Focus: Respiratory Assessment
Shift to shift Handover
Introduction Kaylene McCallum is a 64-year-old female admitted under Dr. Tracy Taylor
Situation Kaylene presented as an inpatient to the surgical Ward 4 days ago for a right
knee replacement. Discharge was delayed due to constipation which is now
resolved as a result of the laxatives administered – bowels well open this
Background Kaylene has a history of hypertension, asthma and osteoporosis. She lives
alone with her dog Sam. Nil known allergies. Kaylene receives an annual
zoledronic acid infusion for her osteoporosis and she takes irbesartan for
blood pressure control. She uses a Seretide inhaler daily and salbutamol
PRN to manage her asthma. Appendectomy at 12 years of age.
Assessment Vital observations
Respiratory rate – 20 breaths per minute
Oxygen saturation – 95% on room air
Pulse – 105 bpm, thready and regular
Blood pressure – 105/60 mmHg
Temperature – 37.6°C
Pain – 1/10 at rest
Dressing to right knee remains dry and intact.
Recommendations Remove IVC ready for discharge.
Change dressing to right knee.
Contact her neighbour to arrange transport home once reviewed by
You have arrived for your shift and are looking after Kaylene as part of your patient allocation. A few
hours into your shift you notice she has become short of breath (dyspnoeic), tachypnoeic (RR24) and
has an audible respiratory wheeze.
Relate principles of anatomy, physiology, and
pathophysiology to the collection and
interpretation of data collected during a nursing
Your facilitator explains that Kaylene’s
symptoms indicate an asthma attack. They
explain that primary assessment findings that
support this include:
• use of accessory muscles & tracheal
• dyspnoea & unable to speak in
• oxygen saturation is below 95%
Choose one of the above assessment findings
and explain the pathophysiological changes that
have resulted in this abnormal assessment