NCM 112 LEC | MEDICAL – SURGICAL NURSING by: tinyya~

OXYGENATION: RESPIRATORY SYSTEM

Current Health History, Physical Examination, Normal & Abnormal breath sounds, breathing patterns

OVERVIEW: Pleural Cavity

- The space enclosed by the pleura, w/c is a thin
layer of tissue that covers the lungs & lines the
interior wall of the chest cavity.

- The pleural cavity aids optimal functioning of the

lugs during breathing. It transmits movements of
the chest wall to the lungs, particularly during
heavy breathing. The closely approved chest wall
transmits pressures to the visceral pleural
surface and hence to the lung.

 Dyspnea  Pain  Cough

 Orthopnea  Cyanosis  Fatigue
 Precipitating factors  Accumulation of mucus  Clubbing of fingers
 Frequency of DOB  Sputum production  Weakness
 Effect on activity  Hemoptysis  SOB

 Gas Exchange
o External – between environment & lungs
o Internal – between blood & cell
 Ventilation
o Mechanics of breathing in & out
o Muscles contract on inhalation, lifting the ribs & pulling them outward
o Diaphragm moves downwards enlarging the chest cavity
o Reduction in air pressure causes air to enter the lungs
o Expiration reverses these step

1) Health Perception management pattern 7) Self-perception – self-concept pattern

2) Nutritional/metabolic pattern 8) Role relationship pattern
3) Elimination pattern 9) Coping-stress tolerance pattern
4) Actively/exercise pattern 10) Value-belief pattern
5) Cognitive/perceptual pattern 11) Environmental/lifestyle patterns
6) Sleep-rest pattern

Vocabulary:
Hemoptysis – it is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs.
Kussmaul respirations – are fast, deep breaths that occur in response to metabolic acidosis.
NCM 112 LEC | MEDICAL – SURGICAL NURSING by: tinyya~

Vital Signs Adult

Pulse rate (PR) 60 – 100 beats per minute
Respiratory rate (RR) 12 – 20 breaths per minute
Oxygen Saturation (O2 Sat.) 95 – 100%

How would you describe this?

1. Barrel chest happens when the lungs become overfilled (hyperinflated) w/ air like a balloon as they
work harder. This keeps the rib cage open or expanded for a long time.
2. Kyphosis is an exaggerated, forward rounding of the upper back. In older people, kyphosis is often due
to weakness in the spinal bones that causes them to compress or crack.
3. Pectus carinatum is also known as “pigeon chest” is a deformity of the chest wall in w/c the
breastbone & ribs are pushed outward. The condition occurs in about 1 out of 1,500 children & more
frequently in boys.
4. Pectus excavatum is a condition in w/c a person's breastbone is sunken into his or her chest. Severe
cases can eventually interfere w/ the function of the heart & lungs.
5. Scoliosis is a sideways curvature of the spine that most often is diagnosed in adolescents.

Vocabulary:
Hemoptysis – it is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs.
Kussmaul respirations – are fast, deep breaths that occur in response to metabolic acidosis.
NCM 112 LEC | MEDICAL – SURGICAL NURSING by: tinyya~

How does spine abnormality affect oxygenation?

 Signals sent from your brain can no longer pass beyond the damage to the spinal cord, so your brain
can no longer control the muscles that you would normally use for inhaling and exhaling. The extent of
your muscle control loss depends on your level of injury & if there is complete or incomplete spinal
cord damage.

 Detecting chest
 Tactile fremitus excursion
o Tactile fremitus is a clinical sign commonly
assessed as part of a routine physical
examination of the lungs.
o Also known as tactile vocal fremitus refers to
the vibration of the chest wall which results
from sound vibrations created by speech or
other vocal sounds. When a person speaks,
airflow from the lungs causes the vocal cords in the larynx to vibrate. These vibrations, w/c is
also known as vocal fremitus, are transmitted down the tracheobronchial tree & through the
lung tissue to the chest wall, where they can be felt by the hand as a palpable vibration.

1) Vesicular – rustling sounds, higher pitch on inspiration, fades on expiration

2) Bronchovesicular – equal lung sounds during inspiration to expiration periods
3) Tracheal – I/E are both loud

Vocabulary:
Hemoptysis – it is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs.
Kussmaul respirations – are fast, deep breaths that occur in response to metabolic acidosis.
NCM 112 LEC | MEDICAL – SURGICAL NURSING by: tinyya~

Auscultation sites for anterior and posterior lungs/thorax

 Breath sounds
o Vesicular sounds – normal-heard over periphery; gentle rustling sounds; fades on expiration
o Bronchial sounds – normal-heard over suprasternal notch; LOUDER – expiratory lasts longer;
silent internal
o Bronchovesicular – normal-heard 1st & 2nd intercostal space anteriorly and between scapulate
posteriorly; intermediate intensity

 Other Breath sounds

o Pleural rub – it is an adventitious breath sound which results from the movement of inflamed
& roughened pleural surfaces against one another during movement of the chest wall
o Crackles/rales (course & fine) – are a higher-pitched sound sometimes called crackles or
bibasilar crackles
o Wheezes/inspiratory stridor – Wheezing is a musical sound produced primarily during
expiration by airways of any size. Stridor is a single pitch, inspiratory sound that is produced by
large airways with severe narrowing

 Breathing patterns
o Eupnea – normal, good, healthy & unlabored breathing, sometimes known as quiet breathing
or a resting respiratory rate
o Bradypnea – it is an abnormally slow breathing rate
o Tachypnea – it is abnormally rapid breathing
o Hypoventilation – it is breathing that is too shallow or too slow to meet the needs of the body
o Hyperventilation/Kussmaul’s respiration – it is rapid or deep breathing, usually caused by
anxiety or panic & is also called as over breathing
o Apnea – it is a potentially serious sleep disorder in w/c breathing repeatedly stops & starts
o Cheyne-strokes – it is a type of breathing disorder characterized by cyclical episodes of apnea
& hyperventilation.
o Biot’s respiration – a pattern that is characterized by regular deep respirations interspersed
with periods of apnea

Vocabulary:
Hemoptysis – it is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs.
Kussmaul respirations – are fast, deep breaths that occur in response to metabolic acidosis.
NCM 112 LEC | MEDICAL – SURGICAL NURSING by: tinyya~

Safety considerations:
 Perform hand hygiene  Be organized and systemic in your assessment
 Introduce yourself to the patient  Use appropriate listening & questioning skills
 Verify patient’s identity using 2 identifiers  Listen & attend to patient cues
(name & b-day)  Ensure patient privacy and dignity
 Explain procedures to the patient  Document according to agency guidelines

(data that we can observe with our senses)

1. Observe the work of breathing including use of accessory muscles
a. Increased work of breathing may be observed through a spectrum of responses including a
small amount of nasal flaring through to use of all accessory muscles. It is also associated w/ an
increased RR
b. The patient may appear distressed and/or feel anxious. Likewise, they may not appear
distressed, depending on the severity & other comorbidities. Ability to speak may be affected
c. Unusual findings should be followed up with a focused respiratory assessment
2. Expansion/Retraction of chest wall
a. Assess RR by inconspicuously observing breathing. One way to do this is to palpate radial pulse
for a full min. but use some of that time to count respirations
b. Likewise, placing your hand on the patient’s chest & counting the rise & fall cycles
c. The chest wall should expand & contract symmetrically. If not, consider if this is a new or pre-
existing condition
d. Chest expansion may be asymmetrical w/ conditions such as ‘atelectasis, pneumonia, fractured
ribs, pneumothorax, or hemothorax’
e. Normal RR (per min.)
 Newborn: 30-60
 Infant [6 months]: 30-50
 Toddler [2 yrs.]: 25-32
 Children [3-12 yrs.]: 20-30

Vocabulary:
Hemoptysis – it is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs.
Kussmaul respirations – are fast, deep breaths that occur in response to metabolic acidosis.
NCM 112 LEC | MEDICAL – SURGICAL NURSING by: tinyya~

 Adolescents [13-18 yrs.]: 12-20

 Adults: 12-20
f. If patient’s respiratory status is stable, it may be appropriate to count respirations for 30 secs. &
multiply by 2 to determine RR.
3. Pulse oximetry
a. Consists of a probe w/ a light-emitting diode (LED) attached to the pt.’s finger, forehead, or ear.
b. The light wavelengths are absorbed differently by the oxygenated & deoxygenated Hgb
molecules. The receiving sensor measures the amount of light absorbed by the oxygenated &
deoxygenated Hgb in the arterial (pulsatile) blood.
c. Normal SpO2 is 95-100%
4. Auscultate breath sounds anterior & posterior for quality of air entry & any adventitious sounds
a. Assess bilaterally comparing one side w/ the other in a systematic fashion
b. Diminished air entry may indicate atelectasis, pneumonia, hemothorax, pneumothorax, or
collapsed lung
c. Presence of crackles or wheezing must be further assessed, documented, and reported. If such
things are affecting the patient negatively, intervention is needed.]
d. Crackles may indicated mucous r/t asthma or COPD, or fluid r/t pulmonary edema
e. Wheezing may indicate bronchoconstriction r/t asthma, bronchitis, or emphysema
f. Friction rub (creaking) may indicate inflammation r/t pleurisy
5. Cough and Sputum
a. The nurse observe coughing & expectorated sputum
b. Reasons for coughing might include bacterial or viral infection, aspiration, or presence of
sputum. Observe & ask if the cough is a concern for the patient
c. If sputum is present, observe or inquire about amount, colour, and consistency. Ask if sputum is
normal for the patient.

 If you don’t already know, ask about Respiratory Distress (COPD, asthma, cystic fibrosis). Presence of
these may provide insight into explaining other respiratory assessment findings.
 Ask about of respiratory medications. People w/ chronic respiratory disease often use one or more
inhaled medications.
 Ask about breathing. Does the person experience trouble w/ breathing or SOB?
 Do they have a cough?
 Is sputum present? If so, what is the amount, color, & consistency? Is this normal?
 Do they smoke? If so, what & how much?
 Ask about environmental exposures that may affect breathing. Some environmental allergies (airborne
nut allergy, perfumes, cleaners) trigger respiratory difficulty.

 If a chest tube is present, ensure the tube is intact & secure & that the drainage system, is functioning.
Auscultate chest sounds, perform a respiratory assessment including palpating for evidence of
subcutaneous emphysema at & near the chest tube insertion site.
 Arterial Blood Gases/ABG (ordered by prescriber or as per agency protocol)

Vocabulary:
Hemoptysis – it is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs.
Kussmaul respirations – are fast, deep breaths that occur in response to metabolic acidosis.
NCM 112 LEC | MEDICAL – SURGICAL NURSING by: tinyya~

 Impaired oxygenation as evidenced by increased respiratory rate and use of accessory muscles to
breathe
 Risk of respiratory infection r/t mucous production associated with COPD
 Readiness to stop smoking

Vocabulary:
Hemoptysis – it is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs.
Kussmaul respirations – are fast, deep breaths that occur in response to metabolic acidosis.