Nursing Management of

Clients with Stressors of

Respiratory Function

Anatomy of Respiratory
Tract

Review your NUR123 objectives on

anatomy of upper and lower airways

Assessment of Respiratory
System

Review your NUR123 objectives on

Subjective and objective
assessment

Anatomy Knowledge
Factors Affecting Respiration
Integrity of the airway system
(ventilation)
Functioning cardiovascular system
(perfusion)
Functioning alveoli (diffusion)
Functioning neurocontrols

Assessment Knowledge
Respiratory Assessment
Respiratory Hx
includes:
Allergies
Medications
Medical Hx

Smoking
Lifestyle
Stressors
Hazard
exposures

Assessing Respiratory
Function
Inspection
Shape (AP diam), skeletal abnormalities,
chest movement and expansion,
rate,rhythm, effort
Percussion
Diaphragmatic excursion, tactile
fremitus
Auscultation
Vesicular +, adventitious sounds

Assessing Respiratory
Functioning

Respiratory Rate:
Eupnea
Tachycardia
Bradycardia
Apnea
Respiratory Depth:
Deep
Shallow

Assessing Respiratory
Functioning

Respiratory Rhythm:
Regular
Cheyne-Stokes
Kussmauls
Apneustic breathing
Biots

Assessing Respiratory
Functioning
Respiratory Quality:

No difficulty
Dyspnea and DOE
Orthopnea
Retractions

Cough:

Nonproductive
Productive
Sputum
Hemoptysis

Assessing Respiratory
Functioning
Auscultation:
Vesicular
Bronchial
Bronchvesicular

Adventitious:
Rales/crackles
Rhonchi
Wheeze
Stridor
Stertor

Diagnostic Studies
Hemoglobin and RBC count
Sputum specimens: C&S, gram stain,
acid-fast, cytology
Radiographics: CXR, CT with contrast,
Ventilation/Perfusion scan,
Bronchoscopy, Pulmonary angiography
Thoracentesis
Pulmonary Function Tests: VC,RV,TLC
Peak Flow Meter
Mantoux PPD (purified protein derivative)
Arterial Blood Gases (ABGs)

Lung Volumes and

Capacities
Tidal Volume (TV) volume of air entering

or leaving the lungs during a single breath.

Average at rest = 500 ml
Vital Capacity (VC)- maximum volume or
air that can be moved out during a single
breath Average = 4500 ml
Residual Volume (RV) minimum volume
of air remaining in the lungs even after a
maximal expiration. Average = 1200 ml
Total Lung Capacity (TLC) maximum
volume of air the lungs can hold
Average = 5700 ml

What are ABGs ?

Arterial Blood Gases
Measurement of bodys acid/base
balance
Indicator of bodys oxygenation status
Most often drawn from radial artery;
usually by RT

Normal ABG Values

PH

7.35 7.45
Acid --------------- Alkaline
PCO2 35-45 mm Hg
Partial Pressure of carbon dioxide
HCO3 22-26 mEq/L
MEMORIZE
Bicarbonate
THESE
VALUES !!!
PO2
80-100 mm Hg
Partial Pressure of oxygen

Memory Tools
Normal CO2 is 35
45
Normal PH is 7.35
7.45
Tip:
Notice that both the
CO2 and PH have
a 35 and 45 in them

Normal HCO3
(Bicarbonate) is 22-26
Tip:
Many a new driver
buys
their own first car
between 22-26 y.o
Think of Bicarbonate as
buycarbonate

What is the difference between

PO2 and SaO2?
PO2 ( from the ABG) reflects the
amount of dissolved O2 in the blood
SaO2 ( from pulse oximetry ) reflects
the percentage of hemoglobin that is
saturated with O2
Normal SaO2 = 95-98%
The O2 bound to hemoglobin does not
contribute to the PO2 of the blood

Carbon Dioxide
transportation
Only 10% of CO2 is physically
dissolved in blood
30% CO2 is bound to hemoglobin
Majority of CO2 ( 60%) is transported
as
Bicarbonate HCO3
CO2 + H2O =

H2CO3 =
(carbonic acid)

H + HCO3

CO2 and H Relationships

Carbon Dioxide Results in
Hydrogen

CO2 + H2O =

H2CO3 =

Free

H + HCO3

More Hydrogen = Lower PH

ACIDOSIS

CO2 and H Relationships

Carbon Dioxide Results in
Hydrogen

CO2 + H2O =

H2CO3 =

Free

H + HCO3

Less Hydrogen = Higher PH

ALKALOSIS

Acid Base Mnemonic

ROME

R Respiratory
O Opposite
pH up PCO2 down = Alkalosis
pH down PCO2 up = Acidosis
M Metabolic
E Equal
pH up
HCO3 up = Alkalosis
pH down HCO3 down = Acidosis

Steps for ABG Analysis

1. Evaluate the PH
< 7.35 is Acidosis
> 7.45 is Alkalosis

PH = 7.29

Steps for ABG Analysis

2.

Evaluate VENTILATION

PCO2 > 45 indicates Respiratory Acidosis

PCO2 < 35 indicates Respiratory Alkalosis

PCO2 = 47

Steps for ABG Analysis

3.

Evaluate METABOLIC PROCESSES

HCO3 < 22 reflects Metabolic

Acidosis
HCO3 > 26 reflects Metabolic
Alkalosis
HCO3 = 24

Steps for ABG Analysis

4. Evaluate OXYGENATION
PO2
PO2
PO2
PO2

80-100
60-80
40-60
< 40

= normal
= mild hypoxia
= moderate hypoxia
= severe hypoxia
PO2 = 58

Steps for ABG Analysis

5. Evaluate COMPENSATION
Is compensation taking place?
Yes if PH within normal limits and:
Compensated
Compensated
Compensated
Compensated

PH 7.37

Respiratory Acidosis = Increased HCO3

Respiratory Alkalosis = Decreased HCO3
Metabolic Acidosis = Decreased PCO2
Metabolic Alkalosis = Increased PCO2

PCO2 46

HCO3

29

PO2

77

Sample NCLEX Question

A nurse reviews the arterial blood gas result
of a client and notes the following:
PH 7.45, PCO2 30 mmHg, HCO3 21 mEq/L.
PO2 = 78
The nurse analyzes these results as
indicating:
a.
b.
c.
d.

Metabolic acidosis, compensated

Metabolic alkalosis, uncompensated
Respiratory alkalosis, compensated
Respiratory acidosis, uncompensated

Causes of Respiratory
Acidosis
Any condition that causes an
obstruction of airway or depresses
respiratory status
Hypoventilation
Sedatives, narcotics, anesthetics
COPD
Atelectasis and/or pneumonia
Pulmonary edema

Assessment of Respiratory
Acidosis
RR increases in rate and depth
(attempt to compensate blow off CO2)
Hypoxia S/S: ha, restlessness, mental
status changes, cyanosis
Hyperkalemia
(excess H moving into cells / K moves
out into blood)
Dysrhythmia leading to V-Fib
Muscle weakness

Interventions for Respiratory

Acidosis
O2 administration and med/neb treatments
HOB elevated
Increase flds to thin secretions/ IV flds to dilute
K
Low carb, Hi fat diet to reduce CO2 production
Deep breathing / pursed lips
Possible ventilator support
Drug therapies:
- bronchodilators and corticosteroids
- mucolytics

Causes of Respiratory
Alkalosis
Any overstimulation to respiratory
system
Hyperventilation
Severe anxiety
Overventilation on mechanical vents
Increased metabolism fever
Pain
Hypoxia in some cases ( ie: high altitudes
and initial stages of pulmonary emboli)

Assessment of Respiratory
Alkalosis
Initial hyperventilation and tachypnea
(in effort to compensate)
Hypoxia S/S: ha, lightheadness,
mental status changes
Muscle cramping can lead to tetany
and convulsions
Numbness/ Tingling of extremities
Hypokalemia and hypocalcemia

Interventions for Respiratory

Alkalosis
Encourage appropriate breathing
patterns
Re-breathing techniques
Anxiety control
O2 therapy with caution

Nursing Diagnoses
Impaired gas exchange
Ineffective airway clearance
Ineffective breathing pattern
Risk for infection
Activity intolerance
Risk for injury
Self-care deficit
+++++++++++++++++++++++++
++++++++

NOC Outcomes
Client will:
Demonstrate improved ventilation and
adequate oxygenation AEB ABG WNL,
clear lung fields, and SaO2 WNL
Demonstrate effective coughing and
clear breath sounds; free of cyanosis &
dyspnea
Maintain a patent airway at all times
++++++++++++++++++++++++++
+++++++

Medications
Bronchodilators Mucolytics
Alupent
Brethine
Isuprel
Proventil
Atrovent
Theophylline

Anti-tuberculars
Isoniazid
Rifampin

Antibiotics

Mucomyst

Antiinflammatory
Corticosteroids:

Dexamethasone
Anti-Leuketrines
Mast Cell Stabilizers