Respiratory Nursing

Respiratory Nursing

Respiratory conditions are high-priority NCLEX topics because they directly affect oxygenation, a fundamental physiological need. This guide covers chronic obstructive pulmonary disease (COPD), asthma, pneumonia, tuberculosis, mechanical ventilation, chest tubes, and oxygen therapy. For a condensed reference, see the Respiratory Nursing Cheat Sheet.

Chronic Obstructive Pulmonary Disease (COPD)

COPD is a progressive, irreversible airflow obstruction. It encompasses two primary conditions:

• Emphysema ("Pink Puffer"): Destruction of alveolar walls leads to loss of elastic recoil and air trapping. Patients are typically thin, barrel-chested, and use pursed-lip breathing. Dyspnea is the predominant symptom. They maintain relatively normal blood gases until late in the disease.
• Chronic Bronchitis ("Blue Bloater"): Chronic inflammation and excess mucus production in the bronchial airways. Patients present with a productive cough for at least 3 months in 2 consecutive years, cyanosis, peripheral edema from right heart failure (cor pulmonale), and frequent respiratory infections.

Key Nursing Considerations for COPD:

• Administer low-flow oxygen (1-2 L/min via nasal cannula). COPD patients have a hypoxic drive for respiration -- high-flow oxygen can suppress respiratory drive. Target SpO2 of 88-92%.
• Medications include bronchodilators (albuterol, ipratropium), inhaled corticosteroids (fluticasone), and combination inhalers. Short-acting bronchodilator (SABA) first, then inhaled corticosteroid. Rinse mouth after corticosteroid use to prevent oral candidiasis.
• Teach pursed-lip breathing (prolongs exhalation, prevents airway collapse) and diaphragmatic breathing.
• Encourage smoking cessation as the single most important intervention to slow disease progression.
• Administer influenza and pneumococcal vaccines.

Asthma

Asthma is a chronic inflammatory disorder characterized by reversible airway obstruction, bronchospasm, and mucus production. Triggers include allergens, exercise, cold air, infections, and stress.

Status Asthmaticus: A severe, prolonged asthma attack that does not respond to standard treatment. It is a medical emergency. The patient may have absent breath sounds (silent chest -- an ominous sign indicating severe obstruction). Treatment includes continuous nebulized bronchodilators, IV corticosteroids, IV magnesium sulfate, and possible intubation.

Asthma Medications:

• Quick-relief (rescue): Short-acting beta-2 agonists (albuterol). Use for acute symptoms. Always carry rescue inhaler.
• Long-term control: Inhaled corticosteroids (first-line maintenance), long-acting beta-2 agonists (salmeterol -- never used alone, always with ICS), leukotriene modifiers (montelukast), and mast cell stabilizers (cromolyn).
• Teach proper inhaler technique: shake, exhale fully, inhale slowly while pressing canister, hold breath 10 seconds. Use spacer device when possible.
• Peak flow monitoring: Green zone (80-100% personal best = good control), Yellow zone (50-79% = caution, adjust medications), Red zone (less than 50% = medical emergency).

Pneumonia

Pneumonia is an infection of the lung parenchyma causing inflammation and consolidation. Classification includes:

• Community-Acquired Pneumonia (CAP): Develops outside the hospital. Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms (Mycoplasma, Legionella). Treatment with oral or IV antibiotics based on severity.
• Hospital-Acquired Pneumonia (HAP): Develops 48 hours or more after hospital admission. Often caused by resistant organisms (MRSA, Pseudomonas). Requires broad-spectrum antibiotics. Ventilator-associated pneumonia (VAP) is a subset.

Nursing Interventions: Elevate head of bed to at least 30 degrees. Encourage deep breathing and coughing exercises. Incentive spirometry every 1-2 hours while awake. Administer antibiotics as prescribed (obtain cultures before starting antibiotics). Monitor oxygen saturation and respiratory status. Encourage adequate fluid intake to thin secretions. For VAP prevention: elevate HOB 30-45 degrees, perform oral care with chlorhexidine, minimize sedation, assess readiness for extubation daily.

Tuberculosis (TB)

TB is caused by Mycobacterium tuberculosis and primarily affects the lungs. It is spread via airborne droplet nuclei.

• Screening: Mantoux tuberculin skin test (TST) -- read in 48-72 hours; measure induration (not redness). Induration of 5 mm or more is positive in immunocompromised, 10 mm or more in high-risk groups, 15 mm or more in low-risk. Interferon-gamma release assays (IGRA) are blood tests as alternatives.
• Isolation: Airborne precautions are required. Place patient in a negative-pressure room. Healthcare workers must wear N95 respirator masks. Patient wears a surgical mask when being transported.
• Medication Regimen: Standard treatment is RIPE therapy for initial 2 months: Rifampin, Isoniazid (INH), Pyrazinamide, and Ethambutol. Then INH and Rifampin continue for 4 additional months (total 6-9 months). Key side effects: INH causes peripheral neuropathy (give vitamin B6/pyridoxine) and hepatotoxicity; Rifampin turns body fluids orange-red (including urine, tears, sweat); Ethambutol causes optic neuritis (monitor visual acuity). Directly Observed Therapy (DOT) ensures adherence.

Mechanical Ventilation

Mechanical ventilation provides respiratory support when a patient cannot maintain adequate ventilation independently.

Common Modes:

• Assist-Control (AC): Delivers a set number of breaths at a set tidal volume. Patient can trigger additional breaths, but each receives the full tidal volume. Risk of hyperventilation.
• SIMV (Synchronized Intermittent Mandatory Ventilation): Delivers set number of mandatory breaths synchronized with patient effort. Spontaneous breaths between mandatory breaths are at whatever tidal volume the patient generates. Used for weaning.
• Pressure Support (PS): Augments spontaneous breaths with positive pressure. Patient controls rate, tidal volume, and inspiratory time. Used for weaning.
• PEEP (Positive End-Expiratory Pressure): Maintains positive pressure at end of expiration to prevent alveolar collapse. Standard 5 cm H2O. Higher PEEP used in ARDS.

Nursing Care: Monitor ventilator settings, alarm parameters, and patient response. Maintain HOB elevation at 30-45 degrees. Perform oral care every 2 hours. Assess for complications: barotrauma (pneumothorax), ventilator-associated pneumonia, and decreased cardiac output from positive pressure. Verify ETT placement (equal bilateral breath sounds, end-tidal CO2 monitoring, chest X-ray).

Weaning: Assessed by spontaneous breathing trials (SBT). Criteria include resolution of underlying condition, adequate oxygenation on minimal settings, hemodynamic stability, and ability to protect airway. Monitor respiratory rate, tidal volume, and rapid shallow breathing index (RSBI less than 105 indicates readiness).

Chest Tubes

Chest tubes drain air, blood, or fluid from the pleural space to restore negative intrapleural pressure and re-expand the lung.

• Water-seal chamber: Should have a fluid level that fluctuates with respiration (tidaling). This is normal and indicates the system is patent. Cessation of tidaling may indicate lung re-expansion or tube obstruction.
• Suction control chamber: Gentle continuous bubbling is expected when suction is applied.
• Continuous bubbling in the water-seal chamber indicates an air leak. Check all connections. If the leak persists, notify the provider.
• Key Nursing Interventions: Keep the drainage system below chest level. Never clamp a chest tube unless specifically ordered (risk of tension pneumothorax). Monitor drainage amount, color, and consistency. Report drainage exceeding 100-200 mL/hr (may indicate hemorrhage). Keep petroleum gauze at bedside for accidental dislodgement. Encourage coughing, deep breathing, and position changes to promote drainage and lung expansion.

Oxygen Therapy

Match the oxygen delivery device to the patient's needs:

Device	Flow Rate	FiO2 Delivered
Nasal Cannula	1-6 L/min	24-44%
Simple Face Mask	5-8 L/min	40-60%
Venturi Mask	4-12 L/min	24-50% (precise)
Non-Rebreather Mask	10-15 L/min	80-95%

The Venturi mask is the preferred device for COPD patients because it delivers precise, controlled FiO2. The non-rebreather is used for acute hypoxemia and is the highest concentration non-invasive delivery device. Always ensure the reservoir bag remains inflated.

ABG Correlation

Arterial blood gases help assess respiratory and metabolic function. Normal values: pH 7.35-7.45, PaCO2 35-45 mmHg, HCO3 22-26 mEq/L, PaO2 80-100 mmHg. Use the ROME mnemonic: Respiratory Opposite (pH and PaCO2 move in opposite directions), Metabolic Equal (pH and HCO3 move in the same direction). Compensation occurs when the unaffected system adjusts to normalize pH. For a deeper review, see the Physiological Study Guide and practice with Physiological Flashcards.