Respiratory Assessment and Symptoms

Respiratory Assessment

• Auscultate lung sounds while the patient takes deep breaths.
• Observe the chest for respiratory effort and symmetry.

Respiratory Symptoms

• Productive cough: May indicate pneumonia.
  • Assess sputum color, crackles, and vital signs (RR, SpO2).
  • Encourage coughing and deep breathing. Avoid cough suppressants.
• Dyspnea (SUBJECTIVE): Respiratory distress.
  • Patients are usually tachypneic.
  • May present with "tripod" positioning.
  • Elevate the head of the bed when dyspnea presents.

Breathing Patterns

• Kussmaul respirations: Constant deep, rapid breathing without pauses.
  • Seen in DKA or metabolic acidosis.
• Cheyne-Stokes: Progressive increase in respiratory depth and rate followed by a period of apnea.

Breath Sounds

• Crackles: Air passing through secretions.
  • Often heard in pneumonia.
  • Typically heard in the bases of the lungs.
  • Should not be present in all lobes.
  • Fine crackles: Soft, high-pitched, like crunching.
  • Coarse crackles: Louder, low-pitched, like Velcro ripping.
• Wheezing: High-pitched sounds caused by air passing through narrow airways.
  • May indicate respiratory distress.
  • Heard in COPD and asthma (typically during dyspnea).
• Rhonchi: Louder and deeper than crackles.
  • Best heard during exhalation in large bronchi (not lung periphery).
• Bronchovesicular: Heard over the sternum anteriorly and between the scapulae posteriorly.

COPD

• Avoid over-oxygenation (patients may need lower spO2 levels).
  • Avoid administering oxygen if spO2 is not low.
• If a COPD patient presents with "anxiety" and SOB, check pulse ox!
• Barrel chest appearance is normal.
• Clubbing may be present.
• Pursed lip breathing is encouraged.

Asthma

• Wheezing is a possible symptom (assess for wheezing with dyspnea).
• Patients often report chest tightness.

Exercise-Induced Bronchospasm

• Wheezing, chest tightness, and dyspnea are possible symptoms.
• Follow up with a provider, prophylactic albuterol inhaler may be needed.
• Encourage exercise with appropriate treatment.

Incentive Spirometer

• Encourage the use of an incentive spirometer to prevent atelectasis and pneumonia.
• Important for post-operative patients, respiratory issues, and prolonged hospitalizations.

Prioritizing

• Perform a focused assessment for priority findings (interview or full head-to-toe assessment can wait).
• Priority findings:
  • RR > 22 or < 12
  • Sudden or severe hypoxia, or if not immediately improving with oxygen.
  • Dyspnea (subjective).
  • Increased work of breathing (objective) - accessory muscle use or depth of respirations.
  • HR > 110 with any acute respiratory symptom.
  • Signs of airway compromise (obstruction or altered mental status).
  • Asymmetry of chest expansion or abnormal breathing pattern.
  • Crackles in ALL lobes.
• Treating low-grade fever is less of a priority than abnormal HR, RR, or pulse ox. BUT if fever > 100.5, the patient is at risk for dehydration (and less able to expectorate).
• Rapid Response Team is used for respiratory distress/hypoxia/airway compromise (not necessary for cough, mild fever, or SpO2 in the high 80s if improved with oxygen).
• First determine the priority issue and then how to intervene.
  • E.g., If SpO2 is the priority finding, administer supplemental oxygen.
  • E.g., If severe pain is impeding respiratory care or directly causing priority findings, treat the pain first (patient will not improve if pain is not addressed).
• Tips:
  • Increasing the head of bed is a universal priority intervention for dyspnea.
  • Perform immediately appropriate nursing interventions before calling the doctor or RRT.
  • BP is not as much of a priority for patients with respiratory issues (ABCs).
  • In the NCLEX world, nurses often don’t call the respiratory therapist (NCLEX wants you to recognize what you can do as the nurse).

Supplemental Oxygen

• Only administer if hypoxia is present.
• If appropriate (low spO2, no COPD, etc.), it is a priority intervention (perform FIRST).
• Patients requiring oxygen via nasal cannula need a portable oxygen tank for ambulation (do NOT discourage ambulation!).

Delegation

• Can delegate hygiene/ADL assistance to a UAP.
  • This includes checking for incontinence ONLY (not assessing the patient).
• CANNOT delegate assessment to a UAP (including the use of the Braden tool).

General Tips

• Resist the urge to go back and change your answers!
• Remember to use OLDCARTS when assessing any chief complaint.
  • There is a time and place for past medical history, family history, etc. but that should wait until after the chief complaint is assessed.
• READ THE QUESTION AND ANSWERS THOROUGHLY.
  • E.g., If the question is asking for subjective data, eliminate all answers that involve objective data and vice versa.

Med Math

• Liters to mL (e.g., 4.5L = 4,500mL).
• Calculate mcg/dose when given an order for medication in mL (e.g., order is for 20mL, but the medication comes in 200mcg/5mL; you will give 800mcg/dose).
• Calculate mL/dose when given an order for medication in mg/mL (e.g., order is for 1,000mcg, but the medication comes in 2mg/mL; you will give 0.5mL/dose).
• kg to pounds (e.g., 140kg = 308 pounds).
• Calculate # tablets/dose while converting mcg to mg (e.g., order is for 100mcg, but the medication comes in 0.1mg/tablet; you will give one tablet).

Respiratory Assessment

• Auscultate breath sounds while the patient takes deep breaths.
• Inspect the chest for respiratory effort and symmetry.

Respiratory Symptoms & Nursing Considerations

• Productive cough may indicate pneumonia.
  • Assess sputum color, crackles, and vital signs (respiratory rate, oxygen saturation).
  • Encourage coughing and deep breathing; do not administer cough suppressants.
• Dyspnea is subjective and indicates respiratory distress.
  • Patients are usually tachypneic.
  • Observe for the "tripod" position.
  • Elevate the head of the bed as the first intervention for dyspnea.

Breathing Patterns

• Kussmaul respirations: constant, deep, rapid breathing without pauses.
  • Seen in diabetic ketoacidosis (DKA) or metabolic acidosis.
• Cheyne-Stokes respirations: progressive increase in respiratory depth and rate followed by a period of apnea.

Breath Sounds

• Crackles: caused by air passing through secretions; often heard in pneumonia.
  • Fine crackles: soft, high-pitched, sound like crunching.
  • Coarse crackles: louder, low-pitched, sound like Velcro ripping open.
• Wheezing: high-pitched sounds caused by air passing through narrowed airways; may indicate respiratory distress.
  • Heard in chronic obstructive pulmonary disease (COPD) and asthma, typically during dyspnea.
• Rhonchi: louder and deeper than crackles.
  • Best heard in large bronchi during exhalation.
• Bronchovesicular breath sounds: heard over the sternum anteriorly and between the scapulae posteriorly.
  • Should not be found in all lobes.

COPD

• Avoid over-oxygenation.
  • Do not administer oxygen if the oxygen saturation (SpO2) is not low.
• If a COPD patient complains of "anxiety" and shortness of breath, check their SpO2.
• Barrel chest appearance is a normal finding.
• Clubbing may be seen.
• Pursed-lip breathing (mouth mostly closed) is encouraged.

Asthma

• May cause wheezing; assess for wheezing when a patient complains of dyspnea.
• Patients often complain of chest tightness.

Exercise-Induced Bronchospasm

• Not a normal finding.
• The patient may experience wheezing, chest tightness, and dyspnea (mimics asthma symptoms).
• Follow up with a provider; the patient may need a prophylactic albuterol inhaler.
• Encourage exercise along with appropriate treatment.

Nursing Interventions

• Encourage the use of an incentive spirometer to prevent atelectasis and pneumonia.
  • Important for post-operative patients, patients with respiratory issues, and those with prolonged hospitalizations.

Prioritizing

• If priority findings are present, perform a focused assessment. A full head-to-toe assessment can wait.
• Priority findings:
  • Respiratory rate (RR) greater than 22 or less than 12 breaths per minute.
  • Sudden or severe hypoxia, or if hypoxia is not immediately improving with oxygen.
  • Dyspnea (subjective).
  • Increased work of breathing (objective): accessory muscle use or depth of respirations.
  • Heart rate (HR) greater than 110 beats per minute along with any acute respiratory symptom.
  • Signs of airway compromise (obstruction or altered mental status).
  • Asymmetry of chest expansion or abnormal breathing pattern.
  • Crackles in all lobes.
• Treating a low-grade fever is less of a priority than abnormal HR, RR, or SpO2, but if fever is greater than 100.5°F, the patient is at risk for dehydration.
• A rapid response team (RRT) is used for respiratory distress/hypoxia/airway compromise, etc. (not necessary for cough, mild fever, or SpO2 in the high 80s if improved with oxygen).
• First determine the priority issue and then how to intervene.
  • Example: if SpO2 is the priority finding, administer supplemental oxygen.
  • Example: if severe pain is impeding respiratory care or directly causing priority findings, treat the pain first.
• Tips:
  • Increasing the head of the bed is a universal priority intervention for dyspnea.
  • Perform all immediately appropriate nursing interventions before calling the doctor or RRT.
  • Blood pressure (BP) is not as much of a priority for patients with respiratory issues (focus on ABCs - airway, breathing, circulation).
  • In NCLEX, nurses usually do not call the respiratory therapist (NCLEX focuses on what you can do as the nurse).

Supplemental Oxygen

• Only administer if hypoxia is present.
• If appropriate (low SpO2, no COPD, etc.), it is a priority intervention.
• Patients requiring oxygen via nasal cannula need a portable oxygen tank for ambulation (do not discourage ambulation!).

Delegation

• You can delegate hygiene/ADL assistance to a UAP (unlicensed assistive personnel).
  • This includes checking for incontinence only (not assessing the patient).
• You cannot delegate assessment to a UAP, including the use of the Braden scale.

General Tips

• Resist the urge to go back and change your answers.
• Remember to use OLDCARTS when assessing any chief complaint.
  • There is a time and place for past medical history, family history, etc., but that should wait until after the chief complaint is assessed.
• Read the question and answers thoroughly.
  • Example: if the question asks for subjective data, eliminate all answers that involve objective data and vice versa.

Med Math

• Liters to milliliters (mL).
• Calculating mcg/dose when given an order for a medication in mL.
• Calculating mL/dose when given an order for a medication in mg/mL.
• Kilograms (kg) to pounds.
• Calculating the number of tablets/dose while converting mcg to mg.

Respiratory Assessment

• Assess respiratory effort and symmetry of respirations during inspection
• Auscultate breath sounds while the patient takes deep breaths
• Observe for respiratory effort and symmetry of respirations during inspection

Symptoms and Nursing Considerations

• Productive cough may be an indicator of pneumonia
• Assess sputum color, crackles, and vital signs for patients with productive cough
• Encourage coughing and deep breathing; do NOT give cough suppressant.
• Dyspnea is a subjective indication of respiratory distress
• Patients experiencing dyspnea are usually tachypneic
• Elevate the head of the bed for patients experiencing dyspnea
• May observe "tripod" position (leaning forward over bedside table)

Breathing Patterns

• Kussmaul respirations are constant deep, rapid breathing without pauses
• Seen in diabetic ketoacidosis (DKA) or metabolic acidosis to correct acidosis
• Cheyne-Stokes respiration involves a progressive increase in respiratory depth and rate, followed by a period of apnea

Breath Sounds

• Crackles are caused by air passing through secretions
• Often heard in pneumonia
• Usually heard in the bases only
• Fine crackles: soft, high-pitched; sound like crunching
• Coarse crackles: louder, low-pitched, sounds like Velcro ripping open
• Wheezing is a high-pitched sound caused by air passing through narrow airways
• May indicate respiratory distress
• Heard in COPD and asthma (typically during dyspnea)
• Rhonchi are deeper and louder than crackles
• Best heard in large bronchi during exhalation (not heard in lung periphery)
• Bronchovesicular sounds are heard over the sternum anteriorly and between the scapulae posteriorly

COPD

• Avoid over-oxygenation in COPD patients (many will need spO2 kept low)
• Do NOT administer oxygen if spO2 is not low
• Barrel chest appearance is a normal finding in COPD
• Clubbing may be seen in COPD
• Pursed lip breathing is encouraged in COPD patients

Asthma

• May cause wheezing
• Patients often complain of chest tightness
• Exercise-induced bronchospasm is not a normal finding
• May experience wheezing, chest tightness, and dyspnea (mimics asthma symptoms)
• Follow up with a provider; may need prophylactic albuterol inhaler
• Encourage exercise along with appropriate treatment

Incentive Spirometer

• Encourage use to prevent atelectasis and pneumonia
• Important for post-operative patients, respiratory issues, and prolonged hospitalizations

Prioritizing

• Perform a focused assessment if priority findings are present (interview or full head-to-toe assessment can wait)
• Priority findings include:
  • RR > 22 or < 12
  • Sudden or severe hypoxia, or if not immediately improving with O2
  • Dyspnea (subjective)
  • Increased work of breathing (objective) - accessory muscle use or depth of respirations
  • HR > 110 along with any acute respiratory symptom
  • Signs of airway compromise (obstruction or altered mental status)
  • Asymmetry of chest expansion or abnormal breathing pattern
  • Crackles in ALL lobes
• Treating low-grade fever is less of a priority than abnormal HR, RR, or pulse ox.
• If fever > 100.5, the patient is at risk for dehydration (and less able to expectorate)
• The Rapid Response Team (RRT) is used for respiratory distress, hypoxia, airway compromise, etc (not necessary for cough, mild fever, or spO2 in the high 80s if improved with O2)
• First determine the priority issue and then how to intervene,
  • For example, if SpO2 is the priority finding, administer supplemental O2
  • For example, if severe pain is impeding respiratory care or directly causing priority findings, treat the pain first (the patient will not improve if pain is not addressed)
• Increasing the head of bed is a universal priority intervention for dyspnea
• Perform all immediately appropriate nursing interventions before calling the doctor or RRT
• BP is not as much of a priority for patients with respiratory issues (ABCs)
• In NCLEX, nurses generally do not call the respiratory therapist (NCLEX expects you to recognize what you can do as the nurse)

Supplemental Oxygen

• Administer only if hypoxia is present
• Priority intervention if appropriate (low spO2, no COPD, etc.) (perform FIRST)
• Patients requiring O2 via nasal cannula need a portable O2 tank for ambulation (do NOT discourage ambulation!)

Delegation

• Can delegate hygiene/ADL assistance to UAP
  • This includes checking for incontinence ONLY (not assessing the patient)
• Cannot delegate assessment to UAP
  • This includes the use of the Braden Tool

### General Tips

• Resist the urge to go back and change your answers!
• Remember to use OLDCARTS when assessing any chief complaint.
  • Use past medical history, family history, etc., after the chief complaint is assessed
• READ THE QUESTION AND ANSWERS THOROUGHLY
• For example, if the question is asking for subjective data, eliminate all answers that involve objective data and vice versa

Med Math

• LitersmL (e.g., 4.5L = 4,500 mL)
• Calculating mcg/dose when given an order for medication in mL (e.g., order 20mL, medication comes in 200mcg/5mL; you will give 800 mcg/dose)
• Calculating mL/dose when given an order for medication in mg/mL (e.g., order 1,000mcg, medication comes in 2mg/mL; you will give 0.5 mL/dose)
• Kgpounds (e.g., 140kg = 308.6 pounds )
• Calculating # tablets/dose while converting mcgmg (e.g., order 100mcg, medication comes in 0.1mg/tablet; you will give 1 tablet)

This quiz covers essential aspects of respiratory assessment, including lung sounds, symptoms like productive cough and dyspnea, and breathing patterns. It emphasizes the importance of recognizing abnormal respiration to facilitate effective patient care. Ideal for nursing and medical students.