Respiratory Assessment in Nursing: Vital Signs, Factors, and Interventions
Respiratory Function Assessment in Nursing
Vital Signs
Respiratory Patterns:
- Frequency, rate, ventilation
- Dyspnea, orthopnea
Breathing Sounds:
- Stridor, wheezing
Chest Movements:
- Retractions (intercostal, suprasternal, supraclavicular)
Secretions and Cough:
- Type of discharge (sputum, hemoptysis, density)
- Presence of cough: dry or productive, irritant
Circulatory Status
- Heart rate (tachycardia or bradycardia)
- Blood pressure
- Oxygenation (anoxia, hypoxemia, hypoxia, cyanosis)
Factors Affecting Respiratory Function
Altitude
- Decreases O2 (higher altitude, lower pressure)
Other Factors
- Environment
- Emotions (increased frequency)
- Exercise (increased frequency)
- Health
- Lifestyle (e.g., work)
- Age
- Sex
Physical Assessment
The nurse assesses for symmetry in lung expansion and listens for abnormal sounds (e.g., fluid, mucus).
Assessment of Vital Signs
Breathing:
- Eupnea, tachypnea, bradypnea, apnea
Volume:
- Hyperventilation, hypoventilation
Rhythm:
- Cheyne-Stokes, Biot
Dyspnea or Orthopnea
Abnormal Sounds:
- Stridor, rales, wheezing, gasping
Chest Movements:
- Rhythmic and symmetrical
- Retractions: substernal, suprasternal, supraclavicular, tracheal tugging
Secretions and Cough:
- Productive or dry
- Coughing: dense, brownish, blackish, bloody (hemoptysis)
Pulse:
- Tachycardia, bradycardia, arrhythmia, weak pulse
Blood Pressure:
- Hypertension, hypotension
Skin Color:
- Pale skin, cyanosis, anoxia, hypoxemia
Clinical Signs of Hypoxia
- Rapid pulse
- Shallow, rapid breathing
- Increased restlessness
- Flaring of the nostrils
- Substernal or intercostal retractions
- Cyanosis
Diagnostic Tests
- Sputum analysis
- Pharyngeal culture
- Blood gases
- Radiological and endoscopic tests
- Pulmonary function tests
- Thoracentesis
Problems Related to Breathing
Ineffective Airway Clearance
- Airway obstruction (e.g., abnormal sounds, cough, shortness of breath, runny nose, changes in breathing frequency and depth, cyanosis)
Ineffective Breathing Patterns
- Insufficient breathing to meet oxygen demands (e.g., dyspnea, retractions, cough, nasal flaring, pursed-lip breathing, orthopnea)
Impaired Gas Exchange
- Due to physiological changes, age, illness
Decreased Cardiac Output
- Factors: decreased heart rate, decreased blood volume, electrolyte imbalance, cardiac arrest
Factors Affecting Airway Clearance
- Discharge
- Trauma
- Pain
- Medication
- Loss of consciousness
- Dehydration
- Immobility
Factors Influencing Ineffective Breathing Patterns
- Inadequate chest expansion
- Neuromuscular disorders
- Musculoskeletal disorders
- Chronic pulmonary disease
- Hyperventilation
- Airway obstruction
Factors Affecting Gas Exchange
- Acidosis
- Alkalosis
Factors Decreasing Cardiac Output
- Heart failure
- Blood volume depletion
- Electrolyte imbalance
- Cardiac arrest
Nursing Interventions for Breathing Problems
Promoting Airway Clearance
- Adequate positioning
- Deep breathing and coughing
- Adequate hydration
- Health promotion practices
- Healthy environment
Improving Breathing Patterns
- Lung inflation techniques (breathing exercises, spirometry)
- Postural drainage (with percussion, vibration, clapping)
Enhancing Airway Clearance
- Humidifiers
- Nebulizers
- Suctioning of secretions
Addressing Ineffective Thoracic Expansion
- Immobility
- Bed rest
- Pain
- Obesity
Managing Cough
- Sudden, spasmodic contraction of the thoracic cavity, resulting in forceful expulsion of air from the lungs
Importance of Deep Breathing
- Mobilizes secretions
- Facilitates expectoration
Patient Hydration
- Maintains moisture of respiratory mucous secretions, preventing thickening
Oxygen Therapy
Purpose
- Increase oxygen supply to tissues
Indications
- Deficient oxygen supply to tissues (cellular hypoxia)
- Decreased oxygen amount or partial pressure in inspired gas
- Decreased alveolar ventilation
- Altered ventilation/perfusion
- Impaired gas transfer
- Decreased cardiac output
- Hypovolemia
- Shock
- Decreased hemoglobin or chemical alteration
Signs of Oxygen Therapy Need
- Rapid pulse
- Rapid, shallow breathing
- Increased restlessness
- Nasal flaring
- Substernal or intercostal retractions
- Cyanosis
Oxygen Administration Methods
- Nasal cannula
- Nasal oxygen or glasses
- Face mask (with or without reservoir)
- Venturi mask
- Oxygen tents
- Incubators
- Mechanical ventilators
Oxygen Toxicity
- Observed in individuals receiving high oxygen concentrations (>60% for >24 hours)
Manifestations of Oxygen Toxicity
- Depression of alveolar ventilation
- Resorption atelectasis
- Pulmonary edema
- Pulmonary fibrosis
- Retrolental fibroplasia (in premature infants)
- Decreased hemoglobin concentration
Nursing Care for Patients on Oxygen Therapy
- Maintain airway patency
- Remove oral, nasal, and tracheal secretions
- Restrict smoking
- Prepare equipment and administer humidified oxygen
- Monitor oxygen flow rate and humidifier
- Check oxygen supply device position
- Change from oxygen mask to nasal cannula during meals (as tolerated)
- Watch for signs of oxygen toxicity and hypoventilation
- Regularly check oxygen delivery device and mask/cannula placement to ensure prescribed concentration
- Monitor oxygen therapy effectiveness (pulse oximetry, arterial blood gases)
- Verify patient’s ability to tolerate oxygen suspension while eating
- Ensure oxygen equipment doesn’t interfere with breathing attempts
- Observe patient anxiety related to oxygen therapy
- Observe for skin breakdown from device friction
Nursing Interventions: Summary
- Adequate positioning
- Deep breathing and coughing techniques
- Respiratory education
- Adequate hydration
- Health promotion practices
- Healthy environment