first. D. In one position long enough to hear an entire inhalation- exhalation set. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 76

77 Case Study Sean is a 10-year-old male child who attends a local middle school. He has two siblings in his home. All of his immunizations are up to date. He has a history of eczema and chickenpox. His favorite activities are baseball and basketball. He loves to go to the movies with his best friend, Josh. His father smokes inside the home. Sean has recently had a hospitalization for asthma. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 77

78 Case Study (contd.)  Subjective data:  Complains of increased shortness of breath, especially with exercise.  Mother says he seems to be using the inhaler more.  Mother admits to not having a lot of knowledge regarding inhaler usage.  Objective data:  Vital signs: T 98.0; P 61; R 17. Height: 4 ft 5 in. Weight 85 lb.  Lungs: Clear on auscultation, no wheezing present.  Heart: RRR, no murmurs present. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 78

79 Case Study (contd.) Questions: 1. What risk factors does Sean have for asthma? 2. What measures might help to prevent asthma exacerbation? 3. What should the nurse do in this clinical situation? Prioritize actions. Copyright © 2013 by Mosby, an imprint of Elsevier Inc. 79


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