1 of 28

Course: Medical Surgical Nursing

Topic: Gas Exchange and Respiratory Function

The Nurses International Community

Contact info: info@nursesinternational.org

2 of 28

COPYRIGHT

NI Privacy Policy and Terms of Use.

Contact info: info@nursesinternational.org

3 of 28

Module Goals

Learners will be able to:

Describe the Anatomy of the Respiratory System.
Describe the Function of the Respiratory System.
Describe the Assessment of the Respiratory System.
Describe the nurse’s role in the assessment and evaluation of the Respiratory System.

Contact info: info@nursesinternational.org

4 of 28

Respiratory System: Anatomy

Lindsay et al.,2019

Contact info: info@nursesinternational.org

5 of 28

Respiratory System: Functions

Primary functions:

Provide oxygen to body tissues
Remove waste product carbon dioxide
Maintain acid-base balance

Non-vital functions:

Sensing odors
Speech production

Lindsay et al.,2019

Contact info: info@nursesinternational.org

6 of 28

Case Study/ Critical Thinking Question/ What Would the Nurse Do?

List the organs of the respiratory system and their main functions.

List the functions of the respiratory system.

Where does the gas exchange occur?

Contact info: info@nursesinternational.org

7 of 28

Respiratory System: Subjective Assessment

Cough (productive/nonproductive)
Hoarseness, or barking cough
Sputum characteristic (clear, purulent, blood tinged, rusty, or pink and frothy)
Dyspnea with or without activity
Wheezing, or stridor
Chest pain (on inspiration, expiration, or with coughing and location and quality of pain)

Fritz, 2015

Contact info: info@nursesinternational.org

8 of 28

Respiratory System: Interview questions

Have you ever been diagnosed with asthma, COPD, pneumonia, or allergies?
Do you use oxygen or a peak flow meter?
Do you use home respiratory equipment like CPAP, BiPAP, or nebulizer devices?
Are you currently taking any medications, herbs, or supplements for respiratory concerns?
Have you had any feelings of breathlessness?
Do you have a cough?
Do you smoke or vape?

(Ernstmeyer & Christman, 2021)

Contact info: info@nursesinternational.org

Follow up questions for shortness of breath:

Are you having any shortness of breath now? If yes, please rate the shortness of breath from 0-10 with “0” being none and “10” being severe?
Does anything bring on the shortness of breath (such as activity, animals, food, or dust)? If activity causes the shortness of breath, how much exertion is required to bring on the shortness of breath?
When did the shortness of breath start?
Is the shortness of breath associated with chest pain or discomfort?
How long does the shortness of breath last?
What makes the shortness of breath go away?
Is the shortness of breath related to a position, like lying down? Do you sleep in a recliner or upright in bed?
Do you wake up at night feeling short of breath? How many pillows do you sleep on?
How does the shortness of breath affect your daily activities?

Cough:

When you cough, do you bring up anything? What color is it?
Do you cough up any blood (hemoptysis)?
Do you have any associated symptoms with the cough such as fever, chills, or night sweats?
How long have you had the cough?
Does anything bring on the cough (such as activity, dust, animals, or change in position)?
What have you used to treat the cough? Has it been effective?

Smoke:

What products do you smoke/vape? If cigarettes are smoked, how many packs a day do you smoke?
How long have you smoked/vaped?
Have you ever tried to quit smoking/vaping? What strategies gave you the best success?
Are you interested in quitting smoking/vaping?

9 of 28

Respiratory System: Objective Assessment

Evaluate vital signs (Respiratory rate, oxygen saturation)
Inspection
Palpation
Auscultation
Percussion

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

10 of 28

Respiratory System: Inspection

Observation:

Facial expression
Level of consciousness
Breathing rate (full minute)
Pattern and effort, use of accessory muscles
Skin color
Chest configuration
Symmetry of expansion
Clubbing

Contact info: info@nursesinternational.org

Observe the depth of respiration and note if the respiration is shallow or deep. Pursed-lip breathing, nasal flaring, audible breathing, intercostal retractions, anxiety, and use of accessory muscles are signs of respiratory difficulty.
Observe pattern of expiration and patient position. Patients who experience difficulty expelling air, such as those with emphysema, may have prolonged expiration cycles. Some may experience difficulty with breathing specifically when lying down. This symptom is known as orthopnea.
Cyanosis is a bluish discoloration of the skin, lips, and nail beds, which may indicate decreased perfusion and oxygenation.
Pallor is the loss of color, or paleness of the skin or mucous membranes and usually the result of reduced blood flow, oxygenation, or decreased number of red blood cells.

Symmetry and configuration:

The trachea should be midline, and the clavicles should be symmetrical

Chest movement should be symmetrical on inspiration and expiration.

Expected finding:

Work of breathing effortless
Regular breathing pattern
Respiratory rate within normal range for age
Chest expansion symmetrical
Absence of cyanosis or pallor
Absence of accessory muscle use, retractions, and/or nasal flaring
Anteroposterior: transverse diameter ratio 1:2

Unexpected findings:

Labored breathing
Irregular rhythm
Increased or decreased respiratory rate
Accessory muscle use, pursed-lip breathing, nasal flaring (infants), and/or retractions
Presence of cyanosis or pallor
Asymmetrical chest expansion
Clubbing of fingernails

11 of 28

Respiratory System: Inspection

Image: Comparison of Chest with Normal Anterior/Posterior Diameter (A) to a Barrel Chest(B)

Contact info: info@nursesinternational.org

12 of 28

Case Study/ Critical Thinking Question/ What Would the Nurse Do?

What is clubbing and what causes it?

Contact info: info@nursesinternational.org

13 of 28

Respiratory System: Palpation

Use light pressure with the fingertips to examine the anterior and posterior chest wall.
Assess for:

Growths
Masses
Crepitus
Pain, or tenderness

Confirm symmetric chest expansion

Unequal expansion may be present in:

Pneumonia
Thoracic trauma
Pneumothorax

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

14 of 28

Respiratory System: Auscultation

Ernstmeyer & Christman, 2021

Anterior Auscultation Areas

Posterior Auscultation Areas

Contact info: info@nursesinternational.org

15 of 28

Respiratory System: Auscultation

Expected breath sounds in various anatomical locations:

Bronchial breath sounds:

Heard over the trachea and larynx
High-pitched and loud

Bronchovesicular sounds:

Heard over the major bronchi.
Medium-pitched

Vesicular breath sounds:

Heard over the lung surfaces
Lower-pitched, and soft, rustling sounds

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

16 of 28

Auscultation: Adventitious Sounds

Rales/crackles
Rhonchi/wheezes
Stridor
Pleural rub

Lungs sounds: https://www.youtube.com/watch?v=2NvBk61ngDY

Indicate an airway problem or disease:

Accumulation of mucus or fluids in the airways
Obstruction
Inflammation
Infection

Ernstmeyer & Christman, 2021

Contact info: info@nursesinternational.org

Rales/ Crackles:

Are popping or crackling sounds heard on inspiration that occur in association with conditions that cause fluid to accumulate within the alveolar and interstitial spaces, such as heart failure or pneumonia.
The sound is similar to that produced by rubbing strands of hair together close to your ear.

Wheezes:

Are whistling-type noises produced during expiration (and sometimes inspiration) when air is forced through airways narrowed by bronchoconstriction or associated mucosal edema.
For example, patients with asthma commonly have wheezing.

Stridor is heard only on inspiration. It is associated with mechanical obstruction at the level of the trachea/upper airway

Pleural rub may be heard on either inspiration or expiration and sounds like the rubbing together of leather.

A pleural rub is heard when there is inflammation of the lung pleura, resulting in friction as the surfaces rub against each other.

Cheyne-Stokes respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation

Cheyne-Stokes respiration is characterized by alternating apnea and hyperventilation during sleep, mostly in the N1 and N2 sleep, and also when awake. This can be clinically observed and documented with a cyclic variation of breathing pattern with a change in saturation from 90% to 100%.

17 of 28

Case Study/ Critical Thinking Question/ What Would the Nurse Do?

Why are normal breath sounds different at different anatomical locations of the chest wall?

What do adventitious lung sounds indicate?

Contact info: info@nursesinternational.org

18 of 28

Respiratory System: Percussion

Purpose:

Determine the density of the underlying lung tissue.

Procedure:

Place the middle finger of the nondominant hand against the chest wall.
Use the tip of the middle finger on the dominant hand to strike the distal phalanx of the middle finger between the cuticle and the first joint.

Fritz, 2015

Contact info: info@nursesinternational.org

19 of 28

Respiratory System: Percussion (Continued)

Normal Sounds:

Clear
Low-pitched
Hollow, and long in duration, or resonant

Dullness:

Fluid or solid tissue replaces air filled lung
May indicate pneumonia, pleural effusion, or atelectasis.

Very loud, lower pitch, and longer percussion sounds, hyperresonance, when unilateral:

May indicate emphysema or pneumothorax

Ernstmeyer & Christman, 2021

Fritz, 2015

Contact info: info@nursesinternational.org

20 of 28

Case Study/ Critical Thinking Question/ What Would the Nurse Do?

Explain the purpose of and technique for palpation

Contact info: info@nursesinternational.org

21 of 28

Respiratory System: Assessment Checklist

Click the link for the complete checklist for respiratory assessment:

Chest Assessment video

Respiratory Examination

Contact info: info@nursesinternational.org

22 of 28

Respiratory System Assessment: Nurses Role

Ensure the safety measures
Perform respiratory assessment according to checklist
Documentation
Education on:

Healthy diet, exercise
Quitting smoking

Sample of documentation: https://wtcs.pressbooks.pub/nursingskills/chapter/10-4-sample-documentation/

Contact info: info@nursesinternational.org

23 of 28

Case Study/ Critical Thinking Question/ What Would the Nurse Do?

Why is the elder population more at risk for pneumonia?

What health protecting interventions can the nurse do to help diminish the risk?

Contact info: info@nursesinternational.org

Common significant deviations of the chest for older adults include marked dorsal curvature, kyphosis, increased AP diameter of the chest (barrel chest), and diminished chest expansion (Hogstel & Curry, 2005).

Bones become thinner, more rigid, and change shape, and muscles may become weakened. This results in a lower oxygen level with less carbon dioxide removed from the body, and decreased ability to cough.

Aging also causes the alveoli to lose their shape causing shortness of breath.

Due to diminished cough reflex with decreased sensitivity, large amounts of particles that are more difficult to expectorate can collect in the lungs.

In addition, the brain is less sensitive to hypoxia (low oxygen) and hypercapnia (higher than normal carbon dioxide) and higher residual volume.

As a result of these changes, older persons are at increased risk for pneumonia and bronchitis (Minaker, 2001; Sharma & Goodwin, 2006).

The nurse can encourage elders to practice deep breathing and coughing as part of their daily exercise and hygiene routine.

Encourage elders to take calcium supplements and perform low impact aerobic exercise (walking, stationary biking, marching in place with support of chair or counter).

Encourage elders to perform safe sitting stress resistant exercises using low weight weights.

Encourage safe and increased activity levels, participation in senior exercise groups. Encourage client to stop smoking.

24 of 28

Red Flags

Labored breathing
Irregular rhythm
Increased or decreased respiratory rate
Accessory muscle use, pursed-lip breathing, nasal flaring (infants), and/or retractions.
Presence of cyanosis or pallor
Asymmetrical chest expansion
Clubbing of fingernails
Adventitious sounds

Contact info: info@nursesinternational.org

25 of 28

Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

Contact info: info@nursesinternational.org

26 of 28

Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

27 of 28

References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals. By Chippewa Valley Technical College, licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingfundamentals/

Fritz, D. (2015). Assessment of Respiratory System. Home Healthcare Now: September 2015 - Volume 33 - Issue 8 - p 414-418. doi: 10.1097/NHH.0000000000000283. https://journals.lww.com/homehealthcarenurseonline/fulltext/2015/09000/assessment_of_the_respiratory_system.3.aspx#:~:text=A%20focused%20assessment%20of%20the,breath

Lindsay et al. (2019). Anatomy and physiology. By Open Oregon State University, licensed under CC BY 4.0. https://open.oregonstate.education/aandp/

Contact info: info@nursesinternational.org

28 of 28

Please go to

My Learning Experience

to provide feedback on your experience.

Thank you, and come back soon!

Contact info: info@nursesinternational.org