Vital Signs Assessment of Respirations PDF

ASSESSING RESPIRATIONS NURS 1090  Process of inspiration Respiration and expiration ASSESSING To breathe RESPIRATIO Inspiration...

ASSESSING RESPIRATIONS NURS 1090  Process of inspiration Respiration and expiration ASSESSING To breathe RESPIRATIO Inspiration in; take oxygen into NS (inspire, inhale, lungs/excha nge for TERMINOLO inhalation) carbon GY dioxide To breathe Expiration out; carbon (expire, exhale, dioxide exhalation) expelled from body INSPIRATION AND EXPIRATION  PHYSIOLOGIC CONTROL OF RESPIRATION RESPIRATORY CONTROL - INVOLUNTARY RESPIRATIONS CONTROLLED BY: MEDULLA OBLONGATA AND PONS OF BRAIN RECEPTOR SITES IN THESE AREAS RESPOND TO LEVELS OF CO2 AS CO2 ACCUMULATES IN BLOOD, IMPULSES SENT TO THE RESPIRATORY CENTERS IN BRAINSTEM (MEDULLA) AND RATE AND DEPTH OF RESPIRATIONS ARE INCREASED RECEPTOR SITES IN AORTIC ARCH AND CAROTID ARTERIES INDUCE RESPIRATION WHEN OXYGEN LEVELS FALL BELOW NORMAL  PHYSIOLOGIC CONTROL OF RESPIRATION RESPIRATORY CONTROL – VOLUNTARY CAN BE CONTROLLED TO A CERTAIN POINT TALKING, SINGING INCREASED LEVELS OF CO2 WILL TRIGGER INVOLUNTARY CONTROL  RESPIRATORY RATES ONE BREATH (IN & OUT); LISTED AS BREATHS PER MINUTE EUPNEA 12-20 IN ADULT TACHYPNEA > 20 (QUICK, SHALLOW BREATHS) BRADYPNEA < 12 (ABNORMALLY SLOW BREATHING) APNEA CESSATION OF BREATHING  Rate Count, within normal limits? Other factors? Depth –degree of movement of chest wall Normal, deep, shallow ASSESSING Rhythm RESPIRATIO Regular, irregular, dyspnea, apnea, orthopnea NS Cheyne-Stokes : alternating periods of very deep to very shallow breathing and Character temporary apnea Amount of effort used; labored, accessory muscles Sounds produced; adventitious, fluid present  Have patient as quiet and comfortable as possible While asleep or at rest Easier if patient is unaware you are counting Sitting is preferred COUNTING Best chest expansion RESPIRATIO Note rise and fall of chest NS Look for movement of chest or clothing May need to lay your hand over chest Count for 30 seconds and multiply by 2 Count for 60 seconds if rate is irregular  FACTORS INFLUENCING RESPIRATORY RATE Exercise (↑ metabolism) Stress, anxiety (stimulation of sympathetic nervous system) Pain Certain medications (example: opioid analgesics) Neurological injury  RESPIRATIONS: OLDER ADULT RESPIRATIONS PER MINUTE DO NOT CHANGE HEALTHY OLDER ADULTS HAVE NORMAL BREATHING PATTERNS (12-20/MINUTE) CHEST EXPANSION OFTEN DECREASED DUE TO ALTERATIONS IN SHAPE OF THORACIC CAVITY DECLINE IN ELASTIC RECOIL OF LUNGS INCREASED WORK OF BREATHING DECREASED PHYSIOLOGIC RESERVE PULSE OXIMETRY PULSE OXIMETER  PULSE OXIMETRY “PULSE OX” VALUES NORMAL - ≥96% NON-INVASIVE DEVICE – < 92 – NEEDS OXYGEN = FINGER SENSOR CHANGE IN LEVEL OF MAY ALSO USE EARLOBE, CONSCIOUSNESS (LOC) TOES, FOREHEAD < 84 – GROGGY; RESTLESS; MEASURES ARTERIAL BLOOD LETHARGIC OXYGEN SATURATION < 80 – UNCONSCIOUS DETECTS AMOUNT OF OXYGEN < 70 – LIFE THREATENING BOUND TO HEMOGLOBIN  FACTORS INFLUENCING PULSE OXIMETER READINGS DARK NAIL POLISH PATIENT MOVEMENT DECREASED CIRCULATION PLACEMENT OF SENSOR