Table of Contents:

1. Oxygenation 4. Oxygenation Alterations

2. Respiratory Assessment 5. Lifespan Considerations
3. Respiratory Diagnostics 6. Oxygen Delivery

Oxygenation

Respiratory
1. Oxygenation
Oxygenation refers to how well
FIGURE 1. OXYGENATION
oxygen (O2) is delivered to the
tissues of the body (FIGURE 1).
Oxygenation occurs through:
1. Ventilation: When we
breathe in, air enters the
lungs, bringing oxygen into
the alveoli (tiny air sacs in the
lungs).
2. Gas exchange: Oxygen
diffuses from the alveoli 
Pulmonary capillaries, where
it binds to hemoglobin in red
blood cells.
3. Transport: The heart pumps
oxygen-rich blood through
the body to deliver oxygen to
the tissues.
Adequate oxygenation is essential for organ function.
Impaired oxygenation can cause these life-threatening
complications:
y Hypoxemia:oxygen in the blood
y Hypoxia:oxygen in tissues
Signs of hypoxia

Early: Restlessness, confusion, tachycardia,
tachypnea, accessory muscle use, and tripod
position (sitting upright, leaning forward on hands)
y Late: Cyanosis, bradypnea, and bradycardia

 Recognizing hypoxia: Restlessness and tachypnea are early signs of hypoxia. Late signs are
cyanosis, bradycardia, and bradypnea.

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2. Respiratory Assessment
Respiratory assessment is performed to determine adequacy of ventilation and detect abnormalities (TABLE 2).
y Notify HCP of abnormalities.

TABLE 2. RESPIRATORY ASSESSMENT

Respiratory
Normal Findings Abnormal Findings

Skin color

y Color normal for race or ethnicity, no y Cyanosis: Bluish color of lips or nail beds indicating hypoxia
pallor or cyanosis y In clients with darker skin:

Assess less pigmented areas (lips, conjunctiva, palms).
y May appear as pallor or gray skin instead of blue

Chest wall movement

y Symmetric and equal chest wall y Retractions: Chest wall pulls inward due toinspiratory
movement effort.
y Accessory muscle use: Visible neck, shoulder, or upper chest
movement with breathing
y Extra muscles compensate for labored breathing.
y Paradoxical breathing: Chest contracts during inhalation and
expands during exhalation, the opposite of normal.
y Caused by chest wall or diaphragm dysfunction (e.g.,
respiratory fatigue in COPD, flail chest from rib fractures)

Pulse oximetry reading

y Normal range: 95-100% y Hypoxemia:oxygen saturation

y In darker skin, readings may appear falsely elevated.

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2. Respiratory Assessment, Continued

TABLE 2. RESPIRATORY ASSESSMENT, CONTINUED

Breathing pattern

Respiratory
y Respiratory rate for adults: 12-20 y Apnea: Absence of breathing
y Faster in children (see GROWTH & y Bradypnea: Respiratory rate <12
DEVELOPMENT CHEAT SHEET) y Tachypnea: Respiratory rate >20
y Dyspnea: Difficulty breathing
y Orthopnea: Difficulty breathing when lying flat, usually due to
pulmonary edema (heart failure)
y Kussmaul respirations: Deep, rapid breathing to “blow off”
CO₂ in acidosis

y Cheyne-Stokes: Alternating deep and shallow breathing with

apnea, often before death

Breath sounds

Clear breath sounds
Stridor: Audible, high-pitched, whistling sound from airway
y Bronchial: Harsh, high-pitched, hollow sounds obstruction (anaphylaxis, epiglottitis)
y Bronchovesicular: Medium-pitched sounds; y Crackles: Bubbling or rattling heard during inspiration from
combination of bronchial and vesicular sounds fluid in airways (pulmonary edema, pneumonia) or from collapsed
y Vesicular: Soft, low-pitched rustling or alveoli opening up (atelectasis)
whispering sounds y Wheezes: High-pitched, musical sounds heard during
expiration from airway narrowing (asthma, COPD)
y Rhonchi: Low-pitched, snoring sounds from mucus or fluid
blocking the upper respiratory tract (cystic fibrosis, pneumonia)
y Pleural friction rub: Grating sound that occurs when inflamed
pleural layers lose their lubricating fluid and the rough surfaces
rub together during breathing (pleurisy)
y Absent: No breath sounds heard from complete airway
obstruction or lung collapse (pneumothorax, atelectasis).

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3. Respiratory Diagnostics
Diagnostics are performed to assess for causes of oxygenation problems (TABLE 3).

TABLE 3. RESPIRATORY DIAGNOSTICS

Test Nursing Considerations

Respiratory
Chest X-ray: Visualizes lungs and airways y Perform urine or blood hCG test to rule out
pregnancy and prevent fetal radiation exposure.

Sputum specimen: Identifies pathogens or abnormal y Obtain specimen before starting antibiotics.
cells (via expectoration or suction) y Collect specimen in the morning after client has
rinsed mouth.
y Position client in Fowler position during collection.

Arterial blood gas (ABG): Measures oxygen, carbon y Avoid hyperoxygenation and suctioning before
dioxide, and pH to assess oxygenation and ventilation collection to ensure accuracy.
(see ACID-BASE IMBALANCES CHEAT SHEET)

Pulmonary function test: Measures lung capacity y Avoid smoking and inhaled bronchodilators 6 hr
and airflow before test to ensure accuracy.

Bronchoscopy:Visualizes bronchi with a fiberoptic y Keep client NPO until gag reflex returns.
scope to diagnose lung conditions (e.g., cancer)

Ventilation-perfusion (V/Q) scan: Assesses airflow y Assess for allergy to contrast.

(ventilation) and blood flow (perfusion) to detect V/Q y Perform urine or blood hCG test to rule out
mismatch (e.g., pulmonary embolism) pregnancy and prevent fetal radiation exposure.

4. Oxygenation Alterations

TABLE 4. OXYGENATION ALTERATIONS

Process Common Alterations Interventions

Ventilation: Air y Asthma and COPD: y Encourage mobility, frequent

movement in and out Bronchoconstriction reduces airflow. repositioning, deep breathing, and
of the lungs y Pneumothorax and atelectasis: incentive spirometry to promote lung
Lung or alveolar collapse that reduces expansion and prevent complications.
ventilation
For clients with respiratory distress:
y Position in high Fowler tolung
Gas Exchange: y Pneumonia, pulmonary edema, ARDS: expansion.
Transfer of O2 from Fluid, exudate, or damagealveolar y Administer supplemental oxygen.
alveoli  blood, and CO2 surface area, impairing gas exchange y Suction as needed to remove
from blood  alveoli and causing hypoxemia. excess secretions.

 Recognizing stridor: High-pitched, audible sound  Respiratory distress interventions: Place clients in
indicates emergent airway obstruction (e.g., anaphylaxis high Fowler position and administer oxygen.
or epiglottitis) and requires immediate intervention.

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5. Lifespan Considerations
Newborns
y Irregular respirations and brief apnea (<20 s) are normal.
y Obligatory nose breathers; nasal congestion can cause dyspnea.
Infants and young children
y Use abdominal breathing due to immature chest muscles.

Respiratory
Pregnant clients
y Tachypnea and dyspnea are common due tooxygen demand and displacement of the diaphragm from the
gravid uterus.
Older adults
y chest expansion and muscle strength reduce lung inflation.
y Diminished cough reflex leads to mucus retention andrisk for aspiration and infections.

6. Oxygen Delivery
Supplemental oxygen is administered using various oxygen delivery devices to improve oxygenation based on the
severity of hypoxia and the client’s needs (TABLE 5).

TABLE 5. OXYGEN ADMINISTRATION

General considerations

Provide supplemental oxygen for SpO2 levels <90% in most clients.
y Titrate oxygen to keep SpO2 levels between 88-92% in clients with COPD.

Use lowest effective oxygen concentration to prevent oxygen toxicity.

Risk for skin breakdown: Assess skin integrity and pad oxygen delivery devices as needed.
y Do not smoke or have flammable items near oxygen (e.g., aerosol sprays).

Device & Flow Rate Indication Considerations

Nasal Cannula y Mild hypoxia Risk for mucus membrane irritation with
1-6 L/min y Long-term oxygen therapy higher flow rates: If oxygen is ≥4 L/min,
provide humidification.

Simple Face Mask y Moderate hypoxia Risk for CO2 buildup: Keep oxygen flow
5-12 L/min y Short-term oxygen therapy rate ≥5 L/min.

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6. Oxygen Delivery, Continued

TABLE 5. OXYGEN ADMINISTRATION, CONTINUED

Device & Flow Rate Indication Considerations

Respiratory
Partial Rebreather
High-flow oxygen: Used for acute
Risk for CO2 buildup: Ensure flow rate
& Non-Rebreather hypoxemia in respiratory emergencies is sufficient to keep bag inflated (≥10
(NRB) Mask y Oxygen fills the reservoir bag, L/min); if bag deflates,oxygen flow
Partial rebreather: which the client breathes from, and rate.
6-11 L/min removable, one-way valves open
Non-rebreather: 10-15 during expiration and close during
L/min inhalation to preventin FiO2 and CO2
buildup.
y Removing one or both valves on the
mask turns an NRB into a partial
rebreather.

Venturi Mask y Delivers precise oxygen Risk for inaccurate oxygen delivery:
Flow rate varies concentration (e.g., 35% FiO2) Keep air intake ports open.
y Used when clients have specific FiO2
requirements (COPD)

High-Flow Nasal y Provides heated, humidified oxygen Risk for airway dryness: Monitor
Cannula y High-flow oxygen therapy, tolerated humidifier water level to maintain
20-60 L/min better than masks adequate humidification.

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6. Oxygen Delivery, Continued

TABLE 5. OXYGEN ADMINISTRATION, CONTINUED

Device & Flow Rate Indication Considerations

Respiratory
Noninvasive Positive y Provides high-level ventilatory support Risk for aspiration: Do not use with
Pressure Ventilation via mask sedated or unresponsive clients.
(CPAP, BiPAP) y Delivers oxygen with positive pressure
Flow rate varies to keep airways and alveoli open for
clients with ventilatory issues (COPD,
sleep apnea)

Mechanical y Provides high-level ventilatory support Risk for ventilator-associated

ventilation with via intubation with ET tube. pneumonia: Turn client and perform
endotracheal y Used for respiratory failure or oral care Q2 hours (see MECHANICAL
intubation temporary airway protection (surgery) VENTILATION & ARDS CHEAT SHEET).
Flow rate varies

Lifespan consideration: Blow-by oxygen, oxygen hoods, and tents deliver humidified oxygen to infants and
young children who cannot tolerate standard devices.

 Oxygen administration: Use the lowest  Nonrebreather safety: When giving high-flow
effective oxygen concentration to prevent oxygen via a non-rebreather mask, the oxygen flow
oxygen toxicity. Apply padding around oxygen rate must be sufficient to keep the bag inflated and
delivery devices to prevent skin breakdown. prevent CO2 buildup.

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  What are two early signs of hypoxia? What are  Use the lowest effective oxygen concentration
three late signs of hypoxia? to prevent _____ and apply _____ around oxygen
delivery devices to prevent skin breakdown.
 What high-pitched, audible sound indicates an

Respiratory
emergent upper airway obstruction and requires  When giving high-flow oxygen via a non-
immediate intervention? rebreather mask, the oxygen flow rate must be
sufficient to keep the bag _____ and prevent _____
 If clients demonstrate signs of respiratory distress, buildup.
place in the _____ position and administer _____.

5. inflated, CO2
Answers: 1. Restlessness and tachypnea; Cyanosis, bradycardia, and bradypnea 2. Stridor 3. high Fowler, oxygen 4. oxygen toxicity, padding

References:

Astle, B., Duggleby, W., Potter, P. A., Stockert, Perry, A. G., & Hall, Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (Eds.). (2023).
A. M. (2024). Potter and Perry’s Canadian fundamentals of Fundamentals of nursing (11th ed.). Elsevier.
nursing (7th ed.). Elsevier.
Tyerman, J., Cobbett, S., Harding, M. M., Kwong, J., Roberts, D.,
Berman, A. J., Snyder, S., & Frandsen, G. (2020). Kozier & Erb’s Hagler, D., Reinisch, C. (Eds.). (2023). Lewis’s medical-
fundamentals of nursing (11th ed.). Pearson Education surgical nursing in Canada: Assessment and management
(US). of clinical problems (5th ed.). Elsevier.

Callahan, B., Hand, M., & Steele, N. (Eds.). (2023). Nursing: A Attributions:
concept-based approach to learning (4th ed., Vol 2).
y Oxygenation: Created with BioRender.com
Pearson.
y Normal Breathing: Created with BioRender.com
Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (Eds.).
(2023). Lewis’s medical-surgical nursing: Assessment and y Kussmaul Respirations: Created with BioRender.com
management of clinical problems (12th ed.). Elsevier. y Cheyne-Stokes Respirations: Created with BioRender.com
Ignatavicius, D., Heimgartner, N., & Rebar, C. (Eds.). (2024). y Breath Sounds: Created with BioRender.com
Medical-surgical nursing: Concepts for clinical judgment
and collaborative care (11th ed.). Elsevier.
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