Oxygenation: (Acute Hypoxia, Asthma, Cystic Fibrosis): know normal to identify abnormal!
Terminology
o Eupnea- normal breathing
o Tachypnea- > 20 breaths/minute
o Bradypnea- < 12 breaths/minute
o Apnea- absence of breathing
o Dyspnea- shortness of breath
o Orthopnea- shortness of breath while lying supine
o Kussmaul Breathing- deep & rapid breathing
Metabolic acidosis (DKA); rids body of LARGE amounts of CO2
o Cheyne-Stokes Breathing- deep and rapid, then slow and shallow with periods of apnea
Drug overdose; CHF
o Hypercapnia- increased level of CO2 in blood
o Hypoxemia- decreased level of oxygen
Late Sign: cyanosis
Normal Respirations
o Newborn- 30-60 breaths/minute
o Adult- 12-20 breaths/minute
Alterations in Oxygenation: changes in breathing; patency of airway; gas exchange; inflammation; damage
o Mild Impairments: fatigue, irritability, discomfort // Severe Impairments: tissue hypoxia, death
Interrelated Concepts
o Acid-Base Balance respiratory acidosis: increased CO2
o Cellular Regulation Anemia: blood loss, aplastic, G6PD
o Cognition decreased oxygen to brain
o Comfort pain: cerebral, cardiac, shock states, pulmonary; decreased O2=pain
o Metabolism —> DM
Abnormal Breath Sounds
o Stridor- high pitched sound in trachea/larynx; most emergent
o Crackles- high pitched popping sound heard on inspiration; fluid, inflammation
o Rhonchi- low pitched sound continuous through inspiration; cleared by coughing
o Wheezing- high pitched, whistle sound; expiration- narrowing of bronchi
Oxygenation Nursing Process
Assessment: interview & Physical
o Interview: current problems, history of respiratory disease, lifestyle, presence of coughing, sputum, chest pain, risk
factors, medication history
o Physical: vital signs, inspection: position & ease of breathing, nose symmetry, accessory muscle use, nail beds:
clubbing, skin color and temperature, thoracic wall symmetry; palpation: chest wall tenderness; auscultate: lung
sounds- stridor, wheezing, crackles (rales), rhonchi
Diagnostic Testing
o Sputum Testing: presence of microbes; determines treatment; Chest X-ray; CT/MRI; Bronchoscopy; Thoracentesis:
drains pleural fluid for analysis and comfort; Pulmonary Function Test: FEV1; Peak expiratory flow rate
Diagnosis: ineffective airway clearance, ineffective breathing pattern, impaired gas exchange, activity intolerance,
imbalanced nutrition: less than body requirements; acute pain; anxiety/fear; risk for infection; risk for falls
Planning: SMART
o Ex: ineffective airway clearance- maintain clear airway during shift; no adventitious breath sounds during shift
Interventions & Therapy
o Deep breathing exercises; positioning; smoking cessation; monitor activity intolerance; promote secretion
clearance; suctioning; assist with ADLs; PO oral intake; nutritional support for caloric intake; medication therapy;
respiratory therapy: breathing treatment; physical and occupational therapy
Evaluation: evaluate effectiveness of outcomes; implement new intervention; update plan of care
Pharmacology
o Short-acting beta-agonists (SABA) // Long-acting beta-agonists (LABA)
o Corticosteroids, Anticholinergics, Methylxanthine’s, Mucolytic/ Expectorants, Broad Spectrum Antibiotics, Oxygen
Terminology
o Eupnea- normal breathing
o Tachypnea- > 20 breaths/minute
o Bradypnea- < 12 breaths/minute
o Apnea- absence of breathing
o Dyspnea- shortness of breath
o Orthopnea- shortness of breath while lying supine
o Kussmaul Breathing- deep & rapid breathing
Metabolic acidosis (DKA); rids body of LARGE amounts of CO2
o Cheyne-Stokes Breathing- deep and rapid, then slow and shallow with periods of apnea
Drug overdose; CHF
o Hypercapnia- increased level of CO2 in blood
o Hypoxemia- decreased level of oxygen
Late Sign: cyanosis
Normal Respirations
o Newborn- 30-60 breaths/minute
o Adult- 12-20 breaths/minute
Alterations in Oxygenation: changes in breathing; patency of airway; gas exchange; inflammation; damage
o Mild Impairments: fatigue, irritability, discomfort // Severe Impairments: tissue hypoxia, death
Interrelated Concepts
o Acid-Base Balance respiratory acidosis: increased CO2
o Cellular Regulation Anemia: blood loss, aplastic, G6PD
o Cognition decreased oxygen to brain
o Comfort pain: cerebral, cardiac, shock states, pulmonary; decreased O2=pain
o Metabolism —> DM
Abnormal Breath Sounds
o Stridor- high pitched sound in trachea/larynx; most emergent
o Crackles- high pitched popping sound heard on inspiration; fluid, inflammation
o Rhonchi- low pitched sound continuous through inspiration; cleared by coughing
o Wheezing- high pitched, whistle sound; expiration- narrowing of bronchi
Oxygenation Nursing Process
Assessment: interview & Physical
o Interview: current problems, history of respiratory disease, lifestyle, presence of coughing, sputum, chest pain, risk
factors, medication history
o Physical: vital signs, inspection: position & ease of breathing, nose symmetry, accessory muscle use, nail beds:
clubbing, skin color and temperature, thoracic wall symmetry; palpation: chest wall tenderness; auscultate: lung
sounds- stridor, wheezing, crackles (rales), rhonchi
Diagnostic Testing
o Sputum Testing: presence of microbes; determines treatment; Chest X-ray; CT/MRI; Bronchoscopy; Thoracentesis:
drains pleural fluid for analysis and comfort; Pulmonary Function Test: FEV1; Peak expiratory flow rate
Diagnosis: ineffective airway clearance, ineffective breathing pattern, impaired gas exchange, activity intolerance,
imbalanced nutrition: less than body requirements; acute pain; anxiety/fear; risk for infection; risk for falls
Planning: SMART
o Ex: ineffective airway clearance- maintain clear airway during shift; no adventitious breath sounds during shift
Interventions & Therapy
o Deep breathing exercises; positioning; smoking cessation; monitor activity intolerance; promote secretion
clearance; suctioning; assist with ADLs; PO oral intake; nutritional support for caloric intake; medication therapy;
respiratory therapy: breathing treatment; physical and occupational therapy
Evaluation: evaluate effectiveness of outcomes; implement new intervention; update plan of care
Pharmacology
o Short-acting beta-agonists (SABA) // Long-acting beta-agonists (LABA)
o Corticosteroids, Anticholinergics, Methylxanthine’s, Mucolytic/ Expectorants, Broad Spectrum Antibiotics, Oxygen
