13) Respiration Flashcards

1
Q

What is respiration?

A
  • Mechanism the body uses to exchange gases between atmosphere and blood
  • Involves ventilation, diffusion, and perfusion
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2
Q

What is ventilation?

A
  • Movement of gases in and out of the lungs
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3
Q

What is diffusion in respiration?

A
  • Movement of oxygen and carbon dioxide between alveoli and red blood cells
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4
Q

What is perfusion in respiration?

A
  • Distribution of red blood cells to and from pulmonary capillaries
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5
Q

How is ventilation assessed?

A
  • By determining respiratory rate, depth, and rhythm
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6
Q

How are diffusion and perfusion assessed?

A
  • By determining oxygen saturation
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7
Q

How is breathing normally regulated?

A
  • Respiratory center in brainstem regulates involuntary control
  • Adults breathe smoothly 12-20 times per minute
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8
Q

What regulates ventilation?

A
  • Levels of CO2, O2, and hydrogen ion concentration in arterial blood
  • CO2 level is most important factor
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9
Q

How does elevated CO2 affect breathing?

A
  • Causes respiratory control system to increase rate and depth
  • Removes excess CO2 (hypercarbia) by increasing exhalation
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10
Q

How is ventilation controlled in chronic lung disease patients?

A
  • Chemoreceptors become sensitive to low arterial O2 (hypoxemia)
  • Signal brain to increase ventilation rate and depth
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11
Q

Why can high oxygen levels be dangerous for chronic lung disease patients?

A
  • Low arterial O2 provides stimulus to breathe
  • High oxygen removes this stimulus
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12
Q

What is involved in moving the lungs and chest wall during breathing?

A
  • Muscular work
  • Inspiration is an active process
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13
Q

What happens during inspiration?

A
  • Respiratory center sends impulses through phrenic nerve
  • Diaphragm contracts, abdominal organs move down/forward
  • Increases length of chest cavity to move air into lungs
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14
Q

How much does the diaphragm and ribs move during inspiration?

A
  • Diaphragm moves about 1 cm
  • Ribs retract upward 1.2-2.5 cm from midline
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15
Q

What is the tidal volume?

A
  • Amount of air inhaled during a normal, relaxed breath
  • 500 mL
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16
Q

What happens during expiration?

A
  • Diaphragm relaxes
  • Abdominal organs return to original positions
  • Lung and chest wall return to relaxed position
  • A passive process
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17
Q

What is eupnea and what interrupts it?

A
  • Eupnea is normal rate and depth of ventilation
  • Interrupted by sighing (prolonged deeper breath)
  • Sigh expands small airways/alveoli not ventilated normally
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18
Q

How is normal respiration assessed?

A
  • By recognizing normal thoracic and abdominal movements
  • Chest wall gently rises and falls
  • No visible accessory muscle use
  • Abdomen rises and falls slowly with diaphragm
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19
Q

What is required for accurate respiratory assessment?

A
  • Observation and palpation of chest wall movement
  • No special equipment needed, but measurement must not be haphazard
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20
Q

Why is noting sudden changes in respiration character important?

A
  • Respiration is tied to function of numerous body systems
  • All variables need consideration when changes occur
  • Example: Abdominal trauma may injure phrenic nerve affecting diaphragm
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21
Q

How should respiratory rate be assessed during nursing assessment?

A
  • Try not to let patient know you are assessing their respiration
  • Patient may consciously alter rate and depth if aware
  • Best time is immediately after pulse, with hand on wrist over chest/abdomen
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22
Q

What should be considered when assessing respiration?

A
  • Patient’s usual ventilatory rate and pattern
  • Influence of any disease/illness on respiratory function
  • Relationship between respiratory and cardiovascular function
  • Influence of therapies on respiration
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23
Q

What are the objective respiratory measurements?

A
  • Rate of breathing
  • Depth of breathing
  • Rhythm of ventilatory movements
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24
Q

What should the nurse observe when counting respiratory rate?

A
  • Both inspiration and expiration
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25
How does respiratory rate vary?
- Varies with age - Usually decreases with age
26
What is an apnea monitor?
- Respiratory monitoring device - Aids in respiratory assessment - Leads attached to chest wall sense movement - Triggers alarm if no chest movement detected
27
How does exercise affect respiration?
- Increases respiratory rate and depth - To meet body's need for additional oxygen - To rid body of carbon dioxide
28
How does acute pain affect respiration?
- Alters rate and rhythm of respiration - Breathing becomes shallow - Patient inhibits or splints chest wall movement when pain is in chest/abdomen area
29
How does anxiety affect respiration?
- Increases respiratory rate and depth - Due to sympathetic stimulation
30
How does chronic smoking affect respiration?
- Changes pulmonary airways - Results in increased respiratory rate at rest when not smoking
31
How does body position affect respiration?
- Straight, erect posture promotes full chest expansion - Stooped or slumped position impairs ventilatory movement - Lying flat prevents full chest expansion
32
How do medications affect respiration?
- Opioids, anesthetics, sedatives depress rate and depth - Amphetamines and cocaine may increase rate and depth - Bronchodilators slow rate by causing airway dilation
33
How does neurological injury affect respiration?
- Injury to brainstem impairs respiratory center - Alters respiratory rate and rhythm
34
How does hemoglobin function affect respiration?
- In anemia, decreased hemoglobin reduces oxygen-carrying capacity - Results in increased respiratory rate - Increased altitude and blood cell abnormalities also increase rate/depth
35
What should be considered when delegating respiratory assessment?
- Inform UCP about patient's history/risk for abnormal respiratory status - Inform frequency of measurement for that patient - Instruct on abnormalities that should be reported to provider
36
What equipment is needed for assessing respirations?
- Watch with second hand or digital display - Pen and vital sign flow sheet or record form
37
What are the first two steps in assessing respirations?
- Identify patient using two identifiers per facility policy - Determine need to assess respiration based on clinical judgment
38
What conditions increase risk for respiratory alterations?
- Fever, pain, anxiety, chest/abdominal conditions - Chronic lung diseases, chest trauma, infections - Pulmonary issues like edema/emboli, anemia, head injury
39
What signs/symptoms indicate respiratory alterations?
- Cyanosis, restlessness, confusion, labored breathing - Adventitious breath sounds, inability to breathe - Abnormal sputum production
40
What do arterial blood gases measure?
- Blood pH - Partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2) - Arterial oxygen saturation (SaO2) reflecting oxygenation
41
What are normal pulse oximetry (SpO2) values?
- 95-100% is normal - 85-89% may be acceptable for some chronic conditions - <85% is abnormal, often with respiratory changes
42
What do hemoglobin, hematocrit, and RBC count measure?
- Concentration of hemoglobin - Volume of red blood cells - Red blood cell count - All reflect patient's oxygen carrying capacity
43
Why determine previous baseline respiratory rate?
- Enables assessing for changes in patient's condition - Provides comparison for future measurements
44
Why perform hand hygiene before assessing respirations?
- Reduces transmission of microorganisms between patient and nurse
45
For patients with breathing difficulty, what positioning is recommended?
- Position of greatest comfort - Repositioning may increase work of breathing and respiratory rate
46
What patient positioning optimizes respiratory assessment?
- Sitting or semi-fowler's position - Head of bed elevated 45-60 degrees - Chest visible for observing movements
47
Where should nurse's hand be placed for assessing respirations?
- Patient's arm relaxed across abdomen/lower chest - Or nurse's hand over patient's upper abdomen - Allows inconspicuous assessment like pulse
48
How do you accurately determine respiratory rate?
- Observe complete respiratory cycle (one inspiration and expiration)
49
How do you count respiratory cycles?
- Look at second hand of watch - When it reaches a number, start counting cycles as "one", "two", etc. - Respirations occur slower than pulse
50
How long do you count respiratory cycles?
- For regular rhythm, count for 30 seconds and multiply by 2 - For irregular, <12/min, or >20/min, count for 1 full minute
51
How do you assess depth of respirations?
- Observe degree of chest wall movement while counting - Can palpate chest wall excursion or auscultate after counting - Describe as shallow, normal, or deep
52
How do you assess rhythm of respirations?
- Normal is regular and uninterrupted - Sighing is normal, not an abnormal rhythm
53
What is a critical finding requiring reporting?
- Any irregular pattern or period of apnea in an adult - Indicates underlying disease, needs reporting and further assessment
54
What are the final steps?
- Reposition bed linens/gown for patient comfort - Perform hand hygiene - Discuss findings with patient as needed
55
What are interventions for abnormal respiratory rate, depth, rhythm or shortness of breath?
- Observe for related factors like airway obstruction, abnormal breath sounds, cough, restlessness, anxiety - Position patient in supported sitting (semi/high fowler's) unless contraindicated - Provide oxygen as ordered - Remove respiratory irritants from environment like smoke, perfumes
56
How should respiratory assessment findings be documented?
- Record rate and character in nurses' notes or vital sign flowsheet - Indicate oxygen therapy type and amount if used - Document rate in narrative notes after therapies
57
What should be reported regarding respiratory assessment?
- Report abnormal findings to nurse in charge or provider
58
What community factors should be assessed for respiratory issues?
- Environmental factors like secondhand smoke, poor ventilation, gas fumes
59
What is the acceptable respiratory rate range for premature infants?
40-70 breaths per minute
60
What is the acceptable respiratory rate range for infants 0-3 months?
35-55 breaths per minute
61
What is the acceptable respiratory rate range for infants 3-6 months?
30-45 breaths per minute
62
What is the acceptable respiratory rate range for infants 6-12 months?
22-38 breaths per minute
63
What is the acceptable respiratory rate range for children 1-3 years?
22-30 breaths per minute
64
What is the acceptable respiratory rate range for children 3-6 years?
20-24 breaths per minute
65
What is the acceptable respiratory rate range for children 6-12 years?
16-22 breaths per minute
66
What is the acceptable respiratory rate range for ages greater than 12 years?
12-20 breaths per minute
67
What is the acceptable respiratory rate range for adults?
12-20 breaths per minute
68
How is ventilatory depth assessed?
- By observing degree of chest wall movement - Described as deep, normal, or shallow - Deep involves full lung expansion and exhalation - Shallow means little air movement, hard to see
69
How is ventilatory rhythm assessed?
- By observing chest or abdomen movements - Diaphragmatic breathing watched by abdominal movements - Healthy men/children use diaphragmatic breathing - Women tend to use upper chest/thoracic muscles
70
What indicates labored respirations?
- Use of accessory neck muscles - Intercostal retractions during inhalation - Longer exhalation phase if obstructed outflow
71
What are infant respiratory distress signs?
- Nasal flaring - Grunting - Wheezing - Important to look, listen, and feel
72
What is bradypnea?
- Breathing rate is regular but abnormally slow (<12 breaths per minute)
73
What is tachypnea?
- Breathing rate is regular but abnormally rapid (>20 breaths per minute)
74
What is hyperpnea?
- Respirations are labored, increased depth and rate (>20 breaths/min) - Occurs normally during exercise
75
What is apnea?
- Respirations cease for several seconds then resume - Persistent cessation results in respiratory arrest
76
What is hyperventilation?
- Rate and depth of respirations increase - May cause hypocarbia
77
What is hypoventilation?
- Respiratory rate abnormally low - Depth of ventilation may be depressed - May cause hypercarbia
78
What is Cheyne-Stokes respiration?
- Rate and depth irregular - Alternating apnea and hyperventilation - Shallow to deep to apnea pattern
79
What are Kussmaul respirations?
- Abnormally deep, regular, increased rate
80
What is Biot's respiration?
- Abnormally shallow for 2-3 breaths - Followed by irregular apnea periods
81
How is respiratory rhythm assessed in infants/children?
- Infants breathe less regularly - Young children may alternate slow and rapid breathing - Estimate time interval after each cycle
82
How is respiratory diffusion and perfusion evaluated?
- By measuring oxygen saturation of the blood - Blood flows through pulmonary capillaries containing red blood cells - Oxygen diffuses from alveoli into blood and binds to hemoglobin
83
What is SaO2?
- Percentage of hemoglobin bound with oxygen in arteries - Normal range is 95-100% - Affected by factors interfering with ventilation, perfusion, or diffusion
84
What is SvO2?
- Saturation of oxygen in venous blood - Lower than SaO2 as tissues remove oxygen from hemoglobin - Normal value around 70% - Affected by factors increasing tissue oxygen need
85
How does a pulse oximeter measure oxygen saturation?
- Contains a probe with light-emitting diode (LED) and photo detector - LED emits light wavelengths absorbed differently by oxygenated and deoxygenated hemoglobin - Photo detector detects amount of oxygen bound to hemoglobin - Oximeter calculates pulse oxygen saturation (SpO2)
86
Where is the photo detector located in a pulse oximeter?
- In the oximeter probe
87
What types of probes are used and how are they selected?
- Digit probes are spring-loaded to conform to different sizes - Earlobe probes have greater accuracy at lower saturations and resist vasoconstriction - Disposable sensor pads can be used on various sites like nose bridge or infant foot - Appropriate probe selected to reduce measurement error
88
What factors affect the pulse oximeter's ability to measure SpO2?
- Factors affecting light transmission - Factors affecting peripheral arterial pulsations - Controlling these factors allows accurate interpretation of abnormal SpO2
89
What measurements enable assessment of ventilation, diffusion, and perfusion?
- Respiratory rate - Respiratory pattern - Respiratory depth - SpO2 (oxygen saturation)
90
What do respiratory assessment data provide clues about?
- The nature of the patient's health problem
91
What are some nursing diagnoses related to respiratory assessment data?
- Activity intolerance - Ineffective airway clearance - Anxiety - Ineffective breathing pattern - Impaired gas exchange - Acute pain - Ineffective tissue perfusion - Dysfunctional ventilatory weaning response
92
How are nursing interventions determined?
- Based on the identified nursing diagnosis and related factors
93
What are defining characteristics of impaired gas exchange?
- Tachypnea - Changes in respiratory depth - Use of accessory muscles - Cyanosis - Decline in SpO2
94
What may be related factors for impaired gas exchange?
- Lung surgery - History of chronic obstructive lung disease - History of heavy smoking
95
How are patient outcomes evaluated after interventions?
- By reassessing respiratory rate, depth, rhythm, and SpO2