Respiratory Assessments and Interventions - Flashcards

RESPIRATORY SYSTEM: FUNCTION AND ASSESSMENT

The respiratory system serves several essential roles in maintaining life and homeostasis. Its primary functions are to transport oxygen into body tissues and to remove metabolic waste in the form of carbon dioxide (CO2). This gas exchange is crucial for cellular respiration and energy production. The system also helps maintain acid–base balance; CO2 is an acid, so retention of CO2 leads to acidosis (hypoventilation), while blowing off CO2 leads to alkalosis (hyperventilation). Assessing respiratory function involves a combination of history, observation, and objective measurements. Key assessment techniques include inspection of chest rise and fall, interpretation of vital signs related to oxygenation and respirations, capnography, and careful auscultation to identify lung sounds. Ventilation is the mechanical movement of air into and out of the lungs, whereas respiration refers to the gas exchange at the cellular level. Understanding these concepts is essential for recognizing when interventions are needed to optimize oxygen delivery and carbon dioxide removal.

STRUCTURE, FUNCTION, AND ACCESSORY ANATOMY OF THE RESPIRATORY SYSTEM

The respiratory system comprises the lungs, rib cage, cartilage, and intercostal muscles, working together with the intact central nervous system to support breathing. Clinically, assess symmetry of chest rise, palpate for muscle tone, temperature, moisture, tenderness, and any abnormal masses, and listen for lung sounds using auscultation over multiple fields (approximately 10 seconds per field). The airway components include the throat, trachea, bronchi, bronchioles, and the alveoli where gas exchange occurs. The vascular system surrounding the alveoli enables oxygen delivery via hemoglobin in the blood. Effective respiration relies on a patent airway and intact CNS control of ventilation, with symmetric chest expansion and absence of masses or obstruction. A clear understanding of the anatomic pathway from the nasal cavity to the alveoli helps explain where and how obstructions or disease processes disrupt ventilation and gas exchange.

AUTONOMIC VERSUS SOMATIC NERVOUS SYSTEM (RELEVANCE TO RESPIRATORY CARE)

The autonomic nervous system (ANS) is involuntary and regulates internal organ function, including the heart, lungs, and digestive tract. It is part of the peripheral nervous system and controls many reflexive processes, such as blood vessel tone and heart rate, without conscious input. In contrast, the somatic nervous system is voluntary and controls skeletal muscles; while it is connected to the brain and enables deliberate movement, it does not regulate involuntary respiratory functions. This distinction is clinically important when considering reflexive responses to hypoxia or hypercapnia and when planning interventions that may affect autonomic regulation (for example, responses to airway obstruction or during anesthesia).

RESPIRATORY ASSESSMENT: HISTORY, INSPECTION, AUSCULTATION, AND PALPATION

A comprehensive respiratory assessment begins with history and subjective reporting, including symptoms of breathlessness, posture such as tripod positioning, use of accessory muscles, depth and rate of respirations, oxygen saturation, skin color (pink with undertones is normal; pallor, dusky, or cyanotic skin are concerning), level of consciousness (LOC), and signs of hypoxia such as agitation or confusion. Objective assessment includes inspection of work of breathing, posture, and accessory muscle use; measurement of pulse oximetry; observation of skin color and LOC; auscultation of lung sounds across multiple regions using a diaphragm; and palpation for tenderness or masses. The clinician should compare corresponding areas bilaterally for symmetry and use 10-second lung sound checks per field to ensure thorough evaluation. Palpation also assesses chest wall movement and chest expansion to detect asymmetry that might indicate infection, atelectasis, pleural effusion, or pneumothorax.

PEDIATRIC RESPIRATORY COMPROMISE: SIGNS OF DISTRESS AND SCORING

In pediatric patients, signs of respiratory distress are critical to identify early. Common distress indicators include raised respiratory rate, use of accessory muscles, intercostal and subcostal recessions, nasal flaring, head bobbing, and tracheal tugging. A simple respiratory rate scoring system by bpm helps quantify distress: ≤ 20 = 1; 21–25 = 2; 26–30 = 3; > 30 = 4. Nasal flaring and sternocleidomastoid/mastoid muscle use indicate increased work of breathing. Tracheal tugging, cyanosis, and abnormal airway noises are additional important signs. Clinicians should assess oxygen saturations against target ranges (94–98% for most patients; 88–92% for those at risk of hypercapnia) and be prepared to investigate with arterial blood gas analysis, chest X-ray, peak flow measurements, or sputum cultures as indicated.

VITAL SIGNS INTERPRETATION AND OXYGENATION TARGETS

Pulse oximetry in pediatric and adult patients typically targets 95–100% in healthy individuals, while adults commonly have a respiratory rate of 12–20 breaths per minute and pediatric patients may have higher rates (often 30–60 breaths per minute in younger children). Symmetric chest rise and fall are expected during normal breathing. Breathing support considerations include evaluating the need for CPAP or other ventilatory assistance and reviewing medications such as bronchodilators, steroids, or asthma management plans.

RESPIRATORY DISORDERS: COMMON CONDITIONS AND RISK FACTORS

Common respiratory disorders include cystic fibrosis (genetic thick mucus causing airway obstruction and digestive issues), emphysema (alveolar destruction with loss of elasticity, a form of COPD), pneumonia (alveolar edema with infection), asthma (chronic inflammatory airway disease with episodic bronchospasm), and COPD (a group of conditions characterized by obstructed airflow). Risk factors span smoking, occupational exposures, air pollution, genetic factors, malnutrition, sleep apnea, and age-related changes. Pneumonia risk factors include older age, chronic illness, exposure to influenza, smoking, aspiration risks, and hospitalization with mechanical ventilation or tracheal devices. COPD management emphasizes airway clearance, oxygen therapy with careful target ranges (often 88–92% for some patients to avoid CO2 narcosis in emphysema), hydration, nutrition, inhaled medications, and patient education.

OXYGEN THERAPY AND DELIVERY SYSTEMS: GOALS, SAFETY, AND SYSTEMS

Goals of oxygen therapy are to improve tissue oxygenation and reduce work of breathing while avoiding oxygen toxicity and CO2 narcosis. Determine sources of oxygen and ensure safety factors (proper storage, handling, and monitoring). Delivery systems are categorized as low-flow or high-flow:

• Low-flow systems deliver variable FiO2 depending on the patient’s inspiratory rate and tidal volume. They include nasal cannula, simple face mask, partial rebreather, and non-rebreather systems. Typical values:
  • Nasal Cannula: 1-6\ \mathrm{L/min}; ~23-42\%\ \mathrm{O_2}.
  • Simple Face Mask: 6-8\ \mathrm{L/min}; ~40-60\%\ \mathrm{O_2} (minimum flow approximately 5 L/min).
  • Venturi Mask: 4-8\ \mathrm{L/min}; ~24-40\%\ \mathrm{O_2} with fixed concentrations via color adapters.
  • Partial Rebreather: 8-11\ \mathrm{L/min}; ~50-75\%\ \mathrm{O_2}; reservoir bag kept ~2/3 full.
  • Non-Rebreather: 12\ \mathrm{L/min}; ~80-100\%\ \mathrm{O_2}; ensure bag remains 2/3 full and does not deflate.
• High-flow systems deliver a stable FiO2 and humidified gas at higher flow rates, which can meet or exceed patient needs; examples include high-flow nasal cannula, ventilators, and oxygen tents.
• Tracheostomy collar or T-piece devices provide 8–10 L/min with FiO2 ranging from 30% to 100% depending on device and tubing setup.
• Oxygen hoods are primarily used for neonates, delivering 8–10 L/min with 30–100% O2, and require monitoring of concentration and patient temperature.
• The Ambu bag (bag-valve-mask) is a manual resuscitation device used to provide positive pressure ventilation at a rate of roughly one squeeze every 5–6 seconds when the patient is not breathing independently.

Practical notes include ensuring patient comfort, monitoring for claustrophobia with masks, and adjusting humidification and hydration to prevent mucosal drying. When using nasal cannula or masks, assess nostril patency and skin integrity, and apply water-soluble jelly as needed every 3–4 hours or provide continuous humidification for comfort and mucociliary function.

NONINVASIVE AND INVASIVE VENTILATION: CPAP, BiPAP, AND ENDOTRACHEAL INTUBATION

Noninvasive positive pressure ventilation includes CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure), which maintain airway patency and support ventilation without an invasive airway. Endotracheal intubation is indicated when airway protection or ventilation cannot be maintained by noninvasive means, indicated by a low Glasgow Coma Scale (GCS) score or inability to maintain adequate oxygenation or ventilation. Invasive ventilation settings typically include PEEP (positive end-expiratory pressure), tidal volume, FiO2, respiratory rate, and alarm limits. Readiness for weaning from oxygen support involves assessing improved oxygenation and respiratory mechanics.

TRACHEOSTOMY CARE: INDICATIONS, SAFETY, AND ROUTINES

A tracheostomy is a surgical airway created through the anterior neck to secure a direct airway into the trachea. Indications include facial trauma, chronic ventilation needs, and certain cancers. A cuff may be present to prevent aspiration, and inflation is managed during continuous ventilation, during meals, and with tube feedings to protect the airway. Recommended cuff pressures should be less than approximately 25\ \mathrm{cm\ H_2O} to prevent tracheal erosion. Because a tracheostomy renders speech impossible, provide written communication aids or a pointing system. At the bedside, ensure equal or smaller cannula at all times and have emergency oxygen (Ambu-bag) ready. Tracheostomy care should be performed every 8 hours or as needed with sterile technique, hyperoxygenation prior to care, and deep breathing exercises to prevent complications.

TRACHEOSTOMY CARE: DETAILED PROCEDURAL STEPS

Key steps include pre-suction with insertion cannula, removing old dressings with clean gloves, opening a sterile trach kit, applying sterile gloves, removing and inspecting the inner cannula (disposable vs reusable), flushing and drying, reinserting into the outer cannula, cleaning the stoma site with hydrogen peroxide or sterile saline and drying, replacing ties or Velcro holders (ties should allow about two fingers to fit under them), applying a new sterile dressing, and avoiding cutting gauze. Strict asepsis is essential to reduce infection risk and maintain airway patency.

TRACH CARE: PRINCIPLES AND COMPLICATION PREVENTION

Core principles include maintaining a patent airway, teaching the patient to cover the stoma rather than the mouth when coughing, keeping the dressing and surrounding skin clean and dry, and preventing skin breakdown. Avoid cutting gauze pads for dressings to prevent frayed material entering the tracheostomy. Ties hold the tube in place; do not remove old ties until new ones are secure. The balloon cuff, if present, allows for positive pressure ventilation; monitor to avoid excessive cuff pressure, which can cause tracheal erosion. Use a Q8-hour assessment or as directed for cuff and tube integrity.

CHEST TRAUMA: CONDITIONS, SIGNS, AND NURSING CARE

Chest trauma may involve flail chest (segment moves paradoxically with respiration), pleural effusion (fluid in the pleural space), pneumothorax (air in the pleural space causing lung collapse), and hemothorax (blood in the pleural space). Signs and symptoms include dyspnea, chest pain, decreased or absent breath sounds on the affected side, cyanosis, fever, and hypotension. Nursing care focuses on monitoring for signs of shock, providing oxygen, encouraging coughing, turning, and deep breathing as possible, and preparing for procedures such as thoracentesis or chest tube placement when indicated.

CHEST TUBES AND PLEURAL DRAINAGE SYSTEMS

Chest tubes drain intrapleural fluid or air and are connected to a drainage system with one or more catheters secured by sutures. When caring for chest tubes, fill the water-seal chamber with sterile water to the prescribed level and the suction-control chamber to the ordered suction (commonly around 20\ \mathrm{cm\ H_2O}). The drainage system must remain below the level of insertion and free of kinks. Chest tubes are clamped only momentarily to check for air leaks or to change systems. Monitor for chest tube fluctuations (the water-seal chamber should show regular pulsations when lungs re-expand). Complications include continuous bubbling indicating a air leak, tube dislodgement, or disconnection from the drainage system; in such events, apply occlusive dressing with an open side to accommodate air escape and notify the RN.

PULMONARY SOUNDS AND RESPIRATORY DIAGNOSTICS

Normal lung sounds include vesicular, bronchovesicular, and bronchial sounds, depending on location. Adventitious sounds include crackles (rales), rhonchi, wheezes, and pleural friction rub. Documentation should acknowledge all lung fields bilaterally. Abnormal sounds such as wheezes or crackles can indicate airway narrowing, secretions, or fluid overload. Additional diagnostic tools include:

• Pulmonary Function Tests (PFTs): assess impairment after ensuring no recent smoking and withholding bronchodilators when indicated.
• Arterial Blood Gases (ABG): evaluate tissue oxygenation, CO2 removal, and acid–base balance; collected in heparinized syringes and kept on ice when required.
• Sputum analysis: identify infectious organisms and assist with antibiotic selection; ensure sterile collection and early morning sampling.
• Bronchoscopy: visualize airways and obtain biopsies or remove obstructions; post-procedure NPO until gag reflex returns and monitor for distress.
• Thoracentesis: remove pleural fluid or air; specimen collection and monitoring following the procedure.
• Chest radiography: identify foreign bodies, fluids, infiltrates, or tumors; remove jewelry near the chest and use lead shielding as required.
• Lung biopsy: obtain tissue samples; post-biopsy sterile dressing and imaging follow-up.

BREATHING PATTERNS AND TERMINOLOGY

Breathing patterns describe how ventilation occurs and are important clinically:

• Eupnea: normal breathing.
• Bradypnea: abnormally slow rate (<12/min).
• Tachypnea: rapid rate (>20/min).
• Apnea: absence of spontaneous breathing.
• Dyspnea: subjective difficulty breathing.
• Hyperpnea: deep, increased breathing effort.
• Orthopnea: inability to breathe when supine.
• Cheyne-Stokes: waxing and waning depth with periods of apnea.
• Kussmaul: rapid, deep breathing often associated with metabolic acidosis.
• Paradoxical breathing: chest wall or lung segments move in the opposite direction during respiration.

CAPNOGRAPHY AND VENTILATION MONITORING

Capnography provides a continuous waveform representing the level of CO2 in exhaled air, enabling early detection of respiratory depression or compromise. Normal end-tidal CO2 is 35-45\ \mathrm{mmHg}. Hypoventilation raises PaCO2 (CO2 retention), while hyperventilation lowers it (rapid loss of CO2). Postoperative, sedated, or opioid-exposed patients require close monitoring for capnography trends. A sudden loss of waveform can indicate disconnection or equipment failure; a correctly functioning waveform supports ongoing assessment of ventilation and airway status.

VENTILATION MODALITIES AND WEANING

Noninvasive ventilation includes CPAP and BiPAP, which deliver positive airway pressure via a mask to support ventilation without an invasive airway. Invasive ventilation involves endotracheal intubation with controlled settings (including PEEP, tidal volume, FiO2, and respiratory rate). Weaning strategies require reassessment of oxygenation, lung mechanics, and the patient’s ability to sustain ventilation with less support.

PREVENTIVE CARE AND AGING OF THE RESPIRATORY SYSTEM

Positive aging of the respiratory system emphasizes lifestyle measures to maintain lung health: adequate calcium intake for bone and airway support, regular exercise, proper hydration, immunizations (pneumococcal and influenza), and avoidance of histamine suppressants or sedatives that may depress respiration. Vaccinations and healthy habits help reduce the risk and severity of respiratory infections and complications.

INHALERS, SPACERS, AND ASTHMA MANAGEMENT

Spacer devices paired with inhalers improve medication delivery to the lungs. An accessible spacer increases the proportion of inhaled medication reaching the lower airways. The steps for using inhalers with spacers include removing the cap, shaking the inhaler, exhaling fully, placing the mouthpiece on the spacer, pressing the inhaler to release medication during a slow inhalation, holding the breath for about 10 seconds, and then exhaling slowly. Patients should carry both spacer and inhaler; spacers should be used every time the inhaler is administered. This approach is particularly important for long-term controller medications and rescue inhalers. Education about spacer use improves adherence and effectiveness of asthma therapy.

ALLERGENS AND ANAPHYLACTIC RESPONSES

Allergen exposure can trigger hypersensitivity reactions ranging from mild cutaneous symptoms (pruritus, urticaria, angioedema) to life-threatening anaphylaxis with bronchospasm, hypotension, and rapid progression to cardiac arrest. Early recognition, removal of the allergen, and prompt administration of epinephrine (when indicated) are essential. Hypersensitivity reactions may not occur on first exposure but can occur after sensitization.

NURSING DIAGNOSIS AND RESPONSE: AIRWAY CLEARANCE AND RESPIRATORY SUPPORT

Nursing diagnoses commonly include ineffective airway clearance and impaired skin integrity related to respiratory distress. The fundamental ABCs (Airway, Breathing, Circulation) guide interventions. Nursing treatments include administering supplemental oxygen and preparing suctioning, providing epinephrine in severe anaphylaxis, and supporting vascular and airway function through medication administration and monitoring. In cases of airway obstruction, assess speaking ability and cough effectiveness to gauge the need for immediate interventions such as bronchodilators or airway opening maneuvers.

EMERGENCY RESPIRATORY INTERVENTIONS: OBSTRUCTION AND RESUSCITATION

When a patient experiences airway obstruction, assess ability to speak or cough. In infants, back blows and chest thrusts are used; in children and adults, abdominal thrusts (Heimlich maneuver) are employed until the airway is cleared or the patient becomes unconscious. If unconscious, begin CPR and consider intubation if airway obstruction persists.

PNEUMONIA: CLINICAL FEATURES AND NURSING CARE

Pneumonia is an inflammatory process that causes edema of lung tissue and alveolar infiltration by fluids or pus, leading to hypoxia. Common symptoms include fever, chills, productive cough (rust-colored, green, or whitish/yellow sputum), dyspnea, pleuritic chest pain, tachycardia, crackles or wheezes on auscultation. Nursing care emphasizes frequent vital signs, monitoring breath sounds and oxygenation, encouraging deep breathing and incentive spirometry, and maintaining patient positioning (semi-Fowler) to improve ventilation. Hydration (approximately 3 L/day), airway clearance techniques, and appropriate antibiotic therapy are integral components of pneumonia management.

PNEUMONIA RISK FACTORS: COMMUNITY-ACQUIRED AND HOSPITAL-ACQUIRED

Community-acquired risk factors include older age, chronic illness, exposure to influenza, smoking, and lack of pneumococcal vaccination. Hospital-acquired risk factors include older age with chronic lung disease, aspiration risk, ventilation or tracheal devices, and decreased level of consciousness. Prevention strategies focus on vaccination, infection control, early mobilization, and prompt treatment of respiratory infections.

COPD AND ITS COMPONENTS: EMPHYSEMA, CHRONIC BRONCHITIS, AND PINK PUFFER VS BLUE BLOATER

Chronic Obstructive Pulmonary Disease (COPD) encompasses conditions with obstructed airflow, often due to smoking, occupational exposures, and environmental factors. Emphysema involves alveolar overinflation and destruction; chronic bronchitis features a chronic productive cough and airway inflammation; cystic fibrosis is a genetic mucus-occlusion disorder with respiratory and digestive implications. Nursing care for COPD includes airway clearance strategies, low-flow oxygen targeting around the 88–92% range when indicated to avoid CO2 narcosis, hydration, small frequent meals, and education on inhaled therapies and exposure reduction. Distinct clinical phenotypes include the “pink puffer” (emphysema, CO2 retention, minimal cyanosis) and the “blue bloater” (chronic bronchitis, hypoxemia, hypercapnia). These descriptions guide monitoring and treatment prioritization.

CYSTIC FIBROSIS, ARDS, AND OTHER RESPIRATORY CONDITIONS

Cystic fibrosis is a hereditary exocrine gland disorder causing thick mucus with risk of nutritional deficiencies; chest physiotherapy is commonly recommended to aid mucus clearance. Acute Respiratory Distress Syndrome (ARDS) is a severe lung condition with fluid accumulation, loss of surfactant, and widespread inflammation leading to reduced oxygenation and often requiring ventilation. Management includes supportive oxygenation, careful fluid management, and targeted pharmacologic therapy to address the underlying cause and secondary complications. COVID-19 is described as a viral illness with respiratory involvement; management emphasizes oxygenation, hydration, isolation, and supportive care, with proning and chest physiotherapy as potential adjuncts.

ASTHMA: COMPARISON WITH COPD AND KEY DIFFERENCES

Asthma is a chronic inflammatory disease with episodic attacks of breathlessness, often associated with allergic responses or atopy. Key comparative features between asthma and COPD include age of onset (asthma can occur in childhood or later; COPD typically presents after age ~40), smoking history (more common in COPD; asthma patients may not have a smoking history), and variability of symptoms (asthma shows intermittent symptoms with potential reversibility on bronchodilators, whereas COPD features persistent airflow limitation with limited bronchodilator reversibility). Diagnostic elements include spirometry with bronchodilator responsiveness and assessment of airway hyperresponsiveness.

DISEASE MANAGEMENT: INHALERS, SPACERS, AND NEBULIZER THERAPIES

Effective inhaled therapy relies on proper inhaler technique and spacer use to maximize drug delivery to the lungs. Education should emphasize regular use of spacer with inhalers, carrying rescue and controller medications, and ensuring adherence to therapy. Nebulizers may be used for bronchodilator or mucolytic therapy in selected patients, especially in those who have difficulty with oral inhaler use. Regular training and demonstration of proper technique improve patient outcomes and reduce exacerbations.

PRACTICE QUESTIONS AND REVIEW (EXAM TIPS)

The following questions summarize common knowledge checks:

• Question 1: Oxygen administration—Which equipment regulates the amount of oxygen delivered? Answer: Flow meter (b).
• Question 2: Normal respiratory rate for a newborn—Typically about 30–60 breaths per minute (d). For newborns, a normal rate falls within that higher range.
• Question 3: Depression of respiratory system due to medication—Opioids can depress respiration (b).
• Question 4: Edema with crackles and frothy sputum suggests congestive heart failure (b).
• Question 5: COPD with low-flow oxygen—Likely delivered via nasal cannula or simple mask rather than fixed high-flow systems; answer is typically c) Nasal Cannula or a similar low-flow modality.
• Question 6: Thoracentesis is performed for pleural effusion (a).
• Question 7: To monitor effectiveness of oxygen therapy, use pulse oximetry (c).
• Question 8: Postoperative pneumonia risk—Atelectasis is a key concern (c).
• Question 9: Water-seal chest tube drainage safety—Chest tube should not be disconnected from the drainage system unless clamped; the system must remain intact (a).
• Question 10: Chest-sucking in a child with acute asthma is due to using chest muscles to assist breathing (c).

KEY CONSTANTS, VALUES, AND FORMULAS

• Oxygenation targets:
  • Normal saturation: 94\% - 98\%
  • Hypercapnic risk patients: 88\% - 92\%
• Oxygen delivery device parameters:
  • Nasal Cannula: 1-6\ \mathrm{L/min}; FiO2 ~23-42\%
  • Simple Face Mask: 6-8\ \mathrm{L/min}; FiO2 ~40-60\%
  • Venturi Mask: 4-8\ \mathrm{L/min}; FiO2 ~24-40\%
  • Partial Rebreather: 8-11\ \mathrm{L/min}; FiO2 ~50-75\%
  • Non-Rebreather: 12\ \mathrm{L/min}; FiO2 ~80-100\%; bag ~2/3 full
  • Tracheostomy collar/T-piece: 8-10\ \mathrm{L/min}; FiO2 ~30-100\%
  • Hood (neonates): 8-10\ \mathrm{L/min}; FiO2 ~30-100\%
• Chest tube suction level: 20\ \mathrm{cm\ H_2O} (as ordered)
• End-tidal CO2 range: 35-45\ \mathrm{mmHg}
• GCS (summary): 3-8 Severe; 9-12 Moderate; 13-15 Mild; total range: 3-15
• Normal breathing rate references:
  • Adult: 12-20\ \text{breaths/min}
  • Pediatric: often higher (24-60+ in infants/young children depending on age)
• Arterial blood gas assessment and timing: follow clinical indications; monitor for changes in pH, PaCO2, PaO2 as part of ABG analysis.

ADDITIONAL NOTES AND REMINDERS

• Always tailor oxygen therapy to the patient’s target saturation and CO2 retention risk. Avoid prolonged exposure to high FiO2 in COPD/emphysema unless clinically indicated.
• Ensure airway patency before airway clearance interventions; maintain aseptic technique during suctioning and tracheostomy care; document secretions, tube tolerance, and site condition.
• Use a stepwise approach to respiratory assessment: history and subjective data, then inspection, palpation, auscultation, and selective diagnostic testing when indicated by the clinical picture.
• Encourage patient education and self-management strategies, including inhaler technique, adherence to therapy, vaccination, and lifestyle modifications to improve respiratory health and reduce risk of exacerbations.