NR 557 Week 4 Findings Interpretation Brief Example

Findings Interpretation Brief: Six Findings From a Home Visit Read First Against the Patient's Own Usual Values, Then Against Published Thresholds, and the Direction Each One Pushes the Decision

Student Name

College of Nursing, Chamberlain University

NR 557: Health Assessment for Professional Nursing Practice

Instructor Name

Month Day, Year

Findings Interpretation Brief: Six Findings From a Home Visit Read First Against the Patient's Own Usual Values, Then Against Published Thresholds, and the Direction Each One Pushes the Decision

Findings, Before Any Reading

The findings from the targeted examination of a 78-year-old patient with COPD (chronic obstructive pulmonary disease) alongside heart failure, seen at home for new breathlessness, are listed here without interpretation, with sides and conditions.

Respiratory rate 28 per minute, counted for 60 seconds at rest, seated, about 50 minutes after a rescue inhaler. Saturation by finger probe 88% breathing room air, at rest, clear waveform. Heart rate 104, regular. Seated left-arm pressure 128/74 mmHg. Temperature 38.3 °C oral. Weight 71.8 kg. Right lung base: dull to percussion, increased tactile fremitus, bronchial breath sounds, coarse crackles not clearing with cough. Left lung base: diminished breath sounds, no crackles, resonant. Scattered wheeze in both upper zones. Jugular venous pressure not visible at 45 degrees. Trace ankle edema on both sides. Oriented to person and place, not to day or month; unable to recite the months backward beyond three.

The Person's Own Usual Figures

Before any published threshold, each finding is compared with where this patient normally sits, from six weeks of home health notes and the heart failure clinic record.

Respiratory rate: recorded as 18 to 20 at every previous visit, though those values may have been estimated rather than counted, a common problem in routine charting (Badawy et al., 2017). Even allowing for that, 28 is well above what has been documented.

Oxygen saturation: usually 92% to 93% at rest on room air. A fall to 88% is a drop of four to five points for this patient, more meaningful than the number alone, since some people with COPD live at saturations in the high 80s.

Heart rate: usually 70 to 80 on a beta-blocker. 104 is high for this patient.

Blood pressure: usually 126 to 138 systolic. 128 is within the usual range.

Temperature: usually around 36.6 °C. 38.3 °C is a fever.

Weight: dry weight 71.0 kg. 71.8 kg is within the clinic's tolerance.

Chest: previous notes record diminished breath sounds at both bases and occasional wheeze, never crackles or dullness. The right-sided findings are new.

Mental status: fully oriented and able to recite the months backward at every previous visit. The disorientation is new.

Which Way Each Finding Pushes

There are three candidate explanations: pneumonia on top of COPD, a COPD exacerbation without pneumonia, and a heart failure exacerbation. Each finding is read for which way it pushes.

Right basal dullness, increased fremitus and bronchial breathing: push strongly toward consolidation, and so toward pneumonia. A COPD exacerbation alone would not produce one-sided dullness and bronchial breathing. Heart failure would usually produce bilateral crackles and, if an effusion, dullness with reduced rather than increased fremitus.

Fever: pushes toward infection, either pneumonia or an infective COPD exacerbation, and away from heart failure alone.

Respiratory rate 28 and saturation 88%: push toward a serious illness under any explanation. They do not distinguish the three, but they raise the stakes.

New confusion: pushes toward a systemic illness, such as infection with sepsis, rather than a local chest problem.

Normal jugular pressure, weight near dry weight and unchanged ankle edema: push away from a heart failure exacerbation as the main problem.

Blood pressure within usual range: reassuring, but does not exclude sepsis in its early stages.

Against Published Thresholds

Two widely used scores help place the findings. In the quick sepsis-related organ failure assessment, one point each goes to breathing at 22 or more per minute, a change in mental status and a systolic pressure no higher than 100 mmHg, and a score of two or more outside intensive care identified patients with suspected infection at greater risk of poor outcomes (Seymour et al., 2016). This patient scores two: respiratory rate and altered mentation. In the CURB-65 score for community-acquired pneumonia severity, confusion and age of 65 or older each score one point, and the patient would score at least two, with blood urea unknown at home; a score of two was associated with increased mortality and suggested consideration of hospital-based care (Lim et al., 2003). Neither score was designed for a home health visit, and neither replaces judgment, but both point the same way as the patient's own baseline.

Findings That Could Mislead

Three findings could have misled the interpretation. The first is the normal blood pressure, which could suggest a patient who is coping, when in fact blood pressure often stays normal until late in serious infection. The second is the oxygen saturation of 88%, which could look acceptable for someone with COPD if judged against a general range; against this patient's usual 92% to 93%, it is a clear drop. The third is the patient's own statement that this is a familiar COPD flare. The patient has had flares before, but never with fever, one-sided chest signs or confusion.

Each of these would have pushed toward waiting if taken alone. Reading them against the patient's own baseline, and alongside the counted respiratory rate and the tested confusion, prevents them from carrying more weight than they deserve. An interpretation that lists only the findings that support its conclusion is not an interpretation; this brief lists the misleading ones as well so that the reasoning can be checked.

What the Findings Add Up To

Read against this patient's usual values first and published thresholds second, the findings point to probable right lower lobe pneumonia in an older adult with COPD, with signs of systemic illness: fever, raised heart rate, a respiratory rate well above baseline, oxygen saturation below the patient's usual level and new confusion. A heart failure exacerbation is unlikely to be the main problem. The combination of respiratory rate and confusion, both counted and tested rather than estimated, puts this patient in a higher-risk group that needs medical evaluation today, not at the next scheduled visit. Respiratory rate, often the first sign of deterioration (Cretikos et al., 2008), is the finding that turned a routine visit into an urgent one.

The next decision is how urgent. That depends on weighing the reassuring findings, a normal blood pressure and a patient who says they are fine, against the worrying ones, which is the subject of the red flag analysis.

References

Badawy, J., Nguyen, O. K., Clark, C., Halm, E. A., & Makam, A. N. (2017). Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults. BMJ Quality & Safety, 26(10), 832-836. https://doi.org/10.1136/bmjqs-2017-006671

Cretikos, M. A., Bellomo, R., Hillman, K., Chen, J., Finfer, S., & Flabouris, A. (2008). Respiratory rate: The neglected vital sign. Medical Journal of Australia, 188(11), 657-659. https://doi.org/10.5694/j.1326-5377.2008.tb01825.x

Lim, W. S., van der Eerden, M. M., Laing, R., Boersma, W. G., Karalus, N., Town, G. I., Lewis, S. A., & Macfarlane, J. T. (2003). Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax, 58(5), 377-382. https://doi.org/10.1136/thorax.58.5.377

Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., Rubenfeld, G., Kahn, J. M., Shankar-Hari, M., Singer, M., Deutschman, C. S., Escobar, G. J., & Angus, D. C. (2016). Assessment of clinical criteria for sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 762-774. https://doi.org/10.1001/jama.2016.0288