the guided notes, filled in. Based on “Respiratory I: Gas Exchange — Nursing Management of Clients with Upper Respiratory Disorders.”
When assessing a respiratory patient, I should ALWAYS look at:
The two that change first are respiratory rate and mental status. Saturation and skin color change late — do not wait for them.
Respiratory function is the body moving oxygen from the AIR into the CELLS. Five things have to work. Ask which one broke.
Can the patient physically move air?
Examples of ventilation problems:
Poor ventilation causes: ↑CO2 → respiratory acidosis — pH falls, and the patient gets drowsy, headachy, then confused
Problems that interfere:
Result: less oxygen available for exchange.
Oxygen moves: from the alveolus into the pulmonary capillary blood, down its pressure gradient
Carbon dioxide moves: from the blood back into the alveolus, and out with exhalation
Conditions that impair gas exchange:
Even with perfect lungs, oxygen still needs a ride.
Problems:
Low hemoglobin can cause: tissue hypoxia even when SpO2 and PaO2 look normal — there are simply fewer carriers
Perfusion problems:
Respiratory problems usually come down to: poor air movement · blocked alveoli · impaired gas exchange · low hemoglobin · poor perfusion. Name which one before you pick an intervention.
Two different failures. They are treated differently, so name which one you are looking at.
| Ventilation — "move AIR" | Oxygenation — "move OXYGEN" | |
|---|---|---|
| Main problem | CO2 retention — hypercapnia | low oxygen in the blood — hypoxemia |
| What the labs show | ↑PaCO2 with a falling pH (respiratory acidosis) | ↓PaO2 and ↓SpO2, with PaCO2 often normal or low at first |
| Examples | COPD · opioid overdose · hypoventilation | Pulmonary edema · pneumonia · pulmonary embolism |
| Fix aimed at | helping them move air — reverse the sedation, support ventilation, BiPAP | improving exchange — oxygen, treat the pneumonia or the edema |
Oxygen alone does not fix a ventilation problem. If the patient is not moving air, giving more oxygen does not remove the CO2.
| Hypoxemia | Hypoxia | |
|---|---|---|
| Where | Low oxygen in the BLOOD | Low oxygen at the TISSUE |
| Usually caused by | a problem in the lung — V/Q mismatch, shunt, poor diffusion, or hypoventilation | a problem with delivery or use — the lungs may be fine |
| Examples | pneumonia · pulmonary edema · PE · atelectasis · COPD exacerbation | anemia · carbon monoxide poisoning · shock or low cardiac output · severe hemorrhage |
A patient can have normal lungs and still be hypoxic. That is the whole point of this section — anemia, carbon monoxide, and shock all starve tissue while the lungs look fine.
When a patient deteriorates, ask which of the four broke:
| Early signs — act here | Late signs — already in trouble |
|---|---|
| Restlessness · anxiety · irritability · tachypnea · tachycardia · mild hypertension · pallor | Cyanosis · bradycardia · hypotension · dysrhythmias · confusion → somnolence → unresponsive |
Cyanosis is a late sign. If you are waiting for it to confirm hypoxia, you waited too long.
The heart speeds up to push the oxygen it does have around faster — a compensatory rise in cardiac output.
Chemoreceptors sense the falling oxygen and rising CO2 and drive faster breathing to blow off CO2 and pull in more oxygen.
The brain is the most oxygen-sensitive organ in the body. Cerebral hypoxia shows up as restlessness and anxiety before anything else changes — which is exactly why a "difficult, agitated" patient may be hypoxic, not difficult.
| Restrictive | Obstructive | |
|---|---|---|
| Problem | Difficulty getting air IN | Difficulty getting air OUT |
| Examples | Pulmonary fibrosis · pneumonia · atelectasis · pleural effusion · obesity · kyphoscoliosis · neuromuscular disease | COPD — emphysema and chronic bronchitis · asthma |
| Expected findings | Rapid shallow breathing · decreased lung volumes · decreased compliance · dyspnea on exertion | Prolonged expiratory phase · wheezing · air trapping and barrel chest · decreased FEV1/FVC |
Restrictive = cannot fill. Obstructive = cannot empty.
URIs involve the nose, sinuses, pharynx, and larynx.
Most URIs are: viral
Because of this, antibiotics are: not indicated — they do nothing for a virus. Reserve them for a confirmed bacterial cause such as strep.
Expected findings:
Why does sinus pressure occur? Swollen, inflamed mucosa blocks the sinus openings so mucus cannot drain. The sinus is a fixed bony box — trapped mucus has nowhere to go, so pressure builds.
Expected findings:
Findings concerning for strep:
Concerning findings: drooling · muffled voice · difficulty swallowing · trismus (cannot open the mouth).
Why is drooling concerning? It means the patient can no longer swallow their own saliva — the airway is being threatened. Keep them upright, do not put anything in the mouth, have suction and emergency airway equipment ready, and notify the provider now.
Main manifestation: hoarseness or complete loss of the voice
Avoid: talking — and whispering, which strains the cords more than normal speech · smoking and irritants · alcohol and caffeine, which dry the throat
Encourage: voice rest · humidified air · plenty of fluids
Rebound congestion (rhinitis medicamentosa) comes from using topical decongestant sprays longer than 3 days — the vessels rebound wider than before, so the patient feels more congested and uses more spray.
Which URI patient worries you MOST, and why?
| Finding | What it tells you | Rank |
|---|---|---|
| Stridor | The upper airway is actively narrowing. This is an emergency now. | 1st |
| Drooling | The patient cannot handle their own secretions — obstruction is close behind. | 2nd |
| Cyanosis | A LATE sign. Hypoxia is already significant by the time you see it. | 3rd |
| Confusion | Cerebral hypoxia — also late, and it means compensation is failing. | 4th |
| Accessory muscle use | Real distress and increased work of breathing, but the airway is still open. | 5th |
Airway beats everything. Stridor and drooling are both telling you the airway is closing. Cyanosis and confusion mean the hypoxia is already severe — they are late, not early.
OSA involves repeated: episodes of upper airway collapse during sleep — the airway closes, breathing stops for 10 seconds or more, and the patient partially wakes to reopen it
This causes hypoxia, hypercapnia, and sympathetic stimulation over and over, all night.
Why do patients wake up exhausted? The repeated arousals fragment sleep. They never stay in deep or REM sleep long enough to restore anything — so a full night in bed still produces no real rest.
| CPAP | BiPAP | |
|---|---|---|
| Provides | ONE continuous pressure, the same on inhale and exhale | TWO pressures — a higher one on inspiration (IPAP) and a lower one on expiration (EPAP) |
| Purpose | Splints the airway open so it cannot collapse | Splints the airway AND assists the breath, which also helps blow off CO2 |
Why may patients tolerate BiPAP better? Because exhaling against the lower pressure takes much less work. Breathing out against the single high CPAP pressure is what most people cannot stand.
OSA plus opioids is a dangerous combination. Both suppress the airway and the drive to breathe — that is the next case.
Important cues: obesity · large neck circumference · PCA morphine · post-op · increasing respiratory rate
What complication should the nurse anticipate? Opioid-induced respiratory depression, on top of very likely undiagnosed OSA. The obesity, the neck, and the morphine PCA all stack in the same direction.
Apnea · bradypnea · cyanosis · somnolence · snorting or gasping respirations
What is the PRIORITY problem? Impaired gas exchange from opioid-induced respiratory depression with airway obstruction — an airway and breathing emergency.
Purpose: It is an opioid antagonist — it reverses the respiratory depression and sedation.
Risk of giving it: It reverses the analgesia too, so severe pain returns suddenly, and it can trigger acute withdrawal. Its duration is SHORTER than most opioids, so the patient can re-sedate — keep monitoring and be ready to redose.
Risk factors: HTN · anticoagulants · trauma · dry mucosa · steroid nasal sprays
Correct patient position: Sitting UP and leaning FORWARD
Where should pressure be applied? Pinch the soft part of the nose — over the cartilage, not the bony bridge
How long should pressure be maintained? 10 to 15 minutes of continuous pressure, without letting go to peek
Do not tilt the head backward. Blood runs down the throat instead. The patient swallows it, which causes nausea and vomiting, risks aspiration, and hides how much they are actually losing.
Do not blow the nose forcefully. It dislodges the clot that just formed and starts the bleeding over again.
The larynx does not stretch. Even small swelling can become life threatening fast.
| Stridor | Wheezing | |
|---|---|---|
| Usually indicates | UPPER airway narrowing — larynx or trachea | LOWER airway narrowing — bronchi and bronchioles |
| Heard | Loudest over the neck, usually on inspiration; often audible without a stethoscope | Over the lung fields, usually on expiration |
| Urgency | Emergency — airway | Serious, but the airway is open |
Risk factors: smoking · alcohol · HPV · occupational exposure
Concerning manifestations: persistent hoarseness · dysphagia · weight loss · a lump in the throat
Which symptom is often ignored early? Persistent hoarseness. People write it off as a cold or overuse — but hoarseness lasting more than 2 weeks needs to be evaluated.
Do not memorize diseases. Think through the patient.
Can this patient maintain an airway? Are they oxygenating effectively? Those two questions answer most of this module.
Filled from the Respiratory I guided notes handout · NUR 198 Exam 2 — Respiratory