13) Respiration Flashcards
What is respiration?
- Mechanism the body uses to exchange gases between atmosphere and blood
- Involves ventilation, diffusion, and perfusion
What is ventilation?
- Movement of gases in and out of the lungs
What is diffusion in respiration?
- Movement of oxygen and carbon dioxide between alveoli and red blood cells
What is perfusion in respiration?
- Distribution of red blood cells to and from pulmonary capillaries
How is ventilation assessed?
- By determining respiratory rate, depth, and rhythm
How are diffusion and perfusion assessed?
- By determining oxygen saturation
How is breathing normally regulated?
- Respiratory center in brainstem regulates involuntary control
- Adults breathe smoothly 12-20 times per minute
What regulates ventilation?
- Levels of CO2, O2, and hydrogen ion concentration in arterial blood
- CO2 level is most important factor
How does elevated CO2 affect breathing?
- Causes respiratory control system to increase rate and depth
- Removes excess CO2 (hypercarbia) by increasing exhalation
How is ventilation controlled in chronic lung disease patients?
- Chemoreceptors become sensitive to low arterial O2 (hypoxemia)
- Signal brain to increase ventilation rate and depth
Why can high oxygen levels be dangerous for chronic lung disease patients?
- Low arterial O2 provides stimulus to breathe
- High oxygen removes this stimulus
What is involved in moving the lungs and chest wall during breathing?
- Muscular work
- Inspiration is an active process
What happens during inspiration?
- Respiratory center sends impulses through phrenic nerve
- Diaphragm contracts, abdominal organs move down/forward
- Increases length of chest cavity to move air into lungs
How much does the diaphragm and ribs move during inspiration?
- Diaphragm moves about 1 cm
- Ribs retract upward 1.2-2.5 cm from midline
What is the tidal volume?
- Amount of air inhaled during a normal, relaxed breath
- 500 mL
What happens during expiration?
- Diaphragm relaxes
- Abdominal organs return to original positions
- Lung and chest wall return to relaxed position
- A passive process
What is eupnea and what interrupts it?
- Eupnea is normal rate and depth of ventilation
- Interrupted by sighing (prolonged deeper breath)
- Sigh expands small airways/alveoli not ventilated normally
How is normal respiration assessed?
- 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
What is required for accurate respiratory assessment?
- Observation and palpation of chest wall movement
- No special equipment needed, but measurement must not be haphazard
Why is noting sudden changes in respiration character important?
- 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
How should respiratory rate be assessed during nursing assessment?
- 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
What should be considered when assessing respiration?
- 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
What are the objective respiratory measurements?
- Rate of breathing
- Depth of breathing
- Rhythm of ventilatory movements
What should the nurse observe when counting respiratory rate?
- Both inspiration and expiration
How does respiratory rate vary?
- Varies with age
- Usually decreases with age
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
How does exercise affect respiration?
- Increases respiratory rate and depth
- To meet body’s need for additional oxygen
- To rid body of carbon dioxide
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
How does anxiety affect respiration?
- Increases respiratory rate and depth
- Due to sympathetic stimulation
How does chronic smoking affect respiration?
- Changes pulmonary airways
- Results in increased respiratory rate at rest when not smoking
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
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
How does neurological injury affect respiration?
- Injury to brainstem impairs respiratory center
- Alters respiratory rate and rhythm
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
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
What equipment is needed for assessing respirations?
- Watch with second hand or digital display
- Pen and vital sign flow sheet or record form
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
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
What signs/symptoms indicate respiratory alterations?
- Cyanosis, restlessness, confusion, labored breathing
- Adventitious breath sounds, inability to breathe
- Abnormal sputum production
What do arterial blood gases measure?
- Blood pH
- Partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2)
- Arterial oxygen saturation (SaO2) reflecting oxygenation
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
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
Why determine previous baseline respiratory rate?
- Enables assessing for changes in patient’s condition
- Provides comparison for future measurements
Why perform hand hygiene before assessing respirations?
- Reduces transmission of microorganisms between patient and nurse
For patients with breathing difficulty, what positioning is recommended?
- Position of greatest comfort
- Repositioning may increase work of breathing and respiratory rate
What patient positioning optimizes respiratory assessment?
- Sitting or semi-fowler’s position
- Head of bed elevated 45-60 degrees
- Chest visible for observing movements
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
How do you accurately determine respiratory rate?
- Observe complete respiratory cycle (one inspiration and expiration)
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
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
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
How do you assess rhythm of respirations?
- Normal is regular and uninterrupted
- Sighing is normal, not an abnormal rhythm
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
What are the final steps?
- Reposition bed linens/gown for patient comfort
- Perform hand hygiene
- Discuss findings with patient as needed
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
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
What should be reported regarding respiratory assessment?
- Report abnormal findings to nurse in charge or provider
What community factors should be assessed for respiratory issues?
- Environmental factors like secondhand smoke, poor ventilation, gas fumes
What is the acceptable respiratory rate range for premature infants?
40-70 breaths per minute
What is the acceptable respiratory rate range for infants 0-3 months?
35-55 breaths per minute
What is the acceptable respiratory rate range for infants 3-6 months?
30-45 breaths per minute
What is the acceptable respiratory rate range for infants 6-12 months?
22-38 breaths per minute
What is the acceptable respiratory rate range for children 1-3 years?
22-30 breaths per minute
What is the acceptable respiratory rate range for children 3-6 years?
20-24 breaths per minute
What is the acceptable respiratory rate range for children 6-12 years?
16-22 breaths per minute
What is the acceptable respiratory rate range for ages greater than 12 years?
12-20 breaths per minute
What is the acceptable respiratory rate range for adults?
12-20 breaths per minute
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
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
What indicates labored respirations?
- Use of accessory neck muscles
- Intercostal retractions during inhalation
- Longer exhalation phase if obstructed outflow
What are infant respiratory distress signs?
- Nasal flaring
- Grunting
- Wheezing
- Important to look, listen, and feel
What is bradypnea?
- Breathing rate is regular but abnormally slow (<12 breaths per minute)
What is tachypnea?
- Breathing rate is regular but abnormally rapid (>20 breaths per minute)
What is hyperpnea?
- Respirations are labored, increased depth and rate (>20 breaths/min)
- Occurs normally during exercise
What is apnea?
- Respirations cease for several seconds then resume
- Persistent cessation results in respiratory arrest
What is hyperventilation?
- Rate and depth of respirations increase
- May cause hypocarbia
What is hypoventilation?
- Respiratory rate abnormally low
- Depth of ventilation may be depressed
- May cause hypercarbia
What is Cheyne-Stokes respiration?
- Rate and depth irregular
- Alternating apnea and hyperventilation
- Shallow to deep to apnea pattern
What are Kussmaul respirations?
- Abnormally deep, regular, increased rate
What is Biot’s respiration?
- Abnormally shallow for 2-3 breaths
- Followed by irregular apnea periods
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
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
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
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
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)
Where is the photo detector located in a pulse oximeter?
- In the oximeter probe
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
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
What measurements enable assessment of ventilation, diffusion, and perfusion?
- Respiratory rate
- Respiratory pattern
- Respiratory depth
- SpO2 (oxygen saturation)
What do respiratory assessment data provide clues about?
- The nature of the patient’s health problem
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
How are nursing interventions determined?
- Based on the identified nursing diagnosis and related factors
What are defining characteristics of impaired gas exchange?
- Tachypnea
- Changes in respiratory depth
- Use of accessory muscles
- Cyanosis
- Decline in SpO2
What may be related factors for impaired gas exchange?
- Lung surgery
- History of chronic obstructive lung disease
- History of heavy smoking
How are patient outcomes evaluated after interventions?
- By reassessing respiratory rate, depth, rhythm, and SpO2
