Respiratory assessment

Look, listen, and measure — and trend the findings.

Early hypoxiaRestlessness, anxietyNew confusionTachycardiaTachypneaElevated blood pressureLate hypoxiaCyanosisBradycardiaHypotensionDecreasing consciousnessRespiratory arrest riskvs
Hypoxia cues. Never treat restlessness with a sedative before checking oxygenation.
Breath soundWhat it suggests
Crackles (fine or coarse)Fluid in small airways: pneumonia, heart failure, atelectasis
WheezesNarrowed airways: asthma, COPD
RhonchiSecretions in larger airways; may clear with coughing
StridorUpper-airway obstruction: an emergency
Diminished or absentPoor air movement, pneumothorax, effusion, or consolidation
Pleural friction rubInflamed pleura; grating sound that does not clear with coughing

Also assess rate, rhythm, depth, accessory muscle use, tripod positioning, ability to speak in full sentences, and SpO₂.

Pneumonia

A leading cause of hospitalization and a frequent NCLEX scenario.

Pneumonia careOxygenateO₂ to orderedtarget; HOB upTreatCultures, thenantibiotics on timeClear airwayCough, deep breathe,fluidsPreventVaccines, aspirationcare
Pneumonia. Older adults may present with confusion or falls rather than fever and cough.
  • Cues: fever, chills, productive cough, pleuritic chest pain, crackles or bronchial breath sounds over the affected area, tachypnea, low SpO₂.
  • Prevention: pneumococcal and influenza vaccines, hand hygiene, early mobility, oral care, head of bed at least 30° for tube-fed clients, swallow screening.
  • Incentive spirometry: sit upright, exhale, seal lips around the mouthpiece, inhale slowly and deeply, hold the breath a few seconds, and repeat about 10 times each hour while awake.

Suctioning and tracheostomy care

Airway skills are tested for both technique and emergencies.

AssessCoarsesounds, lowSpO₂Oxygenate100% O₂ firstInsertSterile; nosuctionWithdrawSuction≤10–15 sReassessRest,re-oxygenate
Suctioning. Limit passes; stop for bradycardia, dysrhythmia, or falling SpO₂.
Tracheostomy situationNursing action
Routine careClean the stoma and inner cannula per policy; keep one finger of space under the ties; change ties with a second person holding the tube
CuffKeep cuff pressure within the ordered range (commonly about 20–30 cm H₂O) to protect the tracheal wall
Bedside equipmentObturator, spare tubes (same size and one size smaller), suction, oxygen, and a bag-valve device
Accidental dislodgementCall for help; with a mature tract, reinsert using the obturator; with a fresh tract (about the first week), oxygenate and ventilate per protocol rather than forcing a tube
Cannot pass a suction catheterSuspect obstruction: remove the inner cannula, then follow the emergency protocol

Clients with a tracheostomy cannot speak with an inflated cuff; provide a communication board.

Ventilator alarms

Know the common causes so you can respond quickly.

High-pressure alarmSecretions: suctionCoughing or biting the tubeKinked tubingBronchospasmPneumothoraxLow-pressure alarmDisconnection: reconnectCuff leakTubing leakTube displacedCheck all connectionsvs
Ventilator alarms. If the cause cannot be found and corrected quickly, disconnect and ventilate manually with a bag-valve device and call for help. Never silence an alarm without assessing the client.

Interpreting arterial blood gases

A step-by-step method avoids errors.

StepspHBelow 7.35 acidosis; above 7.45 alkalosisPaCO₂Respiratory: moves opposite to pH (35–45)HCO₃⁻Metabolic: moves in the same direction as pH (22–26)MatchWhich value explains the pH abnormality?CompensationIs the other system moving to correct it?
ABG steps. Memory aid ROME: Respiratory Opposite, Metabolic Equal (direction of pH vs the causative value).

NGN-style case

Recognizing respiratory failure.

functions Clinical judgment case — the drowsy postoperative client

A client on a morphine PCA 1 day after abdominal surgery is difficult to arouse. RR 8/min and shallow, SpO₂ 86% on room air. ABG: pH 7.28, PaCO₂ 58 mm Hg, HCO₃⁻ 25 mEq/L. What is happening, and what should the nurse do first?

  1. Recognize cues: oversedation, slow shallow breathing, hypoxemia.
  2. ABG: pH low (acidosis); PaCO₂ high (respiratory, moving opposite to pH); HCO₃⁻ normal (no compensation yet) — uncompensated respiratory acidosis.
  3. Stop the PCA, stimulate the client, support the airway and breathing, and apply oxygen.
  4. Give naloxone per protocol, call the rapid response team, and monitor closely, because naloxone can wear off before the opioid.

Answer. Opioid-induced respiratory depression causing uncompensated respiratory acidosis. Stop the opioid, support breathing, and give naloxone per protocol.