Respiratory Assessment and Care

Respiratory care protects life by recognizing early distress, verifying airway/ventilation/perfusion problems, and sequencing interventions that restore gas exchange while treating the cause. These notes are clinical job aids for quick use in triage, wards, ED, and ICU.

Safety anchors: ABCs • SpO₂ targets per policy • Upright positioning early • Ready suction/airway access • Rapid escalation for stridor, silent chest, cyanosis, severe dyspnea, altered LOC

Clinical judgment: Collect cues → identify pattern (airway, ventilation, diffusion, perfusion) → choose and sequence actions → reassess and hand off

Use this pack: Scan tables, practice Quick Checks, then try the NGN mini-item + answer keys.

Policy note: follow unit protocols for oxygen devices/targets, escalation triggers, and isolation/PPE.

1) History & Symptom Interview 🗣️

1.1 Present illness (O.L.D. C.A.R.T.S.)

Onset • Location • Duration • Character (tight/burning/pleuritic) • Aggravating/Relieving (position/exertion) • Timing (nocturnal) • Severity (0–10)

1.2 Dyspnea — D.Y.S.P.N.E.A. 🫀

Degree (rest/exertion) • Yesterday vs today (trend) • Season/trigger (allergens/cold air) • Position (orthopnea/platypnea) • Noise (wheeze/stridor) • Effort (accessory muscles) • Associated (cough/fever/edema/chest pain)

1.3 Cough — C.O.U.G.H.

Character (dry/productive) • Onset/pattern (night/post-viral) • Up (sputum color/amount/odor/blood) • Gravitational (worse supine?) • Hazards (smoke/dust/chemicals)

1.4 Risk factors & background

Smoking/vaping • occupational exposures • pets/mold • travel/TB contacts • asthma/COPD • HF/PE risk • neuro/aspiration • meds (ACE-i cough, opioids) • vaccines • prior intubations/ICU

2) Physical Exam: Normal vs Abnormal 👀👐🔊

2.1 Vitals & general

RR 12–20/min, pattern regular • SpO₂ ≥ target per policy • HR/BP/Temp trendsRed flags: falling SpO₂ despite O₂ • silent chest • cyanosis • altered LOC • RR >30 or <8

2.2 Inspection (look)

Chest symmetry/shape • retractions • accessory muscles • tracheal deviation • clubbing • edema • cyanosis

2.3 Palpation (feel)

Symmetric expansion • Tactile fremitus ↑ with consolidation, ↓ with effusion/air trapping • subcutaneous emphysema (crepitus)

2.4 Percussion (tap)

Note	Meaning	Examples
Resonant	Normal air	Healthy lung
Hyperresonant	Too much air	Emphysema, pneumothorax
Dull / Stony dull	Fluid/solid	Consolidation, effusion

2.5 Auscultation (listen)

Normal: vesicular (peripheral) • bronchovesicular (1st/2nd ICS, between scapulae) • bronchial (trachea)Adventitious: crackles (fluid/alveolar opening) • wheezes (narrowed airways) • rhonchi (secretions) • pleural rub • stridor (upper airway emergency)

Voice tests (consolidation): egophony • bronchophony • whispered pectoriloquy

3) Common Patterns at a Glance 🔄

Pattern	Likely problem	Bedside clues	First moves
Asthma/bronchospasm	Airway narrowing	Wheeze, prolonged expiration	Upright, bronchodilator, calm coaching
Pneumonia/consolidation	Alveoli filled	Fever, productive cough, crackles, ↑fremitus, dullness	O₂ to target, lung expansion, cultures/abx per orders
Pulmonary edema	Fluid in alveoli	Orthopnea, fine crackles, frothy sputum	Sit up, O₂, diuresis per orders
Pleural effusion	Fluid outside lung	↓sounds, stony dull, ↓fremitus	Upright, O₂, possible drainage per orders
Pneumothorax	Air in pleural space	Sudden dyspnea, pleuritic pain, hyperresonance, ↓sounds	O₂, urgent eval; tension → emergent decompression
Pulmonary embolism	Blocked perfusion	Sudden dyspnea, pleuritic pain, clear lungs, tachycardia	O₂, rapid workup, anticoag per orders

Memory aid — M.A.P.: Match findings to Airway, Parenchyma, or Perfusion to pick the right first move.

4) Diagnostics & Monitoring 🧪

Tool	What it shows	Caveats
Pulse oximetry (SpO₂)	Hb saturation estimate	Motion, poor perfusion, nail polish, CO poisoning can mislead; check waveform
Capnography (ETCO₂)	Ventilation status	↓ETCO₂ = hyperventilation/low perfusion; ↑ETCO₂ = hypoventilation
Chest X-ray (A-B-C-D-E)	Airway, Bones, Cardiomediastinum, Diaphragm, Everything else	Compare to prior films; correlate with exam
Lung ultrasound	Effusion, pneumothorax, edema (B-lines)	Operator dependent; great for bedside trends
Spirometry / Peak flow	Obstructive vs restrictive; asthma trends	Effort dependent; use best of three
Microbiology	Sputum culture/viral tests	Proper collection needed; don’t delay empiric care if unstable

ABG/VBG may be ordered for targeted questions; keep FiO₂/device documented with results (full ABG guide is separate).

5) Nursing Diagnoses & Care Plans 🧩

Write: Diagnosis → Related to (R/T) → As evidenced by (AEB) → Goals → Interventions (why) → Evaluation.

5.1 Impaired Gas Exchange

R/T: alveolar–capillary changes, V/Q mismatchAEB: low SpO₂, dyspnea, confusionGoals: SpO₂ within target; RR 12–20; clear mentationInterventions (why): Upright (better V/Q) • titrate O₂ to target (restore gradient) • IS/C&DB hourly while awake (recruit alveoli) • cluster care (↓O₂ demand) • escalate if worsening

5.2 Ineffective Airway Clearance

R/T: secretions, weak cough, painAEB: rhonchi, thick sputum, ineffective coughGoals: Effective cough; clear breath soundsInterventions: Hydration/humidification • huff cough/CPT • suction PRN • bronchodilator/mucolytic per orders • splint incision for cough

5.3 Ineffective Breathing Pattern

R/T: pain, anxiety, neuromuscular limitsAEB: shallow/irregular breaths, accessory musclesInterventions: Analgesia • anxiolysis/non-pharm calming • pursed-lip/diaphragmatic breathing • pace activity

5.4 Risk for Aspiration

HOB ≥30° • swallow screen • appropriate diet/texture • oral suction readiness • enteral tube care per policy

5.5 Activity Intolerance

Pace/rest • pre-oxygenate if ordered • PT/OT • progressive mobility pathway4

6) Interventions Toolkit 🧰

Intervention	How	Why
Positioning	HOB ↑; unilateral disease: good lung down	Improves V/Q matching
Breathing exercises	Pursed-lip, diaphragmatic, incentive spirometer	↓air trapping; recruit alveoli
Airway clearance	Hydrate, humidify, huff cough, CPT, suction PRN	Mobilize secretions
Oxygen therapy	Cannula → Venturi → NRB/HFNC/CPAP (per order)	Restore O₂ gradient; ↓work of breathing
Energy conservation	Cluster care; rest periods	Match demand to supply
Medication support	Bronchodilators, steroids, mucolytics, diuretics, antibiotics (as ordered)	Treat underlying cause
Monitor & trend	Vitals, SpO₂/ETCO₂, lung sounds, I&O, response	Catch improvement or deterioration early

Memory aid — B.R.E.A.T.H.E.: Breathe with IS • Reposition • Educate cough/splint • Ambulate early • Titrate O₂ • Hydrate/humidify • Evaluate response

7) Patient Education 📝

Inhaler/spacer technique (demo + return demo) • IS & cough routine • hydration for mucus • trigger avoidance & smoke cessation • action plans (asthma/COPD) • vaccinations • when to seek help (worsening dyspnea, chest pain, fever, cyanosis, confusion)

8) Documentation & Handoff 🗎

Subjective symptoms • objective exam (vitals, sounds, percussion, fremitus) • device & settings • interventions and response • sputum character • trends (SpO₂, ETCO₂, peak flow) • SBAR with what is needed next (imaging, RT eval, med changes)

Quick Checks (Retrieval) 🧠✅

1. Name three red flags that require immediate escalation.

2. Which percussion & fremitus changes suggest pleural effusion?

3. Differentiate wheeze vs rhonchi and your first move for each.

4. List three high-value elements in a dyspnea history.

5. Obstructive vs restrictive—how does FEV₁/FVC change?

Answer Key (for review):

1. Stridor/silent chest; falling SpO₂ despite O₂; altered LOC/cyanosis.

2. Stony dull percussion, ↓fremitus.

3. Wheeze = narrowed airways → bronchodilator/position; rhonchi = secretions → hydrate/clear/suction.

4. Onset & triggers; positional effects; associated symptoms (fever/chest pain/edema).

5. Obstructive: ratio decreases; Restrictive: ratio normal/high with both volumes reduced.

6. 
   

NGN-Style Mini Item 🧩

Scenario: 72-year-old with sudden pleuritic chest pain and dyspnea. RR 30, HR 118, BP 132/84, SpO₂ 90% RA. Lungs mostly clear; mild anxiety; no cough.

Select all priority actions:

• ☐ Start O₂ to target and place HOB ↑

• ☐ Encourage IS and vigorous coughing immediately

• ☐ Rapid provider notification; prepare for PE workup per protocol

• ☐ Give large-volume fluids rapidly without orders

• ☐ Trend vitals/SpO₂ and watch for decompensation

Correct: ✅ O₂ + HOB ↑ • ✅ Notify/prepare PE workup • ✅ Trend closelyWhy: Clear lungs with sudden dyspnea/pleuritic pain suggests perfusion problem (possible PE), not a primary secretion issue.

Closing Practice Pearls ✨

A crisp SBAR prevents harm—send the right info to the right person at the right time.Trends beat snapshots. Deteriorating SpO₂ or rising WOB matters more than a single value.Behavior leads numbers. Restlessness often flags oxygen debt before monitors alarm.Position is therapy. Upright and “good lung down” improve V/Q.Clear airways first, then crank O₂. Treat the cause, not just the number.Your presence is a safety device. Verify often; speak up every time.