BACHELOR OF SCIENCE IN NURSING:

NCMB 418: CARE OF THE CLIENT WITH LIFE-

THREATENING CONDITIONS, ACUTELY ILL / MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY
SITUATION (ACUTE AND CHRONIC)
COURSE MODULE COURSE UNIT WEEK
1 4 4
Respiratory Assessment, Techniques and Monitoring Systems

✓ Comprehend the course and unit objectives.

✓ Peruse through the study guide prior to class attendance.
✓ Analyze the required learning resources; refer to unit
terminologies for jargons.
✓ Proactively participate in classroom discussions
✓ Participate in weekly discussion board (Canvas).
Answer and submit course unit tasks on time.

At the end of this unit, the students are expected to:

1. Perform safe and quality respiratory assessment techniques and interventions to address the
client’s identified needs/ problems.
2. Offer client health education using selected and appropriate approaches of care for the sick
adult client.
3. Document nursing care and services rendered and processes outcomes of the findings/ result
of the client data.
4. Ensure completeness, integrity, safety, accessibility, and security of information.
5. Adhere to protocols of confidentiality in safekeeping and releasing of records and other
information.
Burns, S. and Delgado, S. (2019). Essentials of Critical Care Nursing, 4th ed. USA: McGraw-Hill

Schumacher, L., & Chernecky, C. C. (2010). Saunders nursing survival guide: critical care &
emergency nursing. St. Louis, Mo.: Elsevier Saunders.

REVIEW ON THE ASSESSMENT OF RESPIRATORY FUNCTION

PURPOSE OF THE RESPIRATORY SYSTEM
§ The lungs, in conjunction with the circulatory system, deliver oxygen to and expel carbon
dioxide from the cells of the body.
§ The upper respiratory system warms and filters air.
§ The lungs accomplish gas exchange.

STRUCTURES OF THE RESPIRATORY SYSTEM

1. Parts of the Upper Respiratory System
§ Nose § Sinuses and nasal passages
§ Pharynx, Tonsils and adenoids
§ Larynx: epiglottis, glottis, vocal cords, and cartilages

Figure 1. The Upper Respiratory System

The Paranasal Sinuses

Cross section of Nasal Cavity

2. Parts of the Lower Respiratory System

§ Lungs, Pleura and mediastinum
§ Lobes of the lungs: Left (upper & lower); right (upper, middle, lower)
§ Bronchi & bronchioles and the alveoli (gas exchange)
Figure 1. The Lower Respiratory System

The lung lobes and the brochial tree

VENTILLATION
▪ Inspiration: contraction of the diaphragm and contraction of the external intercostal muscles
increases the space in the thoracic chamber (lowered intrathoracic pressure causes air to
enter through the airways and inflate the lungs)
▪ Expiration: with relaxation, the diaphragm moves up and intrathoracic pressure increases
(pushes air out of the lungs); expiration requires the elastic recoil of the lungs.=
▪ Inspiration = 1/3 of the respiratory cycle; expiration = 2/3 of the respiratory cycle

RESPIRATION
▪ Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the
body.
▪ Carbon dioxide diffuses from the blood into the air at the alveoli to be removed form the body.

ASSESSTMENT OF BREATH SOUNDS

▪ Normal breath sounds: Vesicular, Bronchovesicular, Bronchial
▪ Abnormal (adventitious) breath sounds:
o Crackles
o Wheezes
o Friction rubs

VENTILLATION PERFUSION (V/Q) RATIO

▪ Ventilation is the movement of air in and out of the lungs.
▪ Air must reach the alveoli to be available for gas exchange.
▪ Perfusion is the filling of the pulmonary capillaries with blood.
▪ Adequate gas exchange depends upon an adequate V/Q ratio, a match of ventilation and
perfusion.
▪ Shunting occurs when there is an imbalance of ventilation and perfusion. This results in
hypoxia.

LUNG CAPACITIES
▪ Tidal volume (TV): air volume of each breath
▪ Inspiratory reserve volume (IRV): maximum volume that can be inhaled after a normal
inhalation.
▪ Expiratory reserve volume (ERV): maximum volume that exhaled after a normal exhalation.
 ▪ Vital capacity (VC): the maximum volume of air exhaled from a maximal inspiration, VC = TV
+ IRV + ERV.
▪ Forced expiratory volume (FEV): volume exhaled forcefully over time in seconds. Time is
indicated as a subscript, usually 1 second.

MEASUREMENT OF VOLUME AND INSPIRATORY FORCE

▪ A spirometer measures volumes of air exhaled and is used to assess lung capacities.
▪ When assessing TV, measure several breaths. TV varies from breath to breath.
▪ Pulmonary function tests assess respiratory function and determine the extent of dysfunction.
▪ Peak flow rate reflects maximal expiratory flow and is frequently done by patients using a
home spirometer.

INSPIRATORY FORCE
▪ Evaluates the effort of the patient in making an inspiration.
▪ A monometer which measures inspiratory effort can be attached to a mask or endotracheal
tube to occlude the airway and measure pressure.
▪ Normal inspiratory pressure is approximately 100 cm H2O.
▪ Force of less than 25 cm usually requires mechanical ventilation.

ARTERIAL BLOOD GAS

▪ Measurement of arterial oxygenation and carbon dioxide levels.
▪ Used to assess the adequacy of alveolar ventilation and the ability of the lungs to provide
oxygen and remove carbon dioxide.
▪ Also assesses acid base balance

PULSE OXIMETRY
▪ A noninvasive method to monitor the oxygen saturation of the blood.
▪ Does not replace ABGs
▪ Normal level is 95-100%.
▪ May be unreliable

DIAGNOSTIC TESTS
▪ Imaging tests: Chest x-ray, CT scan, MRI, Fluoroscopic Studies and Angiography,
Radioisotope procedure-lung Scans, Bronchoscopy, Thoracoscopy
▪ Pulmonary function tests
▪ Arterial blood gases
▪ Sputum tests
▪ Thoracentesis
▪ Biopsies

RESPIRATORY CONDITIONS:
1. UPPER AIRWAY OBSTRUCTION
▪ Causes: Foreign bodies/materials; enlargement of tissues in the wall of airway, pressure on
the walls of the airway, altered level of consciousness
ASSESSMENT:
▪ Inspection (eye)
▪ Palpation (touch)
▪ Auscultation (hearing)
AIRWAY MANAGEMENT
1. OROPHARYNGEAL AIRWAY (OPA)
o Also known as Oral bite block
o Temporary
o Relieves upper airway obstruction
o Tongue relaxation, secretions, seizures
o Not recommended for alert clients
o May trigger gag and cause vomiting
Nursing Responsibility
o Frequent assessment of the lips and tongue to identify pressure areas
o Removed at least q 24 hours to check for pressure areas and to provide oral hygiene

2. NASOPHARYNGEAL AIRWAY
o a.k.a. Nasal trumpet
o Maintains airway patency
o Also used to facilitate nasotracheal suctioning
o Size: French 26-35
Complications
o Bleeding
o Sinusitis
o Erosion of the mucus membranes
Nursing Responsibility
o Assessment of the pressure areas and occlusion due to secretions
o Rotation of tube from nostril to nostril daily

3. LARYNGEAL MASK AIRWAY

Laryngeal Mask Airway
o An ET with a small mask on one end that can be
passed orally over the larynx
o Provides ventilatory assistance and prevent
aspiration
Combitube
o Esophageal/tracheal double lumen airway
o Used for difficult or emergency intubation
o Permits blind placement
4. Endotracheal (ET) tube
o Includes a 15mm adapter at the end for connection to
life support equipment
o Distance marker on the sides for placement
o Inserted into the trachea through the mouth or nose

Insertion of Endotracheal (ET)Tube

o Using laryngoscope to visualize the upper airway
o Inserted through the vocal cords into the trachea
o 2-4 cm above the carina
o Anchored by inflating the cuff
(prevents air leakage and aspiration)
 Confirm proper placement
o Presence of bilateral breath sounds
o Equal
o Suctexcursion during inspiration
o Absence of breath sounds over the stomach
o PETCO2: 35-40 mmHg

Verification: CXR
o Anchor with tape or ET fixation device
o Centimeter marking at the lip is documented during each shift
o 10-14 days of intubation: tracheostomy is usually indicated

Complications:
o Laryngeal and tracheal damage
o Laryngospasm
o Aspiration
o Infection and discomfort
o Vocal cord paralysis (should not be used longer
than 3 week)

MECHANICAL VENTILLATION
• A form of assisted ventilation; takes over all
part of the work performed by the respiratory muscles
and organs
• Indication: impaired patient’s ability to oxygenate and
exchange carbon dioxide
• Main goal: to support gas exchange until the disease
process is resolved

POSITIVE PRESSURE VENTILLATION (PPV)

• Most common form of mechanical ventilation used in the acute care setting
• Forces oxygen into the lungs with each breath through an endotracheal tube or tracheostomy
tube
• Volume-cycled modes (deliver breath until preset tidal volume is reached with each breath)
• Pressured-cycled modes (deliver breath until a preset pressure is achieved within the airway)

MODES OF VENTILLATION
• Ways in which ventilation is triggered, allowing the patient partial or complete control over
their breathing
• Factors affecting selection of ventilator modes:
➢ Underlying pulmonary status
➢ Oxygenation
➢ Presence of spontaneous breathing

Assist-control Ventilation (ACV)

• Delivers a preset volume at a preset rate and whenever the patient initiates a breath (i.e. if
the patient does not initiate a breath within a preset time, the ventilator will deliver a breath)
• Used in patients with weak respiratory muscles
Synchronized Intermittent Mandatory Ventilation (SIMV)
• Delivers a preset volume at a preset rate and is synchronized with the patient’s effort
• Allows spontaneous breathing between ventilated breaths
• Prevents competition between patient and ventilator
• Common mode for patients requiring minimal ventilation
• Used for WEANING for ventilator support

Pressure-controlled ventilation (PCV)

• Delivers positive-pressure breath until a maximum amount of airway pressure is reached,
then the inspiratory phase of the breath stops
• Maximum inspiratory pressure limit is preset to help minimize ventilator-induced lung injury
(VILI)
• Settings are adjusted to achieve a goal tidal volume designated by physician
• Tidal volume goal: based on patient’s weight and pulmonary status

Pressure-regulated volume control (PRVC)

• A type of PCV in which the ventilator makes pressure adjustments to aim for a predetermined
tidal volume
• Using this mode, the ventilator senses any changes in lung compliance (ex. Increase in peak
inspiratory pressure) and reduces the tidal volume until airway pressures are back within
normal range

ADDITIONAL VENTILATORY MODES

Positive end-expiratory pressure (PEEP)
• Holds positive pressure in the alveoli during expiration
• Frequently used as a supplement to most modes of ventilation

Advantages:
• Prevents alveoli from collapsing at end-expiration
• improves oxygenation
• Increases functional residual capacity
• Range: 2 to 24 cmH2O pressure

Disadvantage:
• PEEP greater than 10 cmH2
• Increased intrathoracic pressure that causes decreased venous return and decreased
cardiac output (HYPOTENSION)
• Increase preload with fluids or vasopressors

HIGH LEVELS OF PEEP

• Increased airway pressure
• VILI, hypotension, increased ICP, alveolar ventilation-perfusion mismatch

Constant Positive Airway Pressure (CPAP)

• Similar to PEEP but provides positive pressure during spontaneous breaths
• Increases oxygenation by preventing closure of alveoli at end-expiration thereby maximizing
functional residual capacity (FRC)
 • General range: 5-10 cmH2O; more than 10cmH20 = hypotension/pneumothorax
• Frequently used to wean patients as a non-invasive method

Pressure Support Ventilation (PSV)

• Augments the tidal volume of spontaneous breaths by delivering a preset positive pressure
during inspiration
• Can be added to SIMV and CPAP for weaning
• Range: 8-20 cmH20
• Increases patient comfort by decreasing the amount of work required in each spontaneous
breath

VENTILLATOR SETTINGS
• Individualized settings
• Adjustments are based on ABG measurements and Arterial Oxygen saturations (SaO2)

Vt (Tidal Volume)
• Amount of oxygen delivered to a patient with each preset ventilated breath; 5-15 mL/kg
(average: 10mL/kg)

Back up rate (BUR) or Respiratory rate

• Number of breaths per minute that ventilator is set to deliver; 4-20 breaths/minute

Fraction of inspired oxygen (FiO2)

• Percentage of oxygen delivered by ventilator with each breath 21 - 100%

Inspiratory to Expiratory ratio (I:E Ratio)

• Number of breaths per minute that ventilator is set to deliver 1;2

Sensitivity
• Determines amount of effort patient must generate before ventilator will give a breath
• Too low: patient works harder to obtain a breath
• Too high: patient’s respiratory effort may compete with ventilator

Flow rate
• Determines how fast Vt will be delivered during inspiration
• High – increase airway pressure
• Low – decrease airway pressure

Pressure limit
• Regulates maximum amount of pressure the ventilator will generate to deliver preset Vt
• Ventilated breath will stop when pressure limit is reached

VENTILATION TERMINOLOGIES
Compliance
• Elasticity of the lung tissue
• Decreased compliance = increased resistance to breath
Peak Inspiratory Pressure (PIP)
• Airway pressure at maximum inspiration
• A.K.A. peak airway pressure

Low pressure alarms

• LEAK or DISCONNECTION in ventilator circuit
• Patient not receiving adequate ventilation

High pressure alarms

• PIP has exceeded a safe limit
• Patient at risk of VILI

Volutrauma
• Injury to the lung tissue from over distension of alveoli

Barotrauma
• Injury to the lung tissue from too much pressure on
the airway

Atelectrauma
• VILI from a low intra-alveolar pressure causing collapse of alveoli

MECHANICAL VENTILLATION COMPLICATIONS:

VENTILLATOR - ASSOCIATED PNEUMONIA (VAP) BUNDLES OF CARE
• Elevation of the head of the bed (HOB)
• Daily sedation vacations and assessment of readiness to extubate
• Peptic ulcer disease prophylaxis
• Deep vein thrombosis (DVT) prophylaxis
• Daily oral care with chlorhexidine (added in 2010)

WEANING PATIENT FROM MECHANICAL VENTILLATION:

METHODS OF MEANING:
1. Assist-Control (A/C) ventilation
• Control rate is decreased, patient strengthens respiratory muscle by triggering
more progressive respirations
• Nursing Management:
o WOF: rapid or shallow breathing, use of accessory muscles, decrease in LOC,
increase in CO2 levels, decrease O2 saturation and tachycardia
2. Synchronized Intermittent mandatory Ventilation (SIMV)
• Indicated for patients who satisfied weaning criteria but cannot sustain adequate
spontaneous ventilation for long periods
• As respiratory muscles strengthen, the pressure is decreased
3. T-piece
• Usually used when patient is awake and alert, breathing without difficulty, and has good gag
and cough reflex
• Maintained on oxygen level on the same or greater than oxygen concentration the patient is
receiving in mech vent
 • WOF: respiratory distress and hypoxia

Respiration – the process of gas exchange between atmospheric air and the blood at the alveoli,
and between the blood cells and the cells of the body; exchange of gases occurs due to
differences in partial pressures.
Ventilation – the movement of air in and out of the lungs

Hinkle, J. and Cheever, K. (2017). Brunner & Suddharth’s Textbook of Medical-Surgical Nursing,
14th ed. USA: Wolters Kluwer

Search, read, and understand journals / research articles from Science Direct and EBSCO on the
common causes of ventilator-induced trauma / injuries and management. List them down and then
develop a plan on how you can prevent these from occurring as future nurses to your future patients.
Submit this via Canvas as a 200–300-word essay.

Burns, S. (2018) AACN Essentials of Critical Care Nursing. Mc Graw Hill

Education.

Schumacher L. (2012) Saunder’s Nursing survival guide: Critical Care and

Emergency Nursing. Elsevier