Nursing Interventions Respiratory

Arterial Blood gas (ABG)

reports the status of oxygenation and acidbase balance of the lbood


the amount of free hydrogen ions in the arterial blood
Normal range 7.35-7.45


Normal range 80-100mm Hg- the partial pressure of oxygen


the partial pressure of carbon dioxide
Normal range- 35-45 mm Hg


the concentration of bicarbonate in arterial blood- Normal range 22-26mEq/L


percentage of oxygen bound to hemoglobin as compared to the total amount that can be possibly carried Normal range 95-100%

Blood pH level below 7.35 reflect ___________, while levels above 7.45 reflect __________.

acidosis, alkalosis


a condition of inadequate levels of oxygen in the blood

signs and symptoms of hypoxemia- early

early- tachypnea, tachycardia, restlessness, pallor of the skin and mucous membranes, elevated blood pressure, symptoms of respiratory distress (use of accessory muscles, nasal flaring, tracheal tugging, adventitious lung sounds)

Signs and Symptoms of Hypoxemia-late

confusion and stupor, cyanosis of skin and mucous membranes, bradypnea, bradycardia, hypotension, cardiac dysrhythmias


chronic inflammatory disorder of the airways. It is an intermittent and reversible airflow obstruction that affects the bronchioles- occurs by either inflammation or airway hyper-responsiveness

Manifestations of Asthma

mucosal edema, bronchoconstricion, excessive secretion production


inflammatory process in the lungs that produces excess fluid. is triggered by infectious organisms or by the aspiration of an irritant.

Community acquired pneumonia (CAP)

most common type and often occurs as a complication of influenza

Hospital acquired pneumonia (HAP)

also known as nosocomial pneumonia, has a higher mortality rate and is more likely to be resistant to antibiotics


airway inflammation and edema leads to alveolar collapse and increase the risk of hypoxemia
diminished or absent breath sounds over affected area
chest x-rays shows area of density

Bactremia (sepsis)

can ocur if pathogens enter the bloodstream from the infection in t he lungs

Tuberculosis (TB)

infectious disease caused by Myobacterium tuberculosis

TB transmission

airborne route- a droplet becomes airborne when an individual coughs, sneezes,... inhalation of this droplet allows transmission of the bacteria

TB primarily affects the ________ but can spread to any organ through the blood.


Preventing transmission of TB

Wear an N95 or HEPA respirator
place the client in a negative airflow room
airborne precations
barrier protection
have client wear mask

Signs and Symptoms of TB

persistent cough, purulent sputum, possibly blood-streaked, fatigue, lethargy, weight loss, anorexia, night sweats, fever

respiratory acidosis- Signs and symptoms

apprehension, confusion, decreased deep tendon reflexes, dyspnea with rapid shallow respiration, nausea and vomiting, restlessness, tachycardia, tremors, warm flushed skin

Allen Test

Continually make fists while compressing radial and ulnar arteries --> Have pt open palm, relase pressure and see whether bld flow is restored. + exam = bld flow not restored and compromise of artery


therapy that uses physical agents: exercise and massage and other modalities, treatment to help loosen secretions

Respiratory alkalosis

anxiety, panic attack, diaphoresis (profuse sweatin), increased respiratory rate and depth, EKG changes, parethesia, tachycarida, tetany


clinical neurological syndrome characterized by muscular twitching and cramps and (when severe) seizures


breath into a paper bag, breathing exhaled CO2 will raise the CO2 level

Metabolic Acidosis signs and symptoms

abdominal cramping, diarrhea, muscle weakness, ECG changes, Kussmal's respiration, lethargy , warm, dry, skin