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Nursing 20G - Vital Signs > 13) Respiration > Flashcards

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
Q

How does respiratory rate vary?

A
  • Varies with age
  • Usually decreases with age
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26
Q

What is an apnea monitor?

A
  • Respiratory monitoring device
  • Aids in respiratory assessment
  • Leads attached to chest wall sense movement
  • Triggers alarm if no chest movement detected
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27
Q

How does exercise affect respiration?

A
  • Increases respiratory rate and depth
  • To meet body’s need for additional oxygen
  • To rid body of carbon dioxide
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28
Q

How does acute pain affect respiration?

A
  • Alters rate and rhythm of respiration
  • Breathing becomes shallow
  • Patient inhibits or splints chest wall movement when pain is in chest/abdomen area
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29
Q

How does anxiety affect respiration?

A
  • Increases respiratory rate and depth
  • Due to sympathetic stimulation
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30
Q

How does chronic smoking affect respiration?

A
  • Changes pulmonary airways
  • Results in increased respiratory rate at rest when not smoking
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31
Q

How does body position affect respiration?

A
  • Straight, erect posture promotes full chest expansion
  • Stooped or slumped position impairs ventilatory movement
  • Lying flat prevents full chest expansion
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32
Q

How do medications affect respiration?

A
  • Opioids, anesthetics, sedatives depress rate and depth
  • Amphetamines and cocaine may increase rate and depth
  • Bronchodilators slow rate by causing airway dilation
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33
Q

How does neurological injury affect respiration?

A
  • Injury to brainstem impairs respiratory center
  • Alters respiratory rate and rhythm
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34
Q

How does hemoglobin function affect respiration?

A
  • In anemia, decreased hemoglobin reduces oxygen-carrying capacity
  • Results in increased respiratory rate
  • Increased altitude and blood cell abnormalities also increase rate/depth
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35
Q

What should be considered when delegating respiratory assessment?

A
  • 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
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36
Q

What equipment is needed for assessing respirations?

A
  • Watch with second hand or digital display
  • Pen and vital sign flow sheet or record form
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37
Q

What are the first two steps in assessing respirations?

A
  • Identify patient using two identifiers per facility policy
  • Determine need to assess respiration based on clinical judgment
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38
Q

What conditions increase risk for respiratory alterations?

A
  • Fever, pain, anxiety, chest/abdominal conditions
  • Chronic lung diseases, chest trauma, infections
  • Pulmonary issues like edema/emboli, anemia, head injury
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39
Q

What signs/symptoms indicate respiratory alterations?

A
  • Cyanosis, restlessness, confusion, labored breathing
  • Adventitious breath sounds, inability to breathe
  • Abnormal sputum production
40
Q

What do arterial blood gases measure?

A
  • Blood pH
  • Partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2)
  • Arterial oxygen saturation (SaO2) reflecting oxygenation
41
Q

What are normal pulse oximetry (SpO2) values?

A
  • 95-100% is normal
  • 85-89% may be acceptable for some chronic conditions
  • <85% is abnormal, often with respiratory changes
42
Q

What do hemoglobin, hematocrit, and RBC count measure?

A
  • Concentration of hemoglobin
  • Volume of red blood cells
  • Red blood cell count
  • All reflect patient’s oxygen carrying capacity
43
Q

Why determine previous baseline respiratory rate?

A
  • Enables assessing for changes in patient’s condition
  • Provides comparison for future measurements
44
Q

Why perform hand hygiene before assessing respirations?

A
  • Reduces transmission of microorganisms between patient and nurse
45
Q

For patients with breathing difficulty, what positioning is recommended?

A
  • Position of greatest comfort
  • Repositioning may increase work of breathing and respiratory rate
46
Q

What patient positioning optimizes respiratory assessment?

A
  • Sitting or semi-fowler’s position
  • Head of bed elevated 45-60 degrees
  • Chest visible for observing movements
47
Q

Where should nurse’s hand be placed for assessing respirations?

A
  • Patient’s arm relaxed across abdomen/lower chest
  • Or nurse’s hand over patient’s upper abdomen
  • Allows inconspicuous assessment like pulse
48
Q

How do you accurately determine respiratory rate?

A
  • Observe complete respiratory cycle (one inspiration and expiration)
49
Q

How do you count respiratory cycles?

A
  • Look at second hand of watch
  • When it reaches a number, start counting cycles as “one”, “two”, etc.
  • Respirations occur slower than pulse
50
Q

How long do you count respiratory cycles?

A
  • For regular rhythm, count for 30 seconds and multiply by 2
  • For irregular, <12/min, or >20/min, count for 1 full minute
51
Q

How do you assess depth of respirations?

A
  • Observe degree of chest wall movement while counting
  • Can palpate chest wall excursion or auscultate after counting
  • Describe as shallow, normal, or deep
52
Q

How do you assess rhythm of respirations?

A
  • Normal is regular and uninterrupted
  • Sighing is normal, not an abnormal rhythm
53
Q

What is a critical finding requiring reporting?

A
  • Any irregular pattern or period of apnea in an adult
  • Indicates underlying disease, needs reporting and further assessment
54
Q

What are the final steps?

A
  • Reposition bed linens/gown for patient comfort
  • Perform hand hygiene
  • Discuss findings with patient as needed
55
Q

What are interventions for abnormal respiratory rate, depth, rhythm or shortness of breath?

A
  • 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
Q

How should respiratory assessment findings be documented?

A
  • 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
Q

What should be reported regarding respiratory assessment?

A
  • Report abnormal findings to nurse in charge or provider
58
Q

What community factors should be assessed for respiratory issues?

A
  • Environmental factors like secondhand smoke, poor ventilation, gas fumes
59
Q

What is the acceptable respiratory rate range for premature infants?

A

40-70 breaths per minute

60
Q

What is the acceptable respiratory rate range for infants 0-3 months?

A

35-55 breaths per minute

61
Q

What is the acceptable respiratory rate range for infants 3-6 months?

A

30-45 breaths per minute

62
Q

What is the acceptable respiratory rate range for infants 6-12 months?

A

22-38 breaths per minute

63
Q

What is the acceptable respiratory rate range for children 1-3 years?

A

22-30 breaths per minute

64
Q

What is the acceptable respiratory rate range for children 3-6 years?

A

20-24 breaths per minute

65
Q

What is the acceptable respiratory rate range for children 6-12 years?

A

16-22 breaths per minute

66
Q

What is the acceptable respiratory rate range for ages greater than 12 years?

A

12-20 breaths per minute

67
Q

What is the acceptable respiratory rate range for adults?

A

12-20 breaths per minute

68
Q

How is ventilatory depth assessed?

A
  • 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
Q

How is ventilatory rhythm assessed?

A
  • 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
Q

What indicates labored respirations?

A
  • Use of accessory neck muscles
  • Intercostal retractions during inhalation
  • Longer exhalation phase if obstructed outflow
71
Q

What are infant respiratory distress signs?

A
  • Nasal flaring
  • Grunting
  • Wheezing
  • Important to look, listen, and feel
72
Q

What is bradypnea?

A
  • Breathing rate is regular but abnormally slow (<12 breaths per minute)
73
Q

What is tachypnea?

A
  • Breathing rate is regular but abnormally rapid (>20 breaths per minute)
74
Q

What is hyperpnea?

A
  • Respirations are labored, increased depth and rate (>20 breaths/min)
  • Occurs normally during exercise
75
Q

What is apnea?

A
  • Respirations cease for several seconds then resume
  • Persistent cessation results in respiratory arrest
76
Q

What is hyperventilation?

A
  • Rate and depth of respirations increase
  • May cause hypocarbia
77
Q

What is hypoventilation?

A
  • Respiratory rate abnormally low
  • Depth of ventilation may be depressed
  • May cause hypercarbia
78
Q

What is Cheyne-Stokes respiration?

A
  • Rate and depth irregular
  • Alternating apnea and hyperventilation
  • Shallow to deep to apnea pattern
79
Q

What are Kussmaul respirations?

A
  • Abnormally deep, regular, increased rate
80
Q

What is Biot’s respiration?

A
  • Abnormally shallow for 2-3 breaths
  • Followed by irregular apnea periods
81
Q

How is respiratory rhythm assessed in infants/children?

A
  • Infants breathe less regularly
  • Young children may alternate slow and rapid breathing
  • Estimate time interval after each cycle
82
Q

How is respiratory diffusion and perfusion evaluated?

A
  • 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
Q

What is SaO2?

A
  • Percentage of hemoglobin bound with oxygen in arteries
  • Normal range is 95-100%
  • Affected by factors interfering with ventilation, perfusion, or diffusion
84
Q

What is SvO2?

A
  • 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
Q

How does a pulse oximeter measure oxygen saturation?

A
  • 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
Q

Where is the photo detector located in a pulse oximeter?

A
  • In the oximeter probe
87
Q

What types of probes are used and how are they selected?

A
  • 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
Q

What factors affect the pulse oximeter’s ability to measure SpO2?

A
  • Factors affecting light transmission
  • Factors affecting peripheral arterial pulsations
  • Controlling these factors allows accurate interpretation of abnormal SpO2
89
Q

What measurements enable assessment of ventilation, diffusion, and perfusion?

A
  • Respiratory rate
  • Respiratory pattern
  • Respiratory depth
  • SpO2 (oxygen saturation)
90
Q

What do respiratory assessment data provide clues about?

A
  • The nature of the patient’s health problem
91
Q

What are some nursing diagnoses related to respiratory assessment data?

A
  • Activity intolerance
  • Ineffective airway clearance
  • Anxiety
  • Ineffective breathing pattern
  • Impaired gas exchange
  • Acute pain
  • Ineffective tissue perfusion
  • Dysfunctional ventilatory weaning response
92
Q

How are nursing interventions determined?

A
  • Based on the identified nursing diagnosis and related factors
93
Q

What are defining characteristics of impaired gas exchange?

A
  • Tachypnea
  • Changes in respiratory depth
  • Use of accessory muscles
  • Cyanosis
  • Decline in SpO2
94
Q

What may be related factors for impaired gas exchange?

A
  • Lung surgery
  • History of chronic obstructive lung disease
  • History of heavy smoking
95
Q

How are patient outcomes evaluated after interventions?

A
  • By reassessing respiratory rate, depth, rhythm, and SpO2

Nursing 20G - Vital Signs (19 decks)

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