Respiratory Part 1: Preliminary Stats

Client Observation

• Visual and Auditory Inspection

  • Respiratory assessment involves checking:

    • Respiratory rate (RR)

    • Rhythm

    • Depth

    • Effort of breathing

  • Observe for physical signs:

    • Sweating

    • Strained facial expressions

    • Noises during breathing (wheezing, stridor)

Position of Breathing

• Client Settling

  • Observe comfort in breathing position; some find:

    • Leaning forward while seated (grabbing knees/pillows) assists with breathing.

• Expected Findings:

  • Relaxed posture (sitting or standing) when respirations are normal.

  • Occasional sighing aids alveolar expansion.

• Thoracic vs. Diaphragmatic Breathing:

  • Thoracic: chest movements; more common in females.

  • Diaphragmatic: abdominal movements; more common in males.

Unexpected Findings

• Distressed Positioning:

  • Clients with COPD may assume tripod position:

    • Body leaning forward, hands on knees/table to aid in expiration.

    • Engaging abdominal, intercostal, and neck muscles; difficulty speaking.

  • Muscle Retractions:

    • Intercostal and accessory muscles may retract during difficult breaths.

  • Diaphragmatic Breathing:

    • Involves extra energy and oxygen use, leading to distress.

Assessment of Level of Consciousness

• Importance of Observation:

  • Evaluate for decreased oxygenation or hypoxia.

  • Assess by asking questions regarding condition and medical history.

• Expected Findings:

  • Client appears relaxed and comfortable.

• Unexpected Findings:

  • Anxious, agitated, or confused client, indicating hypoxia.

Assessment of Skin and Extremities

• Skin Color Check:

  • Lighter skin: pinkish hue on cheeks/nail beds.

  • Darker skin: look for color changes in oral mucosa/nail beds.

• Cyanosis:

  • Occurs in respiratory distress; cool, damp skin; blue lips/nail beds—indicating late hypoxemia.

  • Different presentations for darker skin tones (ashen/dusky bluish appearance).

• Clubbing:

  • Round/boon-ended fingers or toes signal long-term hypoxia.

Measuring Respiratory Rate and Quality

• Assessment of Breathing:

  • Expected RR: 12-20 breaths/min.

• Observable Signs:

  • Smooth, even, silent breathing without accessory muscle use.

• Factors Influencing Rate:

  • Anxiety can increase RR to >20.

  • Sedation/injury can decrease RR.

Pulse Oximetry Check

• Purpose of Monitoring:

  • Oximeters measure hemoglobin oxygen content.

  • Expected value: ≥95%.

  • <90% is an emergency and requires immediate nursing intervention.

• Check Conditions for Reliability:

  • Note unreliability in hypothermia, cardiac arrest, shock, or vascular disease.

Hyperventilation Assessment

• Definition:

  • Hyperventilation: breathing faster and deeper than necessary.

  • Results in hypocarbia and respiratory alkalosis.

• Symptoms:

  • Numbness/tingling, heart palpitations, lightheadedness, potential unconsciousness.

Nursing Actions for Hyperventilation

• Primary Role:

  • Ensure safety by providing a calming environment and positioning.

  • Assist in slowing breathing:

    • Maintain eye contact, focus on voice.

    • Instruct to breathe in through the nose and out through the mouth.

• Rebreathing Technique:

  • Utilize paper bags to promote carbon dioxide re-inhalation.

• Identify and Treat Causes:

  • Investigate potential non-respiratory causes (e.g., pain, anxiety).

Notification and Follow-Up

• Inform Provider:

  • Use SPA format to update on client condition and interventions taken.

• Post-Intervention Reassessment:

  • Recheck respiratory status following actions.

  • Count respirations, assess rhythm/depth, measure oxygen saturation.

  • Document any multidisciplinary involvement in care.