Respiratory

Archer Review Crash Course

Anatomy & Physiology

Terminology
● Ventilation
○ Air movement in and out of the lungs
● Oxygenation
○ Oxygen in the bloodstream
● Perfusion
○ Oxygen in the tissues
 “Work of breathing”

Respiratory System Anatomy

Gas exchange
The delivery of oxygen from the lungs to the bloodstream, and the
elimination of carbon dioxide from the bloodstream to the lungs. Occurs
in the alveoli through passive diffusion.

ABG
Interpretation
Get it right, every time!
Normal Values
pH 7.35-7.45

Bicarbonate (HCO3) 22-28

CO2 35-45

Bicarb = BASE
CO2 = ACID

Step 1: Compensated or uncompensated?

Uncompensated!

NO!

No Compensated!
Is the pH normal??
7.35-7.45

Yes Normal!!
Are the CO2 and
YES!
HCO3 normal?
Step 2: Acidotic or alkalotic?

But… what if it’s compensated?!

If the pH is between 7.35 and 7.45, but you have determined that the gas is compensated, it is an
acidosis if the pH is <7.4 and an alkalosis if the pH is >7.4…. Essentially whatever side it is closest to!

Step 3: Metabolic or Respiratory?

CO2 HCO3

> 45 = TOO MUCH acid = acidotic > 26= TOO MUCH base = alkalotic
< 35 = NOT ENOUGH acid = alkalotic < 22 = NOT ENOUGH base = acidotic
Putting it all together
1. Compensated or uncompensated
2. Alkalosis or acidosis
3. Metabolic or respiratory

Let’s practice together!

Your patient has the following arterial blood gas values:

pH 7.58
CO2 41
HCO3 38
 pH 7.58

CO2 41

HCO3 38

1. Compensated or uncompensated?
○ The pH is in OUT of normal range- this is UNCOMPENSATED.
2. Alkalosis or acidosis
○ The pH is higher than 7.45 - this is ALKALOSIS.
3. Metabolic or respiratory
○ There is a high amount of HCO3, a base, correlating with our alkalosis - this is
METABOLIC.

UNCOMPENSATED METABOLIC ALKALOSIS

ABG Worksheet
Your patient has the following arterial blood gas values:

pH 7.36
CO2 69
HCO3 37

pH 7.36

CO2 69

HCO3 37

1. Compensated or uncompensated?
○ The pH is in normal range, but the CO2 and HCO3 are not - this is COMPENSATED.
2. Alkalosis or acidosis
○ The pH is normal - but closer to 7.35 - this is ACIDOSIS.
3. Metabolic or respiratory
○ There is a high amount of CO2, an acid, correlating with our acidosis - this is
RESPIRATORY.

COMPENSATED RESPIRATORY ACIDOSIS

Respiratory Medications
● Rescue meds
○ Albuterol
○ Ipratropium
● Long-term control meds
○ Guaifenesin
○ Montelukast
○ Theophylline

Albuterol
Therapeutic class: Bronchodilator; short acting beta 2 agonist

Indication: Asthma, COPD

Action: Binds to Beta2 adrenergic receptors in the airway leading to relaxation

of the smooth muscles in the airways

Nursing Considerations:

● Be very cautious when using in patients with heart disease, diabetes,

glaucoma, or seizures.
● Causes tachycardia
Guaifenesin
Therapeutic class: Expectorant

Indication: Cough, congestion

Action: Increases the volume and reduces the viscosity of secretions in the
respiratory system making it easier for the body to clear secretions.

Nursing Considerations:

● Often comes in combo medication - advise your patients to check what they are taking

Montelukast
Therapeutic class: Leukotriene modifier

Indication: Asthma, allergic rhinitis

Action: Blocks the action of leukotrienes in the body; which cause asthma and
allergic rhinitis

Nursing Considerations:

● Prophylaxis and chronic treatment - not a rescue medication

● Not given for acute asthma attacks; patients should have appropriate rescue medication.
● FDA black box warning: Serious neuropsychiatric events that may include suicidal thoughts or
actions have been reported in patients taking montelukast
● Monitor for neuropsychiatric symptoms
Theophylline
Therapeutic class: Phosphodiesterase enzyme inhibitors

Indication: COPD: chronic asthma, emphysema, chronic bronchitis

Action: Relaxes muscles in the airway to cause bronchodilation. Decreases the

lung’s response to irritants.

Nursing Considerations:

● Must be used regularly to be effective.

● PO medication
● Doesn’t work right away - not a rescue medication
● Rescue-inhaler should also be prescribed,

Chronic Obstructive Pulmonary Disease

(COPD)
 Break!

What is Chronic Obstructive Pulmonary Disease?

● A group of lung diseases that
block airflow and make it
difficult to breathe.
● Includes:
○ Emphysema
○ Chronic bronchitis
○ Asthma
● Damage is not reversible.
Categories
● Emphysema
○ Destruction of alveoli is due to chronic inflammation. There is decreased surface
area of the alveoli for participation in gas exchange.
● Chronic Bronchitis
○ There is chronic inflammation with a productive cough and excessive sputum
● Asthma
○ A respiratory condition marked by spasms in the bronchi of the lungs, causing
difficulty in breathing. There is chronic inflammation of bronchi and bronchioles,
and excess mucus.

Assessment
● Barrel chest
● Accessory muscle use
○ Retractions
○ Nasal flaring
○ Tracheal tug
● Congestion
● Lung sounds
○ Diminished
○ Crackles
○ Wheezes
● Acidotic
● Hypercarbic
● Hypoxic
Treatment
● Chest physiotherapy
● Increased fluid intake
● Be very careful with oxygen administration!
○ In the normal patient, hypercarbia stimulates the body to breathe.
○ This patient has been hypercarbic for an extended period of time
○ For them, hypoxia has become the driving factor to stimulate breathing
● Bronchodilators
● Corticosteroids
● Encourage pursed lip breathing to help expire completely.
● Eat small frequent meals to avoid overdistention of the stomach which
impedes the diaphragm.

Asthma
What is Asthma?
● A respiratory condition marked
by spasms in the bronchi of the
lungs, causing difficulty in
breathing.
● Chronic inflammation of
bronchi and bronchioles.
● Excess mucus.
● Result of an allergic reaction or
hypersensitivity.

Pathophysiology
1. Airway is abnormally reactive - heightened sensitivity
2. Trigger causes a response
3. Inflammation and excess mucus production occur
4. Bronchospasm decreases the airway diameter
5. Airflow becomes obstructed

After many asthma reactions, airway remodeling occurs which causes scarring
and changes to lung tissue.
Triggers
A - Allergens

S - Sport / Smoking

T - Temperature change

H - Hazards

M - Microbes

A - Anxiety

Assessment
● Shortness of breath
● Unable to speak
○ Evaluate how many works they can say before taking a breath
● Cough
● Increased work of breathing
○ Retractions
○ Tracheal tug
○ Head bobbing
● Wheeze
● Prolonged expiration
● Can’t hear any breath sounds? Complete obstruction.
Complication - Status Asthmaticus
● Asthma attack that is refractory to
treatment
● Leads to severe respiratory
failure
● Can progress to death if
untreated

Treatment - acute exacerbation

● Airway, breathing, circulation!!
● Oxygen administration
● B-Adrenergic agonists
■ Open up airway
■ Albuterol
● Corticosteroids
■ Can be given IV, IM or PO
● Ipratropium Bromide
● Magnesium sulfate
● Theophylline
Treatment - long-term control
● Inhaled Corticosteroids
○ Budesonide & Fluticasone
○ Take daily
● B-Adrenergic agonists
○ Albuterol & Terbutaline
○ Relaxes smooth muscles and stops bronchospasm
● Leukotriene modifiers
○ Montelukast sodium
○ Blocks leukotrienes from over responding to triggers
● Allergen control
○ Clean environment
○ Minimize dust, pet dander, and mold
○ No secondhand smoke

NCLEX Question
A 15-year-old admitted for status asthmaticus has been stabilized. Which
activity would be most appropriate for the client?

a. Completing a jigsaw puzzle

b. Talking with friends on the phone
c. Watching basketball on television
d. Putting together a necklace
Correct Answer: B
A is incorrect. Teenagers need an opportunity to interact with peers during
their times of sickness to have an outlet to express their concerns. Completing
a jigsaw puzzle does not give the teenager an opportunity to achieve this. B is
correct. Teenagers need an opportunity to interact with peers during their
times of sickness to have an outlet to express their concerns. Talking to
friends over the phone enables the client to achieve this. C is incorrect.
Teenagers need an opportunity to interact with peers during their times of
sickness to have an outlet to express their concerns. Watching television does
not give the teenager an opportunity to achieve this. D is incorrect. Teenagers
need an opportunity to interact with peers during their times of sickness to
have an outlet to express their concerns. Arts and crafts do not give the
teenager an opportunity to achieve this.

Acute Respiratory Distress Syndrome

(ARDS)
What is ARDS?
● “an acute condition
characterized by
bilateral pulmonary
infiltrates and severe
hypoxemia in the
absence of evidence for
cardiogenic pulmonary
edema”

● Fluid collects in alveoli

● Deprives body of oxygen

Pathophysiology
● Inflammatory response in the lungs causes an injury to the capillary
endothelium basement membrane, interstitial space, and alveolar
epithelium of the pulmonary system.
● The damage to the lungs causes increased capillary membrane
permeability allowing fluid to fill the alveoli. This impairs gas exchange.
● The products of cell damage cause the formation of a hyaline membrane,
which further prevents oxygen exchange.
● With impaired gas exchange, respiratory acidosis occurs.
● The damage to the lungs that occurs can not be reversed.
Causes
Anything that causes an inflammatory reaction in the lungs!!

● Sepsis
● Trauma
● Burns
● Aspiration pneumonia
● Overdose
● Near drowning

Assessment
● Chest x-ray
○ Diffuse bilateral infiltrates
○ “Whited-out”
● Hypoxemia
○ Pale
○ Cool
○ Dusky
○ Mottled
○ Low SpO2
Treatment
TREAT THE UNDERLYING CONDITION

● Intubation and mechanical ventilation

○ High pressures
● Prone
● Prevent infection
○ VAP
● Prevent barotrauma

Ventilator Alarms
High Pressure Alarms Low Pressure Alarms
Pressure in the circuit is too high. Pressure in the circuit is too low.

Causes: Causes:
Patient coughing Tubing is disconnected
Gagging Loose connections
Bronchospasm Leak
Fighting the ventilator Extubation
ETT occlusion Cuffed ETT or trach is deflated
Kink in the tubing Poorly fitting CPAP/BiPAP mask
Increased secretions
Thick secretions
Water in ventilator circuit
 Pulmonary Edema

What is Pulmonary Edema?

A buildup of fluid in the

lungs due to blood backup in
the pulmonary vasculature.
Pathophysiology
● Blood back ups in the pulmonary veins.
● There is increased pressure in the pulmonary veins.
● Increased pressure causes fluid to shift from the capillaries into the
alveoli and interstitial space.
● Fluid builds up in the alveoli.
● This causes impared gas exchange
● Impared gas exchange leads to hypoxemia, hypercarbia, and respiratory
acidosis.

Causes
● Decreased cardiac output
○ Heart failure
● Pulmonary hypertension
Assessment
● Tachypnea
● Dyspnea
● Tachycardia
● Diaphoresis
● Crackles
● Cough
● Pink tinged sputum
● ‘Wet’ chest x-ray

Treatment
● Oxygen
○ Nasal cannula
○ Face mask
○ CPAP
○ Intubation
● Monitor ABGs
● Monitor perfusion
● Medications
○ Diuretics
○ Nitroglycerin
○ ACE Inhibitors
 Pulmonary Embolism

What is a Pulmonary Embolism?

● Life threatening blood clot in the lungs
● Can be caused by an embolism from a vein entering the lung, or a clot
during surgery.
● The clot decreases perfusion causing hypoxemia
● Can lead to right heart failure if untreated.
Assessment
● Anxiety
● Dyspnea
● Chest pain
● Hypoxemia
● Rales
● Diaphoresis
● Hemoptysis

Treatment and Nursing Interventions

● Anticoagulants
● Thrombolytics
● Positioning
○ Blood clot:
■ High fowler’s
■ Promotes maximum lung expansion and assists with breathing
○ Air embolism:
■ Durant’s maneuver
■ Left lateral trendelenburg
■ This should prevent an air embolism from lodging in ght lungs. Will stay in the right
heart.
 Pneumonia

What is Pneumonia?
● Inflammation of the lung affecting the alveoli
● Alveoli
○ Tiny air sacs of the lungs which allow for gas exchange
● Alveoli become filled with pus and liquid
Classifications
● Viral
○ Caused by viruses such as RSV, adenovirus, and influenza
● Bacteria
● Fungal
● Chemical irritation
● Aspiration
○ When foreign bodies such as food and secretions enter the lungs
○ Cause inflammation and infection leading to pneumonia

Diagnosis
● Chest x-ray
○ “Patchy infiltrates”
● Sputum culture
○ Will identify a bacterial source
Assessment
● High fever
● Cough
● Tachypnea
● Crackles
● Chest pain
● Work of breathing
○ Retractions
○ Tracheal tug
○ Nasal Flaring
○ Grunting
○ Head bobbing

Treatment
● Maintain airway ● Chest physiotherapy
○ Suction
● Antipyretics
○ Monitor SpO2
● Monitor breathing ● Analgesia
○ Assess for increased work of ● Cough suppressant
breathing ● Expectorants
○ Provide support as needed ● Antibiotics if bacterial
○ Humidified oxygen
● Isolation
● Maintain circulation
○ Monitor for dehydration
○ IVF if unable to tolerate PO
 NCLEX Question
The nurse is reviewing the discharge teaching with a family who will be taking their
12 year old diagnosed with pneumonia home today. Which of the following points
should she review? Select all that apply.

a. Encourage your child to drink lots of water.

b. Administer the full course of antibiotics, even if your child starts to feel
better.
c. Call your pediatrician if there is tan sputum when when child coughs
d. Administer ibuprofen if your child has a fever

Answer: A and B
A is correct. It is appropriate teaching to have the parents encourage their child to drink lots of water. Pneumonia
can frequently cause dehydration, due to tachypnea and increased insensible fluid losses. Parents should encourage
adequate hydration to promote fluid and electrolyte balance while their child is recovering from pneumonia.

B is correct. It is very important to teach parents to administer the full course of antibiotics, even if their child starts
to feel better. If the parents stop administering antibiotics part of the way through the course, they will be promoting
antibiotic resistance and the chance that the infection could return.

C is incorrect. The parents do not need to call the pediatrician if there is tan sputum when the child coughs. This is a
normal finding of pneumonia and should be expected. If there is a new onset of green sputum, this could indicate the
development of a bacterial pneumonia and the need to call the pediatrician.

D is incorrect. It is not appropriate to administer ibuprofen if the child has a fever. Ibuprofen is an analgesic, and
does not have antipyretic properties. If the child develops a fever, the parents should be encouraged to administer
acetaminophen, which is an antipyretic.
NCSBN Client Need:
Topic: Health promotion and maintenance Subtopic:-

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatric
Lesson: Respiratory
But….How do I study?!?!
Answer: The Sure Pass Program

If you follow the Sure Pass

Program and fail the NCLEX,
Archer will give you a 100% money
back refund for ALL PRODUCTS!
Step One: Study, study, study!
● Start watching the On Demand content
○ 40 hours
○ Includes previous Rapid Prep, and subject specific lectures
○ Print the handouts
○ Take notes as you go
● Participate in the next live Rapid Prep class
○ 20 hours
○ Ask questions
○ Take notes
○ Do the practice questions
● STUDY THE CONTENT!!! :)

Step Two: Question bank

● Start off with about 20 questions at a time
● When finished, go through every question and every answer rationale
○ Even if you got it right!
● Pull your notes back out and add to them with things you learn from the
questions and answer rationales
● Increase the number of questions you’re doing at a time until you can do
100 in one sitting comfortably.
○ Focus is key! Make this your norm and the NCLEX won’t phase you!
● Flag questions you need to review again
● Use the performance graphs to see which areas you are struggling with
● Return to those areas in your notes and repeat Step One!!!
Step Three: Learning assessment
● Launch as many as you need
● 75 Questions
● Do it all in one sitting - WITHOUT your notes
● Simulate the conditions of the NCLEX as much as possible
○ No phone
○ No noise
○ No distractions
● Review your score:
○ Below average peer review → Review the areas you were low on, repeat steps one and
two in those areas.
○ At or above average peer review → DO IT AGAIN!
■ 4 times → Go take your NCLEX…. You are ready to pass :)
 y o u f or Sign up for the Sure Pass Program:

Th a n k https://archerreview.com/about-nclex-rn

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